**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and the Wound Care Physicians interviews, the facility failed to notify the Wound Care Physician for evaluation and treatment of a Stage IV (full thickness skin and tissue loss with exposed muscle, tendon, ligament or bone)pressure wound on the left trochanter (boney protrusion on the femur bone) that was present on admission. This occurred for 1 of 1 resident reviewed for wound care (Resident #1). Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including a Stage IV pressure wound to the left trochanter, protein calorie malnutrition, and anemia. An admission note dated 3/8/25 at 3:01 PM documented by Nurse #11 revealed in part; Resident #1 admitted to the facility from the hospital on 3/8/25 at 12:18 AM. Resident #1 was non-verbal and required total care. Contractures noted of all extremities. Wounds to the left hip and sacrum were noted, with dressings clean, dry and intact. A physicians order dated 3/8/25 for Resident #1 revealed calcium alginate with silver every day shift for wound care. Cleanse the area to the left hip with normal saline, place alginate with silver to the wound bed then cover with foam border dressing. A progress note dated 3/10/25 documented by the Nurse Practitioner revealed in part; Resident #1 with a stage four pressure ulcer. She is receiving nutrition via a gastrostomy tube (feeding tube) with continuous feedings. Pressure ulcer of unspecified part of back, Stage II. Implement the wound care protocol, including regular dressing changes and pressure relief measures. Consult the wound care specialist for advanced management. A weekly wound evaluation dated 3/14/25 completed by the Wound Treatment Nurse for Resident #1 revealed Stage IV left trochanter identified on 3/8/25. The wound measured 1.0 centimeter (cm) x 0.6 cm x 0.8 cm., with no tunneling (when the wound extends deep creating a tunnel causing increased risk of infection and impedes wound healing) or undermining (separation of the wound edges from the surrounding healthy tissue creating a pocket which impedes wound healing). Moderate serous exudate (thin watery drainage) was noted. The wound bed with erythema (redness) noted, with 100% granulation tissue. Surrounding tissue with erythema. Current treatment included collagen powder and calcium alginate with silver dry dressing. This was signed and dated by the wound treatment nurse on 3/14/25. Review of Resident #1's electronic medical record from 3/8/25 through 4/2/25 revealed no documentation that the Wound Care Physician was notified of the stage IV left hip wound. An interview was conducted on 04/03/25 at 9:19 AM with the Wound Care Physician. She stated she evaluated Resident #1 today for the first time. She stated Resident #1 had a Stage IV to the left hip measuring 0.7 cm x 0.7 cm x 0.7 cm (depth), with undermining at 6:00 o'clock measuring 2.5 cm. The wound had 100% granulation with moderate serous drainage. She stated she was not notified of Resident #1's stage IV hip wound until today. She stated she should have been notified of the stage IV upon admission to the facility so that she could evaluate and treat the wound and that did not occur. She stated the stage IV hip wound had decreased in size since the last documented measurements. An interview was conducted on 4/3/25 at 1:45 PM with the Wound Treatment Nurse. She stated she was not in the facility daily, and she had resigned and was working out her notice. She stated she was only in the facility 2-3 days per week and when she was not here the assigned nurse was responsible for the wound care. When asked why the Wound Care Physician was not notified of the stage IV left hip pressure wound on admission she did not give an answer. An interview was conducted on 04/03/25 at 4:00 PM with the Director of Nursing (DON) along with Administrator. The DON stated she was not aware that the Wound Care Physician had not been notified upon admission of Resident #1's stage IV pressure wound. Both the Administrator and DON stated the Wound Care Physician should have been notified on admission of the stage IV wound. The Administrator stated education would be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff, Wound Care Physician, and the Medical Director's interviews the facility failed to 1.) conduct an initial wound assessment on admission for a Stage IV (fullthickness skin and tissue loss with exposed muscle, tendon, ligament or bone) left trochanter (bony protrusion on the femur bone) wound to include the wound description with measurements and perform daily wound care treatments according to the physicians orders for a resident (Resident #1) admitted with a stage IV pressure wound and who developed a stage II (partial thickness skin loss involving the dermis) pressure wound on the sacrum and lower back following admission. 2.) provide daily wound care to a stage IV pressure wound (Resident #71). This occurred for 2 of 2 residents (Resident #1, Resident #71) reviewed for pressure wound care. Findings included. 1.) Resident #1 was admitted to the facility on [DATE] with diagnoses including a Stage IV pressure wound to the left trochanter, protein calorie malnutrition, and anemia. An admission note dated 3/8/25 at 3:01 PM documented by Nurse #11 revealed in part; Resident #1 admitted to the facility from the hospital on 3/8/25 at 12:18 AM. Resident #1 was non-verbal and required total care. Contractures noted of all extremities. Wounds to the left hip and sacrum were noted, with dressings clean dry and intact. A physicians order dated 3/8/25 for Resident #1 revealed Calcium alginate with silver every day shift for wound care. Cleanse the area to the left hip with normal saline, place alginate with silver to the wound bed then cover with foam bordered dressing. A physicians order dated 3/8/25 for Resident #1 revealed Calmoseptine external ointment 0.44-20.6 % (Menthol-Zinc Oxide) Apply to sacrum topically every day and evening for protection. Review of Resident #1's electronic medical record from 3/8/25 through 3/14/25 revealed no documentation of a wound assessment of the stage IV left hip or sacrum wound with a wound description and measurements. Attempts were made on 4/03/25 at 4:00 PM and 4:50 PM to contact Nurse #11 the admission nurse on 3/8/25, there was no response. A progress note dated 3/10/25 documented by the Nurse Practitioner revealed in part; Resident #1 with a stage four pressure ulcer. She is receiving nutrition via a gastrostomy tube (feeding tube) with continuous feedings. Pressure ulcer of unspecified part of back, Stage II. Implement the wound care protocol, including regular dressing changes and pressure relief measures. Consult the wound care specialist for advanced management. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. Her weight was 89 pounds, and the stage IV wound was present on admission. A care plan dated 3/14/25 revealed Resident #1 had the potential for pressure ulcer development related to impaired mobility, and incontinence. She was admitted with a Stage IV pressure ulcer to the left hip and moisture associated dermatitis to the lower back. Observe, document, and report any changes in skin status: appearance, color, wound healing, signs of infection, wound size, and stage. Review of Resident #1's electronic medical record from admission on [DATE] through 4/2/25 revealed the following weekly wound evaluations: A weekly wound evaluation dated 3/14/25 for Resident #1 revealed Stage IV left trochanter identified on 3/8/25. Measuring 1.0 centimeters (cm) x 0.6 cm x 0.8 cm. No tunneling (when the wound extends deep creating a tunnel causing increased risk of infection and impedes wound healing) or undermining (separation of the wound edges from the surrounding healthy tissue creating a pocket which impedes wound healing). Moderate serous exudate (thin watery drainage). Wound bed with erythema. 100% granulation tissue. Surrounding tissue with erythema. Current treatment collagen powder and calcium alginate with silver dry dressing. This was signed and dated by the Wound Treatment Nurse on 3/14/25. A weekly wound evaluation dated 3/14/25 for Resident #1 revealed moisture related wound to the lower back measuring 3.0 cm x 1.0 cm x 0.1 cm. The wound was identified 3/8/25. Moderate serosanguineous exudate (mix of blood and fluid drainage) . Tender to touch with 20 % granulation tissue. Surrounding tissue with erythema (redness). Current treatment collagen powder and zinc paste. Treatment ordered 3/14/25. This was signed and dated by the wound treatment nurse on 3/14/25. A weekly wound evaluation dated 3/21/25 for Resident #1 revealed Stage IV left trochanter identified on 3/8/25. Measuring 2.0 centimeters (cm) x 1 cm x 0.8 cm. No tunneling or undermining. Moderate serous exudate. Wound bed with erythema (redness). 100% granulation tissue. Surrounding tissue with erythema. Current treatment collagen powder and calcium alginate with silver dry dressing. This was signed and dated by the wound treatment nurse on 3/21/25. A weekly wound evaluation dated 3/21/25 for Resident #1 revealed moisture-related wound to the lower back measuring 3.5 cm x 3.5 cm x 0.1 cm. The wound was identified 3/8/25. Moderate serosanguineous exudate. Tender to touch with 20 % granulation tissue. Surrounding tissue with erythema. Current treatment collagen powder and zinc paste. Treatment ordered 3/14/25. This was signed and dated by the wound treatment nurse on 3/21/25. A weekly wound evaluation with an effective date of 3/25/25 for Resident #1 revealed Stage IV left trochanter identified on 3/8/25. Measuring 2.0 centimeters (cm) x 1.2 cm x 0.7 cm. No tunneling or undermining. Moderate serous exudate. Wound bed with erythema. 100% granulation tissue. Surrounding tissue with erythema. Current treatment collagen powder and calcium alginate with silver dry dressing. This was signed and dated by the wound treatment nurse on 4/2/25 and entered into the electronic medical record on 4/2/25. A weekly wound evaluation with an effective date of 3/25/25 for Resident #1 revealed moisture-related wound to the lower back measuring 3.5 cm x 3.4 cm x 0.1 cm. The wound was identified 3/8/25. Moderate serosanguineous exudate. Tender to touch with 20 % granulation tissue. Surrounding tissue with erythema. Current treatment collagen powder and zinc paste. Treatment ordered 3/14/25. This was signed and dated by the wound treatment nurse on 4/2/25 and entered into the electronic medical record on 4/2/25. A wound evaluation progress note dated 4/1/25 at 3:37 PM for Resident #1 documented by Nurse #12 revealed the wound treatment was changed to the sacrum. Medi honey and foam dressing ordered daily. The dressing was applied. The wound bed was pink with scant serous drainage. Wound edges noted with dry, peeling skin. Periwound (skin surrounding the wound) intact. Dressing changed to lower back with wound bed pink with scant serous drainage. Periwound was intact. Dressing was changed to the Left hip. The wound bed was pink with a small amount of serous drainage. Undermining was noted at 12 o'clock and 9 o'clock areas. Resident #1 tolerated well. No signs of pain or discomfort. Resident #1 was repositioned using pillows. The stage IV left hip measured 0.9 cm x 0.6 cm x 1.2 cm. The medial lower back measured 0.8 cm x 0.9 cm x 0.1 cm. A care plan dated 4/1/25 for Resident #1 revealed actual pressure ulcer development. Stage II pressure ulcer of the lower back, and stage II pressure ulcer of the sacrum. Interventions included to administer treatments as ordered and observe for effectiveness. Review of the Treatment Administration Record (TAR) for Resident #1 dated March 2025 revealed: Calcium alginate with silver every day shift for wound care. Cleanse the area to the left hip with normal saline, place alginate with silver to wound bed then cover with foam bordered dressing with a start date of 3/8/25 and scheduled to be completed between 7:00 AM until 3:00 PM. The wound care was not signed off as completed on the following dates: 3/10/25: not signed as completed, the assigned nurse was Nurse #2. 3/14/25: not signed as completed, the assigned nurse was Nurse #2 3/27/25: not signed as completed, the assigned nurse was Nurse #2 3/28/25: not signed as completed, the assigned nurse was Nurse #2 3/31/25: not signed as completed, the assigned nurse was Nurse #2 Review of the Treatment Administration Record (TAR) for Resident #1 dated March 2025 revealed: Calmoseptine External Ointment 0.44-20.6 % (Menthol-Zinc Oxide) Apply to sacrum topically every day and evening shift for Protection with a start date of 3/8/25 and scheduled to be completed between 7:00 AM until 3:00 PM. The wound care was not signed off as completed on the following dates: 3/10/25: not signed as completed, the assigned nurse was Nurse #2. 3/14/25: not signed as completed, the assigned nurse was Nurse #2 3/27/25: not signed as completed, the assigned nurse was Nurse #2 3/28/25: not signed as completed, the assigned nurse was Nurse #2 3/31/25: not signed as completed, the assigned nurse was Nurse #2 Review of the Treatment Administration Record (TAR) for Resident #1 dated March 2025 revealed: Collagen powder, zinc paste, and dry dressing to open area located on lower back every day shift for wound care. Cleanse area with normal saline, apply collagen powder, zinc paste, and dry dressing start date 3/15/24 and scheduled to be completed between 7:00 AM until 3:00 PM. The wound care was not signed off as completed on the following dates: 3/27/25: not signed as completed, the assigned nurse was Nurse #2 3/28/25: not signed as completed, the assigned nurse was Nurse #2 3/31/25: not signed as completed, the assigned nurse was Nurse #2 Review of the Treatment Administration Record (TAR) for Resident #1 dated April 2025 revealed: wound care to the stage IV hip, stage II sacrum, and stage II lower back were completed as ordered. During an interview on 04/02/25 at 3:33 PM Nurse #2 stated she was routinely assigned to provide care for Resident #1. She stated she did not do daily wound care, and she thought the treatment nurse was responsible for wound care. She reported she had completed the dressing change on Resident #1 once or twice and signed off on the TAR on the days she did the wound treatments. She stated that if she did not sign off on the TAR then she did not do the wound care because she thought the wound nurse had done the treatment. She stated she was not aware Resident #1 had a stage II on her sacrum, but she knew she had the Stage IV on her hip and an area on her lower back but reported she was not aware it was a stage II. An interview was conducted on 04/02/25 at 10:04 AM with Nurse #12. She stated she typically did not work in this facility but was brought in this week to assist with wound care. She stated Resident #1 had a Stage IV hip wound that was small but deep. She stated she completed the wound care the previous day and the area was clean, with no slough. The order was to pack with iodoform packing strips daily. She reported the lower back wound was now a stage II pressure wound. The treatment ordered was collagen powder with dry dressing. She stated Resident #1 also had a stage II pressure wound to the sacrum that developed since admission. The treatment ordered on 4/1/25 to the sacrum was Medi honey with foam dressing and change daily. She stated the wounds on her lower back and sacrum started as excoriation (raw irritated skin) on admission but now had developed into stage II pressure wounds. A wound observation was conducted on 04/02/25 at 10:04 AM with Nurse #12. The areas observed were stage IV left hip, stage II sacrum and stage II lower back. The stage IV wound was a small area, with no exudate, no odor, with undermining noted. The wound was packed with iodoform packing strips. Medi honey applied to stage II sacrum and collagen powder with dry dressing applied to lower back wound. There were no concerns with the wound care observation. During a phone interview on 04/02/25 at 3:08 PM Nurse #13 stated she did assist with wound care at times. She stated she primarily worked weekends. She stated some days she would have an assignment and other days she may be assigned to wounds only. She stated if she had completed Resident #1's dressing changes she would have signed it off on the TAR. She stated if she had a resident assignment then it would be up to the assigned nurse to complete the wound treatments. During a phone interview on 04/03/25 at 12:04 PM Nurse #7 stated she was the assigned nurse on Saturday 3/8/25 from 7:00 AM until 3:00 PM. She stated she did skin assessments, but she did not complete wound assessments with a description of the wound or measurements. She stated the wound treatment nurse was responsible for the wound descriptions with measurements. An interview was conducted on 4/3/25 at 1:45 PM with the Wound Treatment Nurse. She stated she was not in the facility daily; she had resigned and was working out her notice. She stated she was only in the facility 2-3 days per week and when she was not here the assigned nurse was responsible for the wound care. She stated there was a second nurse who did wound care at times unless she had a resident assignment, and a treatment aide would complete wound care some weekends. She stated at times she may be in the facility for charting and not doing wound care and the assigned nurse would be responsible. She stated she did an initial assessment of Resident #1's wounds to the left hip and lower back with measurements and a description of wound status on 3/14/25. When asked why the initial assessment with measurements was not completed until 3/14/25, 6 days after admission, she did not give an answer. When asked why she did not enter the wound evaluation on 3/25/25 with measurements until 4/2/25 she stated she left early that day and never entered the measurements. She stated the sacrum was only an area of excoriation and treated with calmoseptine until this week and was now a stage II wound. She stated the wound treatment to the sacrum was changed to Medi honey. She stated if she had completed any of the wound treatments she would have signed it off on the TAR. During a phone interview on 04/03/25 at 11:50 AM Medication Aide #1 stated she only worked weekends and was only assigned to complete wound treatments. She stated she recalled doing Resident#1's wound treatment on the day of admission. She recalled applying calcium alginate to her left hip and stated she thought she also had a wound on her lower back. She stated she did not do wound assessments or measurements and that was the responsibility of the wound treatment nurse. An interview was conducted on 04/03/25 at 9:19 AM with the Wound Care Physician. She stated she evaluated Resident #1 today for the first time. She stated Resident #1 had a Stage IV to the left hip measuring 0.7 cm x 0.7 cm x 0.7 cm., with undermining at 6:00 o'clock measuring 2.5 cm. The wound had 100% granulation with moderate serous drainage. She stated she kept the treatment to the stage IV wound the same and to continue iodoform packing strips daily. She stated the second area was a Stage II to the medial lower back measuring 0.8 cm x 0.9 cm x 0.1 cm. with light serous drainage. The treatment was collagen powder applied daily. She reported the third area was a Stage II pressure wound to the sacrum measuring 3.2 cm x 2.3 cm x 0.1 cm with light serous drainage. She stated that Medi honey was started 2 days ago, and she was willing to try it then reevaluate next week. She stated she was not notified of Resident #1's stage IV hip wound until today. She stated she should have been notified of the stage IV upon admission to the facility so that she could evaluate and treat the wound and that did not occur. She stated the stage IV hip wound had decreased in size since the last documented measurements. An interview was conducted on 04/03/25 at 4:00 PM with the Director of Nursing (DON) along with Administrator. The DON stated the treatment nurses were responsible for wound care when they were here, otherwise the assigned nurse was responsible. She stated either the treatment nurse or the assigned nurse was responsible for completing an initial assessment that included a wound description with measurements on admission and document the assessment in the medical record. She stated the current treatment nurse only worked part time, but they had hired a new treatment nurse who was in training. The DON stated she was not aware the daily treatments were not getting done, and she was not aware that the Wound Care Physician had not been notified upon admission of Resident #1's stage IV wound. Both the Administrator and DON stated wound care should have been completed daily as ordered, an initial evaluation with measurements completed and documented in the medical record and the Wound Care Physician notified of the wound. The Administrator stated education would be provided. During a phone interview on 04/03/25 at 5:11 PM the Medical Director stated Resident #1 was admitted with a stage IV pressure wound to the left hip and multiple comorbidities. Resident #1 required a high level of care. She received enteral feedings and had been declining. She reported Resident #1 was at high risk for wound development and the new areas showed how frail her skin was, therefore, the stage II pressure wounds that developed on the sacrum and lower back were unavoidable. She stated she did expect that wound care orders were followed. 2.) Resident #71 was admitted on [DATE] with diagnoses which included dementia, diabetes and diabetic neuropathy. Resident #71's care plan included a care plan problem dated 12/13/24 which indicated actual impairment to skin integrity with pressure ulcer Stage 4 (full-thickness skin and tissue loss) to the sacrum and an unstageable ulcer due to necrosis (dead skin tissue due to injury, infection or lack of blood supply) to the right second toe with potential for further pressure ulcer development related to impaired mobility, incontinence, malnutrition and history of pressure ulcers. The goal indicated that the resident would have intact skin by the next review date. Interventions included administer treatments as ordered and observe effectiveness. Resident #71's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment and one Stage 4 pressure ulcer which was present upon admission, entry or reentry. Pressure ulcer care and pressure reducing device for the bed were coded. Physician's orders dated 3/7/25 for Resident #71 indicated: - apply calcium alginate to the sacrum and a dry dressing once per day for wound care - apply skin prep (a treatment used to provide a thin, protective film over the skin) to the right second toe every day shift for wound care Resident #71's March 2025 Treatment Administration Record (TAR) revealed no documentation of the application of calcium alginate to the sacrum and a dry dressing or the application of skin prep to the right second toe on 3/10/25 and 3/11/25. The facility's daily assignment sheet for 3/10/25 and 3/11/25 revealed there was no assigned treatment nurse and Medication Aide #1 was assigned to Resident #71 with Nurse #4 assigned to oversee Medication Aide #1. The Wound Care Specialist Physician documentation dated 3/13/25 indicated the following measurements of Resident #71's pressure ulcers: - Stage 4 pressure ulcer: length 4.8 centimeters (cm), width 4.1 cm, and depth 1.1 cm - Unstageable deep tissue injury to the right second toe: length 0.3 cm, width 0.3 cm Resident #71's March 2025 TAR revealed no documentation of the application of calcium alginate to the sacrum and a dry dressing or the application of skin prep to the right second toe on 3/14/25. The facility's daily assignment sheet for 3/14/25 revealed there was no assigned treatment nurse, and that Medication Aide #1 was assigned to Resident #71 with Nurse #4 assigned to oversee the Medication Aide. The Wound Care Specialist Physician documentation dated 3/20/25 indicated the following measurements of Resident #71's pressure ulcers: - Stage 4 pressure ulcer: length 5.1 cm, width 4.0 cm, and depth 1.1 cm - Unstageable deep tissue injury to the right second toe: length 0.5 cm, width 0.5 cm The Wound Care Specialist Physician documentation dated 3/25/25 indicated the following measurements of Resident #71's pressure ulcers: - Stage 4 pressure ulcer: length 5.0 cm, width 3.1 cm, and depth 1.0 cm - Unstageable deep tissue injury to the right second toe: length 0.3 cm, width 0.3 cm Resident #71's March 2025 TAR revealed no documentation of the application of calcium alginate to the sacrum and a dry dressing or the application of skin prep to the right second toe on 3/25/25, 3/27/25, and 3/31/25. The facility's daily assignment sheet for 3/25/25, 3/27/25, and 3/31/25 revealed there was no assigned treatment nurse, and that Medication Aide #1 was assigned to Resident #71 with Nurse #4 assigned to oversee the Medication Aide. An interview was conducted with Nurse #4 on 4/2/25 at 9:55 AM. Nurse #4 stated she worked Monday through Friday on the 7:00 AM to 3:00 PM shift and was assigned to the 800 hall, part of the 700 hall and was assigned to oversee the medication aide on 500 hall, the hall that Resident #71 resided on. Nurse #4 stated she was aware that in the absence of the Wound Care Nurse or an assigned treatment nurse, she was responsible for completion of the ordered wound care for her assigned residents. Nurse #4 stated the Wound Care Nurse frequently was not working and there was no assigned treatment nurse. Nurse #4 stated she did not know if the Medication Aide completed the ordered wound care for her assigned residents when the Wound Care Nurse was not working and there was no assigned treatment nurse. Nurse #4 stated she did not complete the wound care treatments for Resident #71 when she was assigned to oversee the Medication Aide on 3/10/25, 3/11/25, 3/14/25, 3/25/25, 3/27/25, and 3/31/25. An interview with Medication Aide #1 was conducted with on 4/3/25 at 12:30 PM. Medication Aide #1 indicated that she worked Monday through Friday on the 7:00 AM to 3:00 PM shift and was assigned to Resident #71. Medication Aide #1 stated that when the Wound Care Nurse was not working and there was not an assigned treatment nurse, the nurse that was overseeing her was responsible for completion of the ordered wound care treatments. Medication Aide #1 stated that Nurse #4 had not notified her that she had not completed Resident #71's ordered wound care. Medication Aide #1 stated she assumed that Nurse #4 completed the ordered wound care on the days that the Wound Care Nurse was not working. An interview was conducted with the Wound Care Nurse on 4/2/25 at 3:00 PM. The Wound Care Nurse stated she had turned in her resignation and was only working part time until her last day. The Wound Care Nurse indicated that the floor nurses were responsible for completing the ordered wound care when she was not working and there was not an assigned treatment nurse. The Wound Care Nurse stated it was the responsibility of the nurse assigned to oversee the Medication Aide to complete the wound care treatments for those assigned residents. An interview was conducted with the Wound Care Specialist Physician on 4/3/25 at 9:20 AM. The Wound Care Specialist Physician stated she had been seeing Resident #71 due to the Stage 4 pressure ulcer to the sacrum. The Wound Care Specialist Physician stated Resident #71 had an extensive wound to the sacrum that was down to the muscle. The Wound Care Specialist indicated Resident #71's wounds were stable but had the potential for maceration (a softening and breakdown of the skin tissue due to prolonged exposure to moisture), further skin breakdown and worsening of the wound. The Wound Care Specialist indicated that the treatments should be completed daily and that she expected that the wound care would be completed as ordered. The Wound Care Specialist Physician stated that Resident #71's wound treatments were to be completed daily as ordered. Not completing the wound care treatments as ordered to Resident #71's sacrum and toe had the potential to cause worsening of the wounds, however the wounds were currently stable. Wound treatments required consistent care and monitoring to prevent worsening and further complications. An interview was conducted with the Director of Nursing (DON) and Administrator on 4/3/25 at 2:50 PM. The DON and Administrator indicated that the Wound Care Nurse had turned in her resignation in January but had agreed to continue to work a few days per week until a replacement could be hired. The DON and Administrator stated that when a wound care nurse was not scheduled, it was the responsibility of the floor nurse to complete the ordered wound care treatments. The DON and Administrator stated that when a Medication Aide was assigned to a resident with an ordered wound care treatment it was the responsibility of the nurse overseeing the Medication Aide to complete the wound care. The DON and Administrator indicated that they expected wound care to be completed as ordered. The DON stated she did not review the TARs and was not aware of any problems with the completion of the daily wound care treatments. An interview was conducted with the Nurse Practitioner on 4/3/25 at 3:45 PM. The NP indicated that she expected wound care to be completed as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff and the Physician's interviews, the facility failed to obtain weekly weights as ordered for a resident (Resident #1) who was a new admission and receiving enteral feedings (tube feeding). This occurred for 1 of 5 residents reviewed for nutrition. Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including Stage IV pressure wound to the left hip, protein calorie malnutrition, and anemia. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. She had no rejection of care. The care plan dated 3/18/25 revealed Resident #1 received enteral tube feedings and was at risk for dehydration. Interventions included in part to observe, document, and report signs or symptoms of dehydration or sudden weight loss. An order dated 3/21/25 for Resident #1 revealed weights per policy. Review of Resident #1's electronic medical record revealed the following: 3/08/25 no admission weight was recorded 3/13/25 the weight was 89.0 pounds (lbs.) 3/21/25 there was no weight recorded. 3/28/25 the weight was 87.7 lbs. During an interview on 04/03/25 at 9:59 AM the Registered Dietitian stated the facility policy was to weigh new admissions weekly for 4 weeks then monthly if there were no concerns. She stated the facility process in obtaining weights was that after the weekly weight meeting the Director of Nursing (DON) gave her a copy of the current weight orders and then sent the orders out to the staff. She stated the Restorative Aide was the primary staff member who was assigned to obtain the weights. She indicated Resident #1 was to receive weekly weights due to being a new admission and receiving tube feedings. She indicated it was important to obtain weekly weights to determine her nutritional status to ensure she was receiving adequate intake. She stated the weekly weights should have been obtained. During an interview on 04/03/25 at 10:35 AM the Restorative Aide stated that she was responsible for obtaining all resident weights. She stated she attended the weekly care plan meetings. During the weekly meetings, the DON will give her a list to let her know what the weight orders were, and which residents needed daily or weekly weights. She stated new admissions were to receive weekly weights and if there was a resident observed on the hall that was new to the facility and not on her list she would obtain the weight. She stated she was also assigned as a nurse aide on the floor some days and assigned to transport residents to appointments at times which made it difficult to do weights and she was unable to get the weights done at times. She stated she would weigh Resident #1 today. During a follow up interview on 4/3/25 at 1:00 PM the Restorative Aide stated she obtained Resident #1's weight today and it was 89 pounds. During an interview on 04/03/25 at 2:00 PM Nurse #2 stated she was routinely assigned to Resident #1. She stated the Restorative Aide was responsible for obtaining the weights. She indicated she had not obtained weights on Resident #1. An interview was conducted on 04/03/25 at 3:33 PM with the Director of Nursing (DON) along with the Administrator. The DON stated the facility policy included to obtain weekly weights for all new admissions and the Restorative Aide was responsible for obtaining weights. She stated the Restorative Aide attended the weekly weight meetings and she was given a list of residents that needed daily or weekly weights. She indicated that if the Restorative Aide was not available to get the weight for a resident the assigned nurse was responsible for making sure the weights were done. She indicated that a weight should have been obtained on day of admission then weekly. She stated they would review their process for obtaining weights and provide staff education. During a phone interview on 04/03/25 at 5:11 PM the Physician indicated Resident #1 required weekly weights as a new admission receiving tube feedings. She stated weekly weights should have been obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Physician and Consultant Pharmacist's interviews, the Pharmacist failed to identify and address during the monthly medication regimen reviews that a resident's Midodrine 10 mg (milligrams) prescribed for hypotension was administered outside of the set parameters 38 times during January 2025, 44 times in February 2025 and 15 times in March 2025 when the Consultant Pharmacist completed her monthly March review on 03/14/25. This occurred for 1 of 1 resident (Resident #95) reviewed for medication administration. Resident #95 experienced no significant outcome. Finding included: Resident #95 was admitted to the facility on [DATE] with diagnoses that included hypotension. Record review revealed the following active orders: Midodrine 10 mg give 1 tablet by mouth one time a day every Monday, Wednesday, Friday for hypotension hold if sys (systolic) > (greater than) 120 or dys (diastolic) > 80; Start date 01/08/25. Midodrine 10 mg give 1 tablet by mouth three times a day every Tuesday, Thursday, Saturday, and Sunday for hypotension hold if sys > 120 or dys > 80; Start date 01/08/25. Review of the January 2025 Medication Administration Record (MAR) revealed that the medication Midodrine was given in error a total of 38 times, in February 2025 the medication Midodrine was given in error a total of 44 times and in March 2025 the medication Midodrine was given in error a total of 35 times to Resident #95. Review of the Pharmacist Recommendations to the Nursing Staff dated 02/14/25 revealed the pharmacist noted the medication Midodrine had been administered when the systolic blood pressure was >120 on 2/1/25, 2/2/25, 2/4/25, 2/6/25, 2/8/25, 2/13/25 and 2/20/25 in relation to the Midodrine order for Tuesday, Thursday, Saturday and Sunday. The Monday, Wednesday, Friday Midodrine order was not acknowledged in the report. There were no recommendations made to nursing regarding Midodrine medication errors in January 2025 or March 2025 for Resident #95. The Consultant Pharmacist Summary dated as of 1/13/2025 provided to the facility documented, Medication errors were not noted during my review this month. The Consultant Pharmacist Summary dated as of 2/10/2025 provided to the facility documented, Medication errors were not noted during my review this month. The Consultant Pharmacist Summary dated as of 3/10/2025 provided to the facility documented, Medication errors were not noted during my review this month. A telephone interview was conducted with the facility Consultant Pharmacist on 04/01/25 at 10:18 AM. She stated she had not notified the facility that the Midodrine had been given in error in January 2025 because she had not seen a trend and didn't think that giving this medication to Resident #95 when his blood pressure was outside of the parameters was of clinical significance. She reported that she had recommended to the nursing staff on 02/14/25 that the medication had been administered in error when the systolic blood pressure was >120 but only listed a small sample of dates, just enough to show a trend, but not all the dates that the medication was given in error in February 2025. She stated she did not alert the facility that errors continued to occur in March 2025 because she had been told that the nurses had been educated (when she followed up with the facility regarding the February recommendation on March 10, 2025) and she thought the re-education would take a while. An interview was conducted with the Director of Nursing on 04/02/25 at 11:30 AM. She stated that she received the monthly pharmacy recommendations and distributed them to the Unit Manager. She noted no medication errors were documented on the monthly summary reports. She explained she had not seen the February 2025 Pharmacy Recommendation to Nursing Staff that listed a portion of the medication errors. She was not aware of any medication errors in January 2025, February 2025, or March 2025. She stated that the facility should have been notified by the pharmacist if even one medication error had been discovered during the monthly reviews. She noted she was shocked when she found out about the Midodrine medication administration errors. She was not aware of any education that had been provided to the nursing staff related to medication parameters. She stated she had not told the Consultant Pharmacist that the nursing staff had received education for this issue. An interview was conducted with the Unit Manager on 04/02/25 at 12:23 PM. She acknowledged that she received the pharmacy reports each month and acted on the recommendations. She stated she had never seen the February 2025 Pharmacy Recommendation to Nursing Staff that listed a portion of the medication errors. She explained no medication errors had been noted between January 2025 through March 2025. She stated she never told the Consultant Pharmacist that nursing staff had been educated regarding medication errors or parameters. An interview was conducted with the Staff Development Nurse on 04/02/25 at 1:23 PM. She stated she had not provided any education to the nursing staff regarding medication parameters and had not been asked to do so. She had not been aware of the medication errors prior to today. She stated she had not told the Consultant Pharmacist that education had been provided to the nursing staff regarding the administration of medication with parameters. An interview was conducted with the facility Administrator on 04/02/25 at 10:00 AM. She stated she was not aware of any medications errors that had occurred in the facility between January 2025 and March 2025. She explained because she signed off on all medication error reports and/or reprimands that occurred and would have known. She stated that she was surprised when she learned today of the number of medication errors that had occurred. She explained that the Consultant Pharmacist had documented on the monthly pharmacy summary reports for January 2025, February 2025, and March 2025 that there had been no medication errors. She stated the facility should have been made aware even if only one medication error had been discovered during the monthly pharmacy medication reviews. A telephone interview was conducted with the Medical Director on 04/03/25 at 4:36 PM. She stated she would have expected the Consultant Pharmacist to report the medication errors to the facility beginning in January 2025. She concluded that the Consultant Pharmacist should have reported any medication error to the facility when it was discovered. She noted Resident #95 had no significant outcome related to the medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, staff and Nurse Practitioner interviews, the facility failed to provide rehabilitation services per the resident's plan of care. This was for 1 of 2 residents (Resident # 93) reviewed for rehabilitation services. Findings included Review of Resident #93's hospital Discharge summary dated [DATE] indicated the resident was hospitalized from [DATE] through 3/17/25. The discharge summary indicated Resident #93 remained functionally dependent and required skilled nursing facility placement upon discharge from the hospital due to mobility and activity of daily living (bathing, dressing, and toileting) limitations. Physical and occupational therapy was recommended to continue at the skilled nursing facility with possible transition to long-term care. The discharge summary indicated it was important that Resident #93 continued with range of motion exercises. Resident #93 was admitted to the facility on [DATE] with diagnoses of sacral pressure ulcer and stroke. Resident #93's physician orders revealed orders dated 3/17/25 for speech, occupational and physical therapy to evaluate and treat as indicated. A therapy screening form dated 3/18/25 completed by the Rehabilitation Director revealed the reason for the screen was admission to the facility. The form was not completed and the justification for no evaluation indicated Resident #93 was total care, required a mechanical lift for transfers and needed a PRAFO boot before therapy. The form indicated the facility was in the process of obtaining the PRAFO boot. Resident #93's physician orders revealed no order for a PRAFO boot (Pressure Reduction Ankle Foot Orthosis used to manage ankle/foot anomalies by keeping the ankle and foot aligned and relieves pressure off the heel) to be applied to resident's left lower extremity. A Nurse Practitioner note dated 3/18/25 indicated physical and occupational therapy was consulted in the hospital and recommendation was written in the discharge summary for skilled nursing due to activity of daily living limitations and sacral wound. Physical and occupation therapy was recommended with possible transition to long-term care, however the resident reported she would like to return home to family. On assessment Resident #93 was in the room with family members who confirmed the resident would be returning home. The assessment and plan indicated that Resident #93 was to receive physical and occupational therapy to address mobility and activities of daily living with the goal of returning home with family. Resident #93's care plan dated 3/18/25 indicated the resident required assistance with activities of daily living related to stroke with right sided weakness, impaired mobility, and history of an ankle fracture. Interventions included to provide assistance with activities of daily living tasks and therapy as ordered. Resident #93's admission Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact with no rejection of care. Resident #93 required extensive to total assistance with activities of daily living. Resident #93 did not receive occupational, physical or speech therapy services since admission. A physician progress note dated 3/24/25 at 12:37 PM indicated Resident #93 had a history of a left ankle fracture and underwent surgery approximately 2 years ago. The physician note indicated Resident #93 needed to start putting weight on the left ankle since now she had decreased strength and movement in her lower extremity. The physician's assessment indicated Resident #93 had decreased strength and movement in the right upper and lower extremities. An interview was conducted with Resident #93 on 3/31/25 at 2:41 PM. Resident #93 stated she was still waiting to get on therapy services, and she did not know why she could not receive therapy. Resident #93 stated she thought she was supposed to receive therapy services, and she wanted to work with therapy to improve her mobility. An interview was conducted with Nurse #4 on 4/2/25 at 9:30 AM. Nurse #4 was assigned to Resident #93 on the day shift from 7:00 AM to 3:00 PM Monday through Friday. Nurse #4 indicated that residents were usually evaluated by therapy when they were admitted to the facility. Nurse #4 stated she did not know whether Resident #93 had been evaluated by therapy or if she was receiving therapy or not. An interview was conducted with the Therapy Director on 4/2/25 at 1:05 PM. The Therapy Director stated Resident #93 was screened by therapy and was determined to require total assistance with all activities of daily living and therefore was not a priority to receive therapy services. The Therapy Director stated they were waiting to obtain a PRAFO boot for the resident due to the resident's history of an ankle fracture. The Therapy Director stated Resident #93 was required to pay for part of the cost of the PRAFO boot. The Therapy Director stated he spoke with the resident regarding her portion of the cost of the PRAFO boot and Resident #93 stated she was not financially able to do so. The Therapy Director stated Resident #93 was not able to receive therapy services until she was able to pay for the PRAFO. The Therapy Director stated that he was working on recoding the information to submit to the insurance copy for the PRAFO boot however these things can take a while. The Therapy Director was unable to explain why Resident #93 could not receive occupational therapy services that concentrated on upper body movement until the PRAFO boot for the lower body was obtained. A follow up interview with the Therapy Director on 4/2/25 at 2:50 PM revealed he was aware that physical therapy and occupational therapy were recommended by the hospital and by the medical providers however the resident was not able to receive therapy services until she had the PRAFO boot. An interview with the Nurse Practitioner on 4/3/25 at 3:00 PM revealed that Resident #93 was admitted with orders for physical, occupational and speech therapy. The Nurse Practitioner indicated that the expectation was that the facility evaluated residents with orders for therapy services. The Nurse Practitioner stated there was not an order for the PRAFO boot and it was not required for participation in therapy. An interview was conducted with the Administrator on 4/3/25 at 8:15 AM. The Administrator stated the facility had an influx of new admissions all at once that were truly here for short-term rehabilitation. The Administrator stated she understood, from a prior admission to the facility, that Resident #93 was admitted for long-term care and therapy services were not started upon admission due to not being a short-term patient. The Administrator indicated the facility did not require the resident to pay for the PRAFO boot but the facility preferred that she or her insurance paid for the equipment, rather than the facility. The Administrator stated she was not aware that the resident was asked to pay for the PRAFO boot and did not know why the Therapy Director indicated that the resident was responsible for it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #17 was admitted to the facility on [DATE] with diagnosis including congestive heart failure and chronic kidney disease. A physician's order dated 3/1/25 for Resident #17 was to obtain daily weights due to congestive heart failure. Review of the Medication Administration Record (MAR) dated March 2025 for Resident #17 revealed the following weights recorded: 3/01/25 weight 318.6 pounds (lbs.) documented by Nurse #7 3/02/25 weight 318.6 lbs. documented by Nurse #7 3/08/25 weight 292 lbs. documented by Nurse #7 3/09/25 weight 292 lbs. documented by Nurse #7 3/15/25 weight 292 lbs. documented by Nurse #7 3/16/25 weight 292 lbs. documented by Nurse #7 3/17/25 weight 292 lbs. documented by Nurse #7 3/22/25 weight 292 lbs. documented by Nurse #7 3/23/25 weight 292 lbs. documented by Nurse #7 During a phone interview on 04/03/25 at 1:19 PM Nurse #7 stated that when she recorded Resident#17's weights on the Medication Administration Record (MAR) she used the previous weight that she found in the medical record. She stated that she did not obtain the daily weights that she recorded on the MAR from 3/01/25 through 3/23/25. She stated she had not obtained any weights on Resident #17 because she was not sure how the Restorative Aide obtained Resident #17's weight and whether the Restorative Aide used the wheelchair or the mechanical lift to get the weight. She stated she knew that was wrong and she should have obtained the weight and documented accurate weights. An interview was conducted on 04/03/25 at 3:33 PM with the Director of Nursing (DON) along with the Administrator. The DON and Administrator both stated that Nurse #7 should have obtained the daily weights and recorded accurate weights in Resident #17's medical record. Based on record review, and staff and Physician interviews, the facility failed to maintain a complete medical record by 1.) not documenting a pulse (heart rate) prior to the administration of the medication for a resident with an order for hydralazine, a medication to treat high blood pressure, with a parameter to hold the medication for a heart rate less than 60 beats per minute (Resident #24). 2.) maintain an accurate medical record for weight monitoring (Resident #17). This was observed for 2 of 6 residents whose medical record was reviewed. Findings included: 1.) Resident #24 was admitted to the facility on [DATE] with diagnoses which included stroke and hypertension. Resident #24's physician orders revealed an order entered by the Director of Nursing (DON) dated 3/4/25 for hydralazine 25 milligrams (mg) every 8 hours for hypertension. Hold the medication for systolic blood pressure (the top number in the blood pressure) less than 100 or diastolic blood pressure (the bottom number) less than 50 or heart rate less than 60. Resident #24's electronic Medication Administration Record (eMAR) revealed that the entries for hydralazine 25 mg three times per day at 6:00 AM, 2:00 PM and 10:00 PM with the parameter to hold for systolic blood pressure less than 100 or diastolic blood pressure less than 50 or heart rate less than 60 were electronically signed as given. The blood pressure was recorded for each dose administered. The record revealed there was no pulse or heart rate recorded. Review of Resident #24's electronic health record revealed there were no pulse or heart rate results recorded at 6:00 AM, 2:00 PM or 10:00 PM in the vital sign record for March 2024. An interview was conducted with Nurse #5 on 4/2/25 at 10:20 AM. Nurse #5 reviewed the order for hydralazine and the parameters to hold the medication. Nurse #5 stated that the computer required blood pressure to be recorded but a pulse was not required when documenting the administration of the medication hydralazine. Nurse #5 stated that it was an error when the order for hydralazine was entered that it did not require the pulse to be documented. Nurse #5 stated that she used an automatic blood pressure cuff to obtain a blood pressure prior to administering Resident #24's hydralazine and that the cuff also displayed a pulse. Nurse #5 stated she checked the blood pressure and pulse prior to administering the medication per order but there wasn't a place on the eMAR to record the pulse. An interview was conducted with Nurse #9 on 4/2/25 at 4:30 PM. Nurse #9 stated she was assigned to Resident #24 from 3:00 PM to 11:00 PM Monday through Friday. Nurse #9 reviewed the order for hydralazine and the parameters to hold the medication. Nurse #9 stated that the order did not require the pulse (heart rate) to be recorded but she obtained a pulse prior to administering the medication. Nurse #9 stated it was an error that the order did not require the pulse to be documented. An interview was conducted with Nurse #8 on 4/3/25 at 10:35 AM. Nurse #8 stated she was assigned to Resident #24 from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. Nurse #8 stated she checked Resident #24's pulse (heart rate) prior to administering the hydralazine but she did not record it. The eMAR did not require that a pulse be recorded but she obtained it prior to administering the medication. Nurse #8 stated she was aware there was a parameter for holding the medication based on the pulse reading. Nurse #8 stated that the pulse should have been recorded but she did not correct the documentation or ask anyone about correcting it. An interview was conducted with Nurse #7 on 4/3/25 at 12:35 PM. Nurse #7 stated that she was a nurse that worked Saturdays and Sundays from 7:00 AM to 7:00 PM. Nurse #7 indicated she recalled administering Resident #24's hydralazine as ordered and was aware there were parameters for holding the medication based on the blood pressure and pulse readings. Nurse #7 stated she obtained a pulse prior to administering Resident #24's hydralazine after checking to ensure that it was within the parameter. Nurse #7 stated the eMAR did not require the pulse to be recorded and she had not asked anyone about correcting it. Attempts were made on 4/2/25 and 4/3/25 to interview Nurse #3 with messages left and no return call received. Nurse #3 was assigned to Resident #24 on Saturdays and Sundays from 7:00 AM to 3:00 PM. An interview with the Director of Nursing and Administrator on 4/3/25 at 2:50 PM revealed that they expected that medication orders would be transcribed correctly and would be documented appropriately. The DON stated it was an error when she transcribed the order for hydralazine that she did not enter the requirement to record the pulse or heart rate when the medication was administered. An interview with the Nurse Practitioner on 4/3/25 at 3:00 PM revealed that when an order had parameters to hold a medication for a blood pressure or pulse reading, the readings obtained prior to administering the medication should be recorded. The Nurse Practitioner stated that the pulse not being recorded prior to administering Resident #24's hydralazine was an error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Registered Dietitian, Wound Care Physician, and the Medical Director's interviews the facility failed to 1a.) implement treatment orders on admission and provide daily wound treatments as ordered for a resident (Resident#17) with a chronic venous wound on the left lower extremity. b.) obtain daily weights as ordered for Resident #17 who had a diagnosis of congestive heart failure and on fluid restrictions. 2a.) provide treatments as ordered for a resident with arterial ulcers (Resident #24). b.) obtain weekly weights as ordered for Resident #24 with edema, fluid retention and an elevated Brain Natriuretic Peptide (BNP) level ( a blood test used to monitor fluid volume status that when elevated is a strong indicator of heart or kidney failure or infection) and required close monitoring and treatment with a diuretic, a medication used to remove excess fluid. 3.) provide daily wound treatments to non pressure related wounds (Resident #93). This occurred for 3 of 7 residents who were reviewed for wound care and weight monitoring (Resident #17, Resident #24, Resident #93). Findings included. 1a.) Resident #17 was admitted to the facility on [DATE] with diagnosis including congestive heart failure, diabetes, and chronic venous wound (sores caused by blood circulation problems that damage your veins) to the left lower extremity. A care plan dated 1/3/25 revealed Resident #17 had skin alteration related to a venous stasis ulcer of the lower extremity. Interventions included to evaluate the wound for size, depth, margins, exudate (discharge) , edema, granulation (pink-red moist tissue that fills an open wound, when it starts to heal), and infection. Document the progress of wound healing on an ongoing basis. Notify the physician as indicated. Observe for signs of infection and provide treatments as ordered. Review of Resident #17's admission skin assessment dated [DATE] documented by Nurse #4 revealed venous statis ulcer to the front left lower extremity. There was no assessment of the wound to include wound size, depth, exudate, edema, or granulation. There was no wound treatment initiated on 1/3/25. During a phone interview on 4/10/25 at 2:15 PM Nurse #4 stated she was the admission nurse on 1/3/25 and completed an initial skin assessment on Resident #17. She stated a venous ulcer was observed on the front left lower extremity, the area was nickel size and looked like a blister that had ruptured and dried. She stated there was no drainage and Resident #17 had no dressing on the area when she was admitted . She stated since the area appeared dry with no drainage and no dressing she did not initiate any type of wound treatment. She indicated she did not recall seeing any other wounds on the left lower extremity. A physicians order for Resident #17 was initiated on 1/8/25 for calcium alginate with silver to the left lower leg daily for wound care. Cleanse the area with normal saline, apply calcium alginate with silver, apply gauze pads, and wrap with kerlix. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #17 was cognitively intact. She had a venous wound to the left lower extremity. She had no rejection of care. The Wound Care Physician's initial evaluation dated 1/9/25 revealed Resident #17 was evaluated for venous wound of the left lower lateral calf full thickness. The wound size measured 8.7 centimeters (cm) x 6.5 cm x 0.4 cm (depth). The surface area measured 56.55 cm, with 70% granulation tissue, and heavy serosanguinous exudate (wound drainage that is a combination of serous fluid and blood). The wound was noted to be present on admission. The initial weekly wound evaluation that was completed by the Treatment Nurse was dated 1/10/25. The wound description with measurements were the same as the Wound Care Physician's evaluation on 1/9/25. Review of the Treatment Administration Record (TAR) for Resident #17 dated January 2025 revealed calcium alginate with silver to left lower leg daily for wound care with a start date of 1/8/25. Cleanse the area with normal saline, apply calcium alginate with silver, apply gauze pads, and wrap with kerlix. Scheduled for administration between 7:00 AM until 3:00 PM and was not signed off as administered on the following dates: There was no treatment order implemented to the left lower extremity from 1/3/25 through 1/8/25. 1/10/25: not signed as administered, the assigned nurse was Nurse #4 1/11/25: not signed as administered, the assigned nurse was Nurse #5 1/14/25: not signed as administered, the assigned nurse was Nurse #4 1/17/25: not signed as administered, the assigned nurse was Nurse #2 1/24/25: not signed as administered, the assigned nurse was Nurse #2 During an interview on 04/03/25 at 10:16 AM Nurse #2 the assigned nurse on 1/17/25, and 1/24/25 stated she was routinely assigned to provide care for Resident #17. She stated she did not do daily wound care, and she thought the Treatment Nurse was responsible for wound care. She reported she had completed the dressing change on Resident #17's lower extremity at times and signed off on the TAR on the days she did the wound treatments. She stated that if she did not sign off on the TAR then she did not do the wound care because she thought the wound nurse had done the treatment. During a phone interview on 4/10/25 at 2:15 PM Nurse #4 stated if she did not sign off on the TAR then she did not complete the treatment. She stated the wound nurse was responsible for the treatments. During a phone interview on 4/10/25 at 3:05 PM Nurse #5 stated she was assigned to Resident #17 on 1/11/25 but it was a Saturday. She reported on weekends there was a treatment aide that completed wound care. During a phone interview on 4/10/25 at 4:30 the weekend Treatment Aide stated she called out on 1/11/25 so it would have been the nurses responsibility to complete the wound care. Review of the Treatment Administration Record (TAR) for Resident #17 dated February 2025 revealed Calcium alginate with silver to left lower leg daily for wound care. Cleanse the area with normal saline, apply calcium alginate with silver, apply gauze pads, and wrap with kerlix. Scheduled for administration between 7:00 AM until 3:00 PM and was not signed off as administered on the following dates: 2/07/25: not signed as administered, the assigned nurse was Nurse #2 2/14/25: not signed as administered, the assigned nurse was Nurse #2 2/19/25: not signed as administered, the assigned nurse was Nurse #2 2/21/25: not signed as administered, the assigned nurse was Nurse #2 2/28/25: not signed as administered, the assigned nurse was Nurse #10 During an interview on 04/03/25 at 10:16 AM Nurse #2 stated she was the assigned nurse on the February dates listed but thought the treatment nurse completed the wound care. An attempt was made to contact Nurse #10 on 4/10/25 at 4:50 PM, there was no response. Record review revealed Resident #17 was hospitalized on [DATE] due to congestive heart failure and unrelated to wound care. She readmitted to the facility on [DATE]. There was no treatment order implemented to the left lower extremity from 2/28/25 through 3/7/25. Review of the Treatment Administration Record (TAR) for Resident #17 dated March 2025 revealed calcium alginate with silver to left lower leg daily for wound care with a start date of 3/7/25. Cleanse the area with normal saline, apply calcium alginate with silver, apply gauze pads, and wrap with kerlix. Scheduled for administration between 7:00 AM until 3:00 PM and was not signed off as administered on the following dates: 3/10/24: not signed as administered, the assigned nurse was Nurse #2 3/11/25: not signed as administered, the assigned nurse was Nurse #2 3/12/25: not signed as administered, the assigned nurse was Nurse #2 3/14/25: not signed as administered, the assigned nurse was Nurse #2 3/25/25: not signed as administered, the assigned nurse was Nurse #2 3/27/25: not signed as administered, the assigned nurse was Nurse #2 3/28/25: not signed as administered, the assigned nurse was Nurse #2 3/30/25: not signed as administered, the assigned nurse was Nurse #7 3/31/25: not signed as administered, the assigned nurse was Nurse #2 During an interview on 04/03/25 at 10:16 AM Nurse #2 stated she was the assigned nurse on the March dates listed but thought the treatment nurse completed the wound care. During a phone interview on 04/03/25 at 12:04 PM Nurse #7 stated she did provide wound care to Resident #17 at times. She indicated that if she did not sign off on the TAR then she did not do the treatment. She stated the wound nurse also provided the wound treatments. She stated if she did not do the treatment at any time then she must have thought the wound nurse did the treatment. Review of the Treatment Administration Record (TAR) for Resident #17 dated April 2025 revealed calcium alginate with silver to left lower leg daily for wound care with a start date of 3/7/25. Cleanse the area with normal saline, apply calcium alginate with silver, apply gauze pads, and wrap with kerlix. Scheduled for administration between 7:00 AM until 3:00 PM and was not signed off as administered on the following dates: 4/02/25: not signed as administered, the assigned nurse was Nurse #2 4/05/25: not signed as administered, assigned to the weekend Treatment Aide 4/06/25: not administered, signed with chart code number 8 by Nurse #7 During an interview on 04/03/25 at 10:16 AM Nurse #2 stated she was the assigned nurse on 4/02/25 but thought the treatment nurse completed the wound care. During a phone interview on 04/10/25 at 4:20 PM Nurse #7 stated the Treatment Aide was responsible for wound care on 4/5/25 so she did not complete it. She stated she attempted to provide wound care on 4/6/25 but Resident #17 refused at that time. She indicated she did not attempt to try again at a later time. During a phone interview on 4/10/25 at 4:30 PM the weekend Treatment Aide stated she left early on 4/5/25 and she did not do the treatment. She stated it would have been the nurses responsibility to complete the wound care. The most recent Wound Care Physicians note dated 4/3/25 documented Resident #17 with chronic venous wound of the left, lower, lateral calf. The wound was evaluated as a candidate for wound treatment using a skin substitute. This wound had been present for greater than 385 days and had failed to respond appropriately for over 30 days despite standard management. Management has included compression using two-layer compression wraps, pillow elevation, and pressure off-loading boots, elevation, and management of any significant comorbid arterial vascular disease. Compliance to treatment regimen has been observed. The wound has no signs of infection or osteomyelitis. Review of the progress notes from 1/3/25 through 4/6/25 revealed no additional documentation that wound care was completed for Resident #17. An interview was conducted on 4/3/25 at 2:00 PM with Resident #17. She was alert and oriented to person, place, and situation. She stated she received wound care but not every day. She stated she would not refuse wound care. An interview was conducted on 4/3/25 at 1:30 PM with the Wound Treatment Nurse. She stated she was not in the facility daily; she had resigned and was working out her notice. She stated she was only in the facility 2-3 days per week and when she was not here the assigned nurse was responsible for the wound care. She stated there was a second nurse who did wound care at times unless she had a resident assignment, and a treatment aide did wound care some weekends. She stated some days she may be in the facility for charting and not doing wound care and the nurse would be responsible. She stated Resident #17 admitted [DATE] and the admission nurse (Nurse #4) completed the initial skin assessment. She stated the Wound Care Physician evaluated Resident #17 on 1/9/25. The first documented assessment with a wound description and measurements following admission in January completed by her as the wound nurse was on 1/10/25. She acknowledged that treatment orders to the left lower extremity venous wound were not initiated until 1/8/25 which was 5 days after admission. She indicated she was not working on the days following admission and could not say why no treatment was started. She stated she assumed the nurses were doing the wound care. When asked who ordered the treatment on 1/8/25 she stated Resident #17 admitted from another nursing facility and the order was from the admission orders. She stated Resident #17 was hospitalized [DATE] and returned to the facility 2/28/25 but stated she was not working on 2/28/25 and did not implement the treatment order when she readmitted because that would have been the admission nurse. She did not say why the treatment order was not started until 3/7/25 which was 7 days after readmission to the facility. She stated if she had completed the treatment it would be signed off on the TAR. During a phone interview on 4/10/25 at 3:00 PM the Wound Care Physician stated she was in the facility weekly on Thursdays. She stated she knew Resident #17 from her previous facility and managed her wound care at the previous facility. She stated she was aware of the transfer and last evaluated her at the other facility on 12/31/24 and on that day the wound measured 8.7 centimeters (cm) x 6.2 cm x 0.4 cm, and it was present on admission on [DATE]. She stated she had spoken with the Wound Treatment Nurse and had given her the treatment orders prior to admission so the treatment with calcium alginate would start on 1/3/25. She stated she was not aware that the treatment order was not started on 1/3/25 or that the daily treatments were not being done consistently. She was not aware that the treatment was not started back until 3/7/25 following hospitalization and readmission on [DATE]. She reported the wound had been getting smaller each week until recently. She evaluated the wound today and stated it looked okay, but it has looked better, and it had progressed and was larger this week measuring 4.2 cm x 2.1 cm x 0.2 cm. She stated not completing daily treatments as ordered would cause this wound to deteriorate and it had worsened this week. An interview was conducted on 04/03/25 at 4:00 PM with the Director of Nursing (DON) along with Administrator. The DON stated the treatment nurses were responsible for wound care when here, otherwise the assigned nurse was responsible. She stated either the treatment nurse or the assigned nurse was responsible for completing an initial assessment that included a wound description with measurements on admission and document the assessment in the medical record and ensuring treatment orders were implemented. She stated the current treatment nurse only worked part time, but they had hired a new treatment nurse who was in training. The DON stated she was not aware the daily treatments were not getting done. Both the Administrator and DON stated wound care should have been completed daily as ordered. The Administrator stated education would be provided. During a phone interview on 04/03/25 at 5:11 PM the Medical Director stated Resident #17 had multiple comorbidities and her wounds were managed by the Wound Care Physician. She stated she expected the treatment orders to be implemented and followed. During an interview on 4/10/25 at 5:00 PM the Director of Nursing stated she was not aware that there was a delay in starting the treatment orders on admission 1/3/25 or on readmission 2/28/25. She stated they were working to resolve the issue with wound care and indicated the new wound nurse would be starting soon. 1b.) A care plan dated 1/10/25 revealed Resident #17 was at risk for impaired cardiovascular status related to congestive heart failure (CHF). Interventions included to monitor weights and report any significant changes. A physician's order dated 2/26/25 for Resident #17 to maintain 1500 milliliter fluid restrictions per shift: 720 milliliters from dietary, and 780 milliliters from nursing for chronic systolic and diastolic congestive heart failure. A physicians order dated 3/1/25 for Resident #17 was to obtain daily weights due to congestive heart failure. Review of the Medication Administration Record (MAR) dated March 2025 for Resident #17 revealed the following weights recorded: 3/01/25 weight 318.6 pounds (lbs.) documented by Nurse #7 3/02/25 weight 318.6 lbs. documented by Nurse #7 3/08/25 weight 292 lbs. documented by Nurse #7 3/09/25 weight 292 lbs. documented by Nurse #7 3/15/25 weight 292 lbs. documented by Nurse #7 3/16/25 weight 292 lbs. documented by Nurse #7 3/17/25 weight 292 lbs. documented by Nurse #7 3/22/25 weight 292 lbs. documented by Nurse #7 3/23/25 weight 292 lbs. documented by Nurse #7 Further review of Resident #17's electronic medical record revealed the following weight recorded that was not included on the MAR. 3/6/2025 weight 295.6 lbs. documented by the Restorative Aide. The physicians order dated 3/1/25 for Resident #17 to obtain daily weights due to congestive heart failure was discontinued on 3/25/25. Review of Resident #17's progress notes from 3/1/25 through 3/25/25 revealed no other daily weights recorded. During an interview on 04/03/25 at 9:59 AM the Registered Dietitian stated the facility process for obtaining weights was that after the weekly weight meeting the Director of Nursing (DON) gave her a copy of the current weight orders and then sent the orders out to the staff. She stated the Restorative Aide was the primary staff member who was assigned to obtain the weights. She indicated Resident #17 was to receive daily weights due to congestive heart failure and that the weight orders should be followed. During an interview on 04/03/25 at 10:35 AM the Restorative Aide stated that she was responsible for obtaining all resident weights. She stated she attended the weekly care plan meetings. During the weekly meetings, the DON will give her a list to let her know what the weight orders were, and which residents needed daily or weekly weights. She stated she was also assigned as a nurse aide on the floor some days and assigned to transport residents to appointments at times which made it difficult to do weights and she was unable to gets the weights done at times. During a phone interview on 04/03/25 at 1:19 PM Nurse #7 stated that when she recorded Resident#17's weights on the Medication Administration Record MAR) she used the previous weight that she found in the medical record. She stated that she did not obtain the daily weights that she recorded on the MAR from 3/01/25 through 3/23/25. She stated she had not obtained any weights on Resident #17 because she was not sure how the Restorative Aide obtained Resident #17's weight and whether the Restorative Aide used the wheelchair or the mechanical lift to get the weight. She stated she knew that was wrong and she should have obtained the weight and documented accurate weights. During an interview on 04/03/25 at 2:00 PM Nurse #2 stated she was routinely assigned to Resident #17. She stated the Restorative Aide was responsible for obtaining the weights. She indicated she had not obtained weights on Resident #17. An interview was conducted on 04/03/25 at 3:33 PM with the Director of Nursing (DON) along with the Administrator. The DON stated the Restorative Aide was responsible for obtaining weights. She stated the Restorative Aide attended the weekly weight meetings and she was given a list of residents that needed daily or weekly weights. She indicated that if the Restorative Aide was not available to get the daily weight for a resident the assigned nurse was responsible for getting the weights. She stated the physicians orders should be followed, and they would review their process for obtaining weights and provide staff education. During a phone interview on 04/03/25 at 5:11 PM the Physician stated Resident #17 was ordered daily weights due to congestive heart failure to monitor fluid retention which was an indicator of worsening heart failure. She had bilateral lower extremity edema and received diuretics. She stated the goal of care was to keep her asymptomatic. She indicated there had been no change in condition reported to her and Resident #17 has remained asymptomatic. She stated she expected the daily weights to be completed according to the order. 2a.) Resident #24 was admitted on [DATE] with diagnosis which included stroke, failure to thrive, peripheral artery disease, and diabetes. Resident #24 was discharged to the hospital on 2/18/25 and readmitted on [DATE] following a left above knee amputation. The hospital Discharge summary dated [DATE] indicated that Resident #24 had osteomyelitis (an infection of the bone tissue) of the left foot and underwent left above knee amputation. Resident #24's discharge summary indicated a diagnosis of right foot chronic osteomyelitis and required continued treatment with betadine to the wounds on the right foot. Resident #24's care plan dated 3/3/25 included a 3/3/25 care plan of resident had actual impairment to the skin integrity with osteomyelitis of the right foot with arterial wounds (wounds or ulcers caused by poor circulation) to the right foot and heel with treatment in between the toes on the right foot. The goal indicated Resident #24 will maintain or develop intact skin by next review. Interventions indicated providing treatment as ordered. Physician orders dated 3/7/25 for Resident #24 indicated: -Apply betadine to right 2nd toe and right lateral distal foot (the outer edge of the foot from the heel to the little toe) topically every day shift for wound care and wrap with gauze. -Apply calcium alginate in between the right toes every day shift for wound care. -Apply betadine to the right heel and wrap with gauze every day shift. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] indicated the resident had mild cognitive impairment with no episodes of rejection of care. Resident #24 had 2 venous and arterial ulcers, had an infection of the foot, and had application of ointments/medications other than to the feet and application of dressing to the feet. Resident #24's Treatment Administration Record (TAR) revealed no documentation of the application of betadine to the right 2nd toe, right lateral distal foot, and right heel or application of the calcium alginate between the toes on 3/10/25, 3/11/25, 3/14/25, 3/27/25, 3/27/25 and 3/31/25. The facility's daily assignment sheet for 3/10/25, 3/11/25, 3/14/25, 3/25/25, 3/27/25 and 3/31/25 revealed there was no assigned treatment nurse. An interview was conducted with Nurse #5 on 4/2/25 at 10:15 AM. Nurse #5 stated she was assigned to Resident #24 regularly and was familiar with her care. Nurse #5 verified that she was assigned to Resident #24 on 3/10/25, 3/11/25, 3/14/25, 3/27/25 and 3/31/25. Nurse #5 stated there was a Wound Care Nurse who was supposed to complete the wound care treatments however she had recently resigned and had decreased her hours that she worked. Nurse #5 stated the floor nurses were often required to complete the ordered wound care treatments. Nurse #5 stated it was hard to administer the residents' ordered medications and complete the ordered wound care treatments. Nurse #5 indicated that wound care treatments on the electronic TAR that were not electronically signed as completed were not done. Nurse #5 stated the days that she was assigned to Resident #24 that she did not electronically sign the TAR for the ordered wound care treatments indicated that she did not complete the ordered care. A wound care observation was conducted for Resident #24 with the Wound Care Nurse on 4/2/25 at 2:00 PM. The wound care to Resident #24's foot was completed as ordered and the wounds did not have any signs of infection and the skin surrounding the wounds did not have any redness. An interview was conducted with the Wound Care Nurse on 4/2/25 at 3:00 PM. The Wound Care Nurse stated she had turned in her resignation and was only working part time until her last day. The Wound Care Nurse indicated that the floor nurses were responsible for completing the ordered wound care when she was not working and there was not an assigned treatment nurse. The Wound Care Nurse stated she was not aware of any problems with wound care not being completed on the days that she was not working, and she did not review the TARs for completion of the ordered treatments. An interview was conducted with the Director of Nursing (DON) and Administrator on 4/3/25 at 2:50 PM. The DON and Administrator indicated that the Wound Care Nurse had turned in her resignation in January but had agreed to continue to work a few days per week until a replacement could be hired. The DON and Administrator stated that when a wound care nurse was not scheduled, it was the responsibility of the floor nurse to complete the ordered wound care treatments. The DON and Administrator indicated that they expected wound care to be completed as ordered. The DON stated she did not review the TARs and was not aware of any problems with the completion of the daily wound care treatments. An interview was conducted with the Nurse Practitioner on 4/3/25 at 3:45 PM. The NP indicated that she expected wound care to be completed as ordered. The NP stated that Resident #24 was severely debilitated with multiple risk factors, and this made it even more important for wound care to be completed as ordered. 2b.) Review of Resident #24's hospital Discharge summary dated [DATE] indicated resident's weight upon discharge was 161 pounds (lb.). Review of Resident #24's weights listed in the electronic health record revealed: 2/3/25 157 pounds (lb.) (Weight prior to hospitalization and amputation) 3/5/25 184.7 lb. recorded by the Director of Nursing (DON) 3/14/25 164.7 lb. recorded by the DON 3/20/25 No weight was recorded 3/21/25 No weight was recorded 3/28/25 No weight was recorded Review of a Patient at Risk/Standard of Care progress note dated 3/6/2025 at 4:03 PM written by the Assistant Director of Nursing revealed that the interdisciplinary team met and reviewed Resident #24 for weight monitoring with the Registered Dietitian present. Resident#24 had a significant weight gain of 27.7 pounds. A re-weight was conducted. Resident #24 had an above knee amputation during recent hospitalization with all over body swelling at this time. The note indicated weight loss was expected due to the amputation. Resident continues to receive tube feeding as ordered. Tube feeding will be adjusted as needed and Resident #24 will be monitored for weight fluctuations. Review of Resident #24's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact, weighed 185 lb. with no weight loss and weight gain not on a physician prescribed weight gain regimen. Resident #24's physician orders indicated an order dated 3/10/25 indicated give furosemide, a potent diuretic medication that removes excess fluid used to treat conditions such as hypertension, heart failure and fluid retention causing edema 20 milligrams (mg) give 3 tablets via gastrostomy tube STAT (as soon as possible) for elevated BNP level (Brain Natriuretic Peptide, a blood test that measures a hormone in the blood released when the heart is under stress such as from heart or kidney failure or infection) . A 3/11/25 Nurse Practitioner progress note indicated Resident #24 was evaluated due to an elevated BNP level of 15, 751. Resident #24's physician orders indicated an order dated 3/11/25 for furosemide 40 milligrams (mg) twice per day via gastrostomy tube for 5 days for edema (the condition characterized by swelling with abnormal accumulation of fluid in the body's tissues). The order was discontinued on 3/13/25. A 3/13/25 Nurse Practitioner progress note indicated Resident #24 was evaluated due to edema with weight gain and elevated BNP level of 12, 383. The plan indicated Resident #24 was to receive furosemide 40 milligrams twice per day until 3/20/25. The note indicated Resident #24 was to be monitored for respiratory distress, crackles in the lungs or wheezing and contact the provider if needed. Resident #24's physician orders indicated an order dated 3/13/25 for furosemide 40 mg. twice per day for 7 days for edema. Review of Resident #24's care plan last revised on 3/17/25 indicated a care plan for altered cardiovascular status related to diagnoses of hypertension and peripheral vascular disease. The interventions included obtain weights as ordered and monitoring for increased edema. A 3/20/25 Nurse Practitioner progress note revealed Resident #24 had decreased edema. The assessment and plan indicated that daily weights with the first one now were to be obtained due to an elevated BNP. Review of Resident #24's weights listed in the electronic health record revealed: 3/20/25 No weight was recorded. A Registered Dietitian (RD) nutrition progress note dated 3/21/25 at 11:55 AM indicated that Resident # 24 was reviewed due to a weight warning with a current weight of 164.7 Lb. The note indicated Resident #24 was readmitted after an above knee amputation and had significant edema. Resident's edema was improving with weight trending back to baseline. The plan indicated to continue to monitor weights weekly. Review of Resident #24's physician orders revealed an order dated 3/21/25 for weights per policy. Review of Resident #24's weights listed in the electronic health record revealed: 3/21/25 No weight was recorded 3/28/25 No weight was recorded An interview was conducted with the Administrator on 4/3/25 at 9:00 AM. The Administrator stated that weights were to be obtained weekly for 4 weeks following admission or readmission. After the 4 weeks, then weights were to be obtained monthly or as ordered by the physician. The Administrator indicated that weights were to be obtained as ordered and documented in the electronic health record. An interview was conducted with the Registered Dietitian (RD) on 4/3/25 at 10:00 AM. The RD stated that new admissions and readmissions were to be weighed as close to the admission or readmission date as possible and then weekly for 4 weeks. The RD indicated Resident #24 had weights recorded twice since readmission on [DATE] and she should have been weighed weekly for 4 weeks. The RD indicated it was important to have accurate weights, to obtain weights timely and according to the provider's recommendations. The RD indicated that weights were a clinical indicator and were important for monitoring the resident's condition. The RD stated that Resident #24 had an elevated BNP and had changes to her diuretic order and weights were necessary for monitoring her condition. The RD stated she was not aware that the provider requested daily weights on 3/20/25 but the weights should have been obtained per the provider's recommendation. An interview was conducted with the Restorative Nursing Assistant (NA) on 4/3/25 at 10:40 AM. Restorative NA indicated she was responsible for obtaining all resident weights. Restorative NA stated she was assigned to work as an NA on the floor at times and she went to appointments with residents at times, so it was difficult to obtain all the weights. Restorative NA stated there was not a backup system to ensure that weights were obtained as required. Restorative NA indicated there was not a system to ensure that she was informed of admissions and readmissions and to track the resident weights for the first 4 weeks following admission. Restorative NA stated she looked on the hallways and if she saw a new admission or readmission, then she obtained the weight. Restorative NA stated that all residents were to be weighed weekly for 4 weeks and then as ordered. Restorative NA stated when

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Physician, and the Consultant Pharmacist interviews, the facility failed to hold the medication Midodrine when Resident #95 's systolic blood pressure was above 120 mm Hg (millimeters of mercury) or give the medication when the systolic blood pressure was less than 120 mm Hg. Resident #95 experienced no significant outcome. This occurred for 1 of 1 resident reviewed for medication administration. Findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses that included hypotension. Record review revealed the following active orders: Midodrine 10 MG (milligrams) give 1 tablet by mouth one time a day every Monday, Wednesday, Friday for hypotension hold if sys (systolic) > (greater than) 120 or dys (diastolic) > 80; Start date 01/08/25. Midodrine 10 MG (milligrams) give 1 tablet by mouth three times a day every Tuesday, Thursday, Saturday, and Sunday for hypotension hold if sys > 120 or dys > 80; Start date 01/08/25. Review of the Medication Administration Records revealed Resident #95 received 10 MG of Midodrine with a blood pressure reading > 120 mm Hg and did not receive Midodrine with a blood pressure reading < 120 mm Hg on Monday, Wednesday, and Friday on the following dates: 01/08/25 at 7:30 AM blood pressure 118/61 mm Hg, 10 mg of Midodrine was held by Medication Aide (MA) #1 01/08/25 at 7:30 AM blood pressure 114/55 mm Hg, 10 mg of Midodrine was held by MA #1 01/13/25 at 7:30 AM blood pressure 113/51 mm Hg, 10 mg of Midodrine was held by MA #1 01/15/25 at 7:30 AM blood pressure 153/74 mm Hg, 10 mg of Midodrine was given by MA #1 01/17/25 at 7:30 AM blood pressure 131/65 mm Hg, 10 mg of Midodrine was given by MA #1 01/22/25 at 7:30 AM blood pressure 136/72 mm Hg, 10 mg of Midodrine was given by MA #1 01/24/25 at 7:30 AM blood pressure 128/56 mm Hg, 10 mg of Midodrine was given by MA #1 01/27/25 at 7:30 AM blood pressure 130/64 mm Hg, 10 mg of Midodrine was given by MA #1 01/29/25 at 7:30 AM blood pressure 124/66 mm Hg, 10 mg of Midodrine was given by MA #1 02/03/25 at 7:30 AM blood pressure 121/54 mm Hg, 10 mg of Midodrine was given by MA #1 02/07/25 at 7:30 AM blood pressure 135/69 mm Hg, 10 mg of Midodrine was given by MA #1 02/14/25 at 7:30 AM blood pressure 129/70 mm Hg, 10 mg of Midodrine was given by MA #1 02/17/25 at 7:30 AM blood pressure 159/87 mm Hg, 10 mg of Midodrine was given by MA #1 02/19/25 at 7:30 AM blood pressure 129/64 mm Hg, 10 mg of Midodrine was given by MA #1 02/21/25 at 7:30 AM blood pressure 129/64 mm Hg, 10 mg of Midodrine was given by MA #1 02/24/25 at 7:30 AM blood pressure 140/70 mm Hg, 10 mg of Midodrine was given by MA #1 03/03/25 at 7:30 AM blood pressure 140/55 mm Hg, 10 mg of Midodrine was given by MA #1 03/07/25 at 7:30 AM blood pressure 130/74 mm Hg, 10 mg of Midodrine was given by MA #1 03/10/25 at 7:30 AM blood pressure 123/67 mm Hg, 10 mg of Midodrine was given by MA #1 03/12/25 at 7:30 AM blood pressure 147/73 mm Hg, 10 mg of Midodrine was given by MA #1 03/14/25 at 7:30 AM blood pressure 132/72 mm Hg, 10 mg of Midodrine was given by MA #1 03/17/25 at 7:30 AM blood pressure 121/57 mm Hg, 10 mg of Midodrine was given by MA #1 03/19/25 at 7:30 AM blood pressure 134/79 mm Hg, 10 mg of Midodrine was given by MA #1 03/21/25 at 7:30 AM blood pressure 127/73 mm Hg, 10 mg of Midodrine was given by MA #1 03/24/25 at 7:30 AM blood pressure 136/62 mm Hg, 10 mg of Midodrine was given by MA #1 03/26/25 at 7:30 AM blood pressure 130/72 mm Hg, 10 mg of Midodrine was given by MA #1 03/28/25 at 7:30 AM blood pressure 132/71 mm Hg, 10 mg of Midodrine was given by MA #1 03/31/25 at 7:30 AM blood pressure 127/60 mm Hg, 10 mg of Midodrine was given by MA #1 Review of the Medication Administration Records revealed Resident #95 received 10 MG of Midodrine with a blood pressure reading > 120 mm Hg and did not receive Midodrine with a blood pressure reading < 120 mm Hg on Tuesday, Thursday, Saturday, and Sunday on the following dates: 01/09/25 at 7:30 AM blood pressure 112/59 mm Hg, 10 mg of Midodrine was held by MA #1 01/09/25 at 12:00 PM blood pressure 116/58 mm Hg, 10 mg of Midodrine was held by MA #1 01/09/25 at 7:00 PM blood pressure 122/82 mm Hg, 10 mg of Midodrine was given by MA #5 01/11/25 at 12:00 PM blood pressure 128/60 mm Hg, 10 mg of Midodrine was given by MA #1 01/11/25 at 7:00 PM blood pressure 144/68 mm Hg, 10 mg of Midodrine was given by MA #1 01/12/25 at 7:30 AM blood pressure 139/73 mm Hg, 10 mg of Midodrine was given by MA #3 01/12/25 at 12:00 PM blood pressure 139/73 mm Hg, 10 mg of Midodrine was given by MA #3 01/14/25 at 7:30 AM blood pressure 124/72 mm Hg, 10 mg of Midodrine was given by MA #1 01/14/25 at 12:00 PM blood pressure 136/66 mm Hg, 10 mg of Midodrine was given by MA #1 01/14/25 at 7:00 PM blood pressure 126/62 mm Hg, 10 mg of Midodrine was given by MA #1 01/16/25 at 7:30 AM blood pressure 147/72 mm Hg, 10 mg of Midodrine was given by Nurse #1 01/16/25 at 12:00 PM blood pressure 140/76 mm Hg, 10 mg of Midodrine was given by Nurse #1 01/16/25 at 7:00 PM blood pressure 122/67 mm Hg, 10 mg of Midodrine was given by MA #6 01/18/25 at 7:30 AM blood pressure 132/66 mm Hg, 10 mg of Midodrine was given by MA #4 01/18/25 at 12:00 PM blood pressure 132/66 mm Hg, 10 mg of Midodrine was given by MA #4 01/19/25 at 7:30 AM blood pressure 116/60 mm Hg, 10 mg of Midodrine was held by MA #4 01/19/25 at 7:00 PM blood pressure 140/80 mm Hg, 10 mg of Midodrine was given by MA #4 01/21/25 at 7:30 AM blood pressure 130/62 mm Hg, 10 mg of Midodrine was given by MA #1 01/21/25 at 12:00 PM blood pressure 130/68 mm Hg, 10 mg of Midodrine was given by MA #1 01/21/25 at 7:30 PM blood pressure 136/72 mm Hg, 10 mg of Midodrine was given by MA #1 01/23/25 at 12:00 PM blood pressure 136/68 mm Hg, 10 mg of Midodrine was given by MA #1 01/26/25 at 7:30 AM blood pressure 125/65 mm Hg, 10 mg of Midodrine was given by MA #1 01/26/25 at 12:00 PM blood pressure 132/74 mm Hg, 10 mg of Midodrine was given by MA #1 01/28/25 at 7:30 AM blood pressure 127/67 mm Hg, 10 mg of Midodrine was given by MA #1 01/28/25 at 12:00 PM blood pressure 138/74 mm Hg, 10 mg of Midodrine was given by MA #1 01/28/25 at 7:00 PM blood pressure 103/52 mm Hg, 10 mg of Midodrine was held by MA #2 01/30/25 at 7:30 AM blood pressure 147/62 mm Hg, 10 mg of Midodrine was given by MA #1 01/30/25 at 12:00 PM blood pressure X, 10 mg of Midodrine was held by MA #2 01/30/25 at 7:00 PM blood pressure 118/58 mm Hg, 10 mg of Midodrine was held by MA #2 02/01/25 at 7:30 AM blood pressure 158/80 mm Hg, 10 mg of Midodrine was given by MA #4 02/01/25 at 12:00 PM blood pressure 147/77 mm Hg, 10 mg of Midodrine was given by MA #4 02/01/25 at 7:00 PM blood pressure 147/77 mm Hg, 10 mg of Midodrine was given by MA #4 02/02/25 at 12:00 PM blood pressure 134/80 mm Hg, 10 mg of Midodrine was given by MA #4 02/02/25 at 7:00 PM blood pressure 157/75 mm Hg, 10 mg of Midodrine was given by MA #4 02/04/25 at 7:30 AM blood pressure 130/70 mm Hg, 10 mg of Midodrine was given by MA #1 02/04/25 at 12:00 PM blood pressure 160/80 mm Hg, 10 mg of Midodrine was given by MA #4 02/04/25 at 7:00 PM blood pressure 112/58 mm Hg, 10 mg of Midodrine was held by MA #2 02/06/25 at 7:30 AM blood pressure 135/69 mm Hg, 10 mg of Midodrine was given by MA #1 02/06/25 at 12:00 PM blood pressure 138/72 mm Hg, 10 mg of Midodrine was given by MA #1 02/06/25 at 7:00 PM blood pressure 128/78 mm Hg, 10 mg of Midodrine was given by MA #2 02/08/25 at 7:30 AM blood pressure 128/66 mm Hg, 10 mg of Midodrine was given by MA #1 02/08/25 at 12:00 PM blood pressure 136/74 mm Hg, 10 mg of Midodrine was given by MA #1 02/09/25 at 12:00 PM blood pressure 128/76 mm Hg, 10 mg of Midodrine was given by MA #1 02/09/25 at 7:00 PM blood pressure 142/83 mm Hg, 10 mg of Midodrine was given by MA #3 02/11/25 at 7:30 AM blood pressure 139/75 mm Hg, 10 mg of Midodrine was given by MA #1 02/13/25 at 7:30 AM blood pressure 138/76 mm Hg, 10 mg of Midodrine was given by MA #1 02/13/25 at 12:00 PM blood pressure 136/74 mm Hg, 10 mg of Midodrine was given by MA #1 02/15/25 at 7:30 AM blood pressure 138/76 mm Hg, 10 mg of Midodrine was given by MA #4 02/15/25 at 12:00 PM blood pressure 1139/67 mm Hg, 10 mg of Midodrine was given by MA #4 02/15/25 at 7:00 PM blood pressure 105/60 mm Hg, 10 mg of Midodrine was held by MA #4 02/16/25 at 12:00 PM blood pressure 105/60 mm Hg, 10 mg of Midodrine was held by MA #4 02/16/25 at 7:00 PM blood pressure 130/79 mm Hg, 10 mg of Midodrine was given by MA #4 02/18/25 at 7:30 AM blood pressure 132/72 mm Hg, 10 mg of Midodrine was given by Nurse #2 02/18/25 at 12:00 PM blood pressure 132/72 mm Hg, 10 mg of Midodrine was given by MA #1 02/18/25 at 7:00 PM blood pressure 136/74 mm Hg, 10 mg of Midodrine was given by MA #1 02/20 25 at 7:30 AM blood pressure 123/68 mm Hg, 10 mg of Midodrine was given by MA #1 02/20/25 at 7:00 PM blood pressure 123/68 mm Hg, 10 mg of Midodrine was given by MA #3 02/22/25 at 12:00 PM blood pressure 124/66 mm Hg, 10 mg of Midodrine was given by MA #1 02/22/25 at 7:00 PM blood pressure 146/82 mm Hg, 10 mg of Midodrine was given by MA #6 02/23/25 at 7:30 AM blood pressure 144/70 mm Hg, 10 mg of Midodrine was given by MA #5 02/23/25 at 12:00 PM blood pressure 124/61 mm Hg, 10 mg of Midodrine was given by MA #5 02/23/25 at 7:00 PM blood pressure 136/72 mm Hg, 10 mg of Midodrine was given by MA #7 02/25/25 at 7:30 AM blood pressure 142/68 mm Hg, 10 mg of Midodrine was given by MA #1 02/25/25 at 12:00 PM blood pressure 136/72 mm Hg, 10 mg of Midodrine was given by MA #1 02/25/25 at 7:00 PM blood pressure 113/60 mm Hg, 10 mg of Midodrine was held by MA #2 02/27/25 at 7:30 AM blood pressure 122/65 mm Hg, 10 mg of Midodrine was given by MA #1 03/01/25 at 7:30 AM blood pressure 118/70 mm Hg, 10 mg of Midodrine was held by MA #4 03/01/25 at 12:00 PM blood pressure 129/65 mm Hg, 10 mg of Midodrine was given by MA #4 03/01/25 at 7:00 PM blood pressure 113/60 mm Hg, 10 mg of Midodrine was held by MA #4 03/02/25 at 7:30 AM blood pressure 133/62 mm Hg, 10 mg of Midodrine was given by MA #4 03/02/25 at 12:00 PM blood pressure 135/69 mm Hg, 10 mg of Midodrine was held by MA #4 03/04/25 at 7:00 PM blood pressure 139/77 mm Hg, 10 mg of Midodrine was given by MA #3 03/06/25 at 12:00 PM blood pressure 136/74 mm Hg, 10 mg of Midodrine was given by MA #1 03/06/25 at 7:30 PM blood pressure 136/74 mm Hg, 10 mg of Midodrine was given by MA #3 03/08/25 at 7:30 AM blood pressure 125/70 mm Hg, 10 mg of Midodrine was given by MA #1 03/11/25 at 7:30 AM blood pressure 132/70 mm Hg, 10 mg of Midodrine was given by MA #1 03/11/25 at 12:00 PM blood pressure 139/63 mm Hg, 10 mg of Midodrine was given by MA #1 03/11/25 at 7:00 PM blood pressure 132/66 mm Hg, 10 mg of Midodrine was given by MA #1 03/13/25 at 7:30 AM blood pressure 138/74 mm Hg, 10 mg of Midodrine was given by MA #1 03/13/25 at 12:00 PM blood pressure 136/68 mm Hg, 10 mg of Midodrine was given by MA #1 03/15/25 at 7:30 AM blood pressure 112/60 mm Hg, 10 mg of Midodrine was held by MA #4 03/15/25 at 12:00 PM blood pressure 141/80 mm Hg, 10 mg of Midodrine was given by MA #4 03/15/25 at 7:00 PM blood pressure 130/60 mm Hg, 10 mg of Midodrine was given by MA #4 03/16/25 at 12:00 PM blood pressure 141/70 mm Hg, 10 mg of Midodrine was given by MA #4 03/18/25 at 7:30 AM blood pressure 136/68 mm Hg, 10 mg of Midodrine was given by MA #1 03/18/25 at 12:00 PM blood pressure 132/66 mm Hg, 10 mg of Midodrine was given by MA #1 03/18/25 at 7:00 PM blood pressure 129/67 mm Hg, 10 mg of Midodrine was given by MA #1 03/20/25 at 7:30 AM blood pressure 136/76 mm Hg, 10 mg of Midodrine was given by MA #1 03/20/25 at 12:00 PM blood pressure 128/68 mm Hg, 10 mg of Midodrine was given by MA #1 03/22/25 at 7:30 AM blood pressure 122/68 mm Hg, 10 mg of Midodrine was given by MA #1 03/23/25 at 7:30 AM blood pressure 138/76 mm Hg, 10 mg of Midodrine was given by MA #1 03/25/25 at 7:30 AM blood pressure 132/74 mm Hg, 10 mg of Midodrine was given by MA #1 03/25/25 at 12:00 PM blood pressure 122/70 mm Hg, 10 mg of Midodrine was given by MA #1 03/25/25 at 7:00 PM blood pressure 130/72 mm Hg, 10 mg of Midodrine was given by MA #1 03/27/25 at 7:30 AM blood pressure 134/72 mm Hg, 10 mg of Midodrine was given by MA #1 03/27/25 at 12:00 PM blood pressure 141/86 mm Hg, 10 mg of Midodrine was given by MA #1 03/27/25 at 7:00 PM blood pressure 138/72 mm Hg, 10 mg of Midodrine was given by MA #1 03/29/25 at 7:00 PM blood pressure 110/60 mm Hg, 10 mg of Midodrine was held by MA #4 03/30/25 at 12:00 PM blood pressure 101/70 mm Hg, 10 mg of Midodrine was held by MA #4 04/01/25 at 7:30 AM blood pressure 128/72 mm Hg, 10 mg of Midodrine was given by MA #1 04/01/25 at 12:00 PM blood pressure 133/66 mm Hg, 10 mg of Midodrine was given by MA #1 Review of the progress notes from 01/08/25 through 04/01/25 for Resident #95 revealed no documentation that the medication Midodrine was correctly held or given on the dates listed. An interview was conducted with MA #1 on 04/01/25 at 2:50 PM. She stated she worked full time on the 100 hall and cared for Resident #95. She acknowledged that this medication order had parameters attached to it because the parameters popped up automatically. She confirmed if there was a check mark on the Medication Administration Record (MAR) it meant that she had administered the medication. She stated she did not know what had happened that caused her to give the medication in error. An interview was conducted with Nurse #2 on 04/01/25 at 3:00 PM. She stated she was familiar with Resident #95. She noted she was familiar with the medication Midodrine and knew it was used to increase the blood pressure. She stated she had made a medication error because she had not noticed the parameters when she administered the medication. An interview was conducted with MA #4 on 04/01/25 at 3:11 PM via phone. She stated she worked on the weekends and was familiar with Resident #95. She stated she knew the medication Midodrine was used to treat low blood pressure by raising the blood pressure. She knew the medication had parameters. She confirmed that if she documented a check mark on the MAR that she had administered the medication. She thought she may have documented incorrectly. A telephone interview was conducted with MA #6 on 04/02/25 at 10:28 AM. She stated that she had worked at the facility for 4 years and was familiar with Resident #95. She explained that she understood that the medication Midodrine was used for orthostatic hypotension and would bring up his blood pressure. She stated she was aware of the parameters and would hold the medication if the systolic blood pressure was > 120. She concluded she must have made a documentation error because she also had to also pass medications on the 500 hall which made the assignment chaotic. An interview was conducted with MA #5 on 04/02/25 at 11:10 AM. She stated that she usually worked on the 300 hall but was occasionally pulled to pass medications on the 100 hall. She stated she had administered the medication to Resident #95 in error. An interview was conducted with MA #3 on 04/02/25 at 4:17 PM. She stated she had worked at the facility for 2 years and was familiar with Resident #95. She indicated that if she signed off the medication on the MAR that she had administered the drug. She stated she had not looked at the parameters as closely as she should have and gave the medication in error. A phone interview was conducted with MA #2 on 04/02/25 at 4:39 PM. She stated that she had worked at the facility for 3 years and was familiar with Resident #95. She noted she usually worked as a nurse aide but did pass medications occasionally. She recalled the parameters on the Midodrine order for Resident #95 and stated she had always taken his blood pressure before administering the drug. She stated she may have misunderstood the order and had given the medication in error. A telephone interview was conducted with Nurse #1 on 04/02/25 at 4:52 PM. She stated that she was familiar with Resident #95. She explained that the medication Midodrine was used for hypotension. She was not sure why she gave the medication when the systolic blood pressure was > 120. She thought she may have interpreted the order to instruct her to hold the medication if the systolic reading was < 120. She confirmed that if there was a check mark on the MAR that she had given the medication. An interview was conducted with the Staff Development Coordinator (SDC) Nurse on 04/03/25 at 8:59 AM. She stated she was familiar with the medication Midodrine and that it was used to bring up a low blood pressure. She explained she had not noticed the order had parameters set and had given the medication in error. A telephone interview was conducted with MA #7 on 04/03/25 at 11:15 AM. She stated she was familiar with Resident #95 but usually did not work the 100 hallway. She explained she did not know why she gave the medication in error. She assumed she had not seen the parameters and gave the medicine to the resident. She noted the 100 hall was very busy and the whole time she passed medication on the 100 hall she was constantly being interrupted by residents approaching her for pain medications. She described the assignment as hectic. Unsuccessful attempts to contact Nurse #3 were made on 04/02/25 at 10:40 AM, 04/03/25 at 9:15 AM and 04/03/25 at 4:22 PM. A message was left on each attempt. An interview was conducted with the Assistant Director of Nursing on 04/01/25 at 4:30 PM. She stated she was familiar with Resident #95 and had administered the medication Midodrine to him in error. She stated she had been a dialysis nurse in the past and knew that dialysis would not be given if the diastolic blood pressure was too low, so she had given the Midodrine on 01/27/25 in the morning in an effort to raise his diastolic pressure and wasn't paying attention to the parameters that had been ordered. She had thought the diastolic pressure of 68 was too low. She stated she had misunderstood the order and thought it read dys hold if < 80 when it actually read dys hold if > 80 and she was trying to raise the diastolic blood pressure up to 80 mm Hg by giving the medication. She had not noticed the systolic parameter was >120 mm Hg when she gave it either because she was focused on her previous dialysis experience. A telephone interview was conducted with the facility Consultant Pharmacist on 04/01/25 at 10:18 AM. She stated she had not notified the facility that the Midodrine had been given in error in January 2025 because she had not seen a trend and didn't think that giving this medication to Resident #95 when his blood pressure was outside of the parameters was of clinical significance. She reported that she had recommended to the nursing staff on 02/14/25 that the medication had been administered in error when the systolic blood pressure was >120 but only listed a small sample of dates, just enough to show a trend, but not all the dates that the medication was given in error in February 2025. She stated she did not alert the facility that errors continued to occur in March 2025 because she had been told that the nurses had been educated (when she followed up with the facility regarding the February recommendation on March 10, 2025) and she thought the re-education would take a while. An interview was conducted with the Unit Manager on 04/02/25 at 12:23 PM. She acknowledged that she received the pharmacy reports each month and acted on the recommendations. She stated she had never seen the February 2025 Pharmacy Recommendation to Nursing Staff that listed the medication errors. She explained she was not aware that any medication errors had occurred. An interview was conducted with the SDC Nurse on 04/02/25 at 1:23 PM. She stated she had not provided any education to the nursing staff regarding medication parameters, and she had not been aware of any medication errors. An interview was conducted with the Director of Nursing on 04/02/25 at 11:30 AM. She stated she had not been aware of any medication errors. An interview was conducted with the facility Administrator on 04/02/25 at 10:00 AM. She stated she was not aware of any medications errors that had occurred in the facility between January 2025 and March 2025. She explained she signed off on all medication error reports and/or reprimands that occurred and would have known. She stated that she was surprised when she learned today of the number of medication errors that had occurred. A telephone interview was conducted with the Medical Director on 04/03/25 at 4:36 PM. She stated that she expected the nursing staff to administer medications according to the ordered parameters. She reported that she had not been notified of the medication errors. She noted Resident #95 had no significant outcome related to the medication errors even though the number of errors was significant.

Based on observations and staff interviews the facility failed to discard expired medications, record an opened date on a multi-dose oral inhaler that had a shortened expiration date, and refrigerate unopened ophthalmic drops according to the manufacturer's guidelines on 2 of 5 medication carts (400 hall, 800 hall) and in 2 of 2 medication storage rooms (300 hall, 400 hall) that were reviewed for medication storage. Findings included. 1.) An observation of the 400-hall medication cart on 04/02/25 at 11:19 AM revealed the following medications: One bottle of Latanoprost .005% ophthalmic drops that was unopened and not refrigerated. Review of the manufacturers guidelines for Latanoprost ophthalmic solution instructed to store unopened bottles under refrigeration at 2° to 8°C (36° to 46°F). Once a bottle was opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks. Fluticasone propionate salmeterol (Advair diskus)100 micrograms (mcg)/50mcg that was in use with no opened date labeled on the inhaler. Fluticasone propionate salmeterol inhaler (Advair diskus)100 micrograms (mcg)/50mcg with an opened date of 1/09/25. Review of the manufacturers guidelines for Fluticasone propionate salmeterol inhaler instructed to discard one month after opening the foil pouch. One box of Hemorrhoidal suppositories that were house stock with an expiration date of 11/2023. Clobetasol 0.5% topical ointment with an expiration date of 9/2024. Imvexxy vaginal suppositories 10mcg with an expiration date of 10/2024. During an interview on 04/02/25 at 11:30 AM Nurse #2 stated all nurses were responsible for checking the medication carts for expired medications. She indicated she had not checked the cart so far today due to being busy with the morning medication pass. She stated the medications should have been discarded and an opened date labeled on the inhaler. She indicated she was not aware that the Latanoprost ophthalmic drops had to be refrigerated if not opened. 2.) An observation of the 800-hall medication cart on 04/02/25 at 11:45 AM revealed the following medications: One bottle of Latanoprost .005% ophthalmic drops that was opened and in use with no opened date recorded. One bottle of Lansoprazole 3 milligrams per milliliter suspension with a use by date of 3/31/25. Review of the manufacturer's instructions for Lansoprazole suspension instructed to discard after 30 days and store in the refrigerator. During an interview on 04/02/25 at 11:45 AM Nurse #4 stated all nurses were responsible for checking the medication carts for expired medications and to ensure medications with short expiration dates were labeled with an opened date. She stated this was an oversight. 3.) An observation of the 300-hall medication storage room on 04/02/25 at 12:30 PM revealed the following: Two bottles of wound cleanser (antiseptic) with an expiration date of 4/30/24 and 9/2023. During an interview on 04/02/25 at 12:30 PM Unit Manager #1 stated she thought she had checked the storage room for expired medications. She stated it was an oversight. 4.) An observation of the 400-hall medication storage room on 04/02/25 at 11:55 AM revealed the following: Lansoprazole suspension 3 mgs with an expiration date of 03/01/25. During an interview on 04/02/25 at 11:55 AM Nurse #2 stated that central supply staff, the Assistant Director of Nursing and the nurses were all responsible for checking the medication storage rooms for expired medications. She stated this was an oversight. During an interview on 04/03/25 at 3:53 PM Central Supply staff member #1 stated she routinely checked the medication storage rooms for expired medications. She stated she was responsible for over-the-counter medications not prescription medications. An interview was conducted on 04/03/25 at 3:01 PM with the Director of Nursing (DON) along with the Administrator. The Administrator stated the assigned nurse was responsible for checking medication carts for expired medications and to ensure all medications were labeled with an opened date. She stated the central supply staff member was responsible for checking the medication storage rooms for expired medications. She stated education regarding medication storage would be provided to nursing staff.

Based on observations and staff interviews, the facility failed to label and date an opened food item in 1 of 1 walk-in refrigerator and failed to remove expired containers of milk from 2 of 3 nourishment rooms (Secured Unit and East Wing). These practices had the potential to affect food service for the residents. The findings included: a. The initial tour of the kitchen with the Dietary Manager on 3/31/2025 at 10:50 AM revealed an open package of sliced turkey in the walk-in refrigerator that was not labeled and dated. An interview with the Dietary Manager was conducted on 3/31/2025 at 11:00 AM. The Dietary Manager stated that all open food in the kitchen was supposed to be labeled with an opened date and an expiration date. She further stated she was going to discard the package of turkey because it was not labeled and dated. b. A tour of the East Wing nourishment room with the Dietary Manager on 3/31/2025 at 11:05 AM revealed a container of 2% milk with the expiration date of 3/29/2025. c. A tour of the Secured Unit nourishment room with the Dietary Manager on 3/31/2025 at 11:08 revealed 2 containers of 2% milk with the expiration date of 3/29/2025. An interview with the Dietary Manager was completed on 3/31/2025 at 11:10 AM. The Dietary Manager stated that the dietary staff were responsible for stocking the nourishment rooms and removing expired items. She indicated the expired milk containers should have been removed from the nourishment rooms. An interview with the Administrator was completed on 4/3/2025 at 1:20 PM. The Administrator stated she expected opened food items to be labeled and dated correctly. She further stated that the milk expired on the weekend and no one was assigned to check the nourishment rooms on the weekend.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Nurse Practitioner (NP) interviews, the facility failed to provide a physician order for the care of and daily flush of a cholecystostomy (gallbladder) drainage tube for 1 of 1 resident (Resident #36) reviewed for a drainage tube. Findings included: Resident #36 was readmitted to the facility on [DATE] with a diagnosis of acute cholecystitis (gallbladder inflammation caused by gallstones). Review of Resident #36's electronic health record revealed an After Visit Discharge summary dated [DATE] which indicated a discharge diagnosis of acute cholecystitis and stated she had a cholecystostomy tube (a drainage tube placed into the gallbladder) for symptomatic improvement of acute cholecystitis. The discharge instructions indicated to flush the cholecystostomy tube one time per day, keep the tube in place and keep the area clean and dry. Review of Resident #36's physician orders revealed no order dated 11/27/23 to flush the cholecystostomy tube or any instructions regarding the care or maintenance of the tube. Review of Resident #36's 12/31/23 quarterly Minimum Data Set (MDS) assessment indicated resident was cognitively intact, had an indwelling catheter and an ostomy. Review of Resident #36's January 2024 electronic Treatment Administration Record (TAR) revealed a 1/4/24 entry to apply a dry dressing around the drainage tube on the abdomen every three days. Review of Resident #36's 1/24/24 care plan indicated the resident required the use of a colostomy related to history of rectal cancer and a urinary catheter related to urinary obstruction. The cholecystostomy tube was not included in the care plan. An interview was conducted with Resident #36 on 1/24/24 at 11:45 AM. Resident #36 revealed she had nausea all the time related to her gall bladder. Resident #36 stated she had the gallbladder drainage tube in place since November 2023 due to gall stones. Resident #36 stated sometimes the nursing staff checked the drainage tube for her gallbladder. Interview with Nurse #1 on 1/24/24 at 11:50 AM revealed Resident #36 had a drainage tube, but she forgot what they called the type of drainage tube or what it was for. Nurse #1 stated there should be a physician order for the care of the drainage tube, but she did not see any orders in Resident #36's electronic health record. Interview with Nurse #3 on 1/24/24 at 3:50 PM revealed Resident #36 had a drainage tube, but she was not sure what type or what it was for. Nurse #3 stated she squeezed the device and drained it every now and then. Nurse #3 stated she did not recall seeing any orders regarding the drainage tube, did not know of anything to observe for or any special care required. Nurse #3 indicated there was no order in the electronic health record to flush Resident #36's cholecystostomy tube. Interview with the Nurse Practitioner (NP) on 1/25/24 at 10:30 AM revealed she expected the physician order from the after-visit summary discharge summary report dated 11/27/23 to flush the cholecystostomy tube one time per day to have been transcribed and followed. The NP stated the cholecystostomy tube site should be monitored daily for infection, the drainage should be monitored and orders for this should have been included in Resident #36's electronic health record. Interview with the Director of Nursing (DON) on 1/25/24 at 1:45 PM revealed there should have been care instructions in Resident #36's electronic health record regarding the cholecystostomy tube. The DON further indicated the order to flush the tube daily should have been transcribed into the electronic Treatment Administration Record (TAR). Interview with the Administrator on 1/25/24 at 1:50 PM revealed the orders for care of the cholecystostomy tube and to flush the tube should have been in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Nurse Practitioner (NP) interviews, the facility failed to provide education to the nursing staff to deliver care for a cholecystostomy (gallbladder)drainage tube for 1 of 1 resident (Resident #36) reviewed for a drainage tube. Findings included: Resident #36 was readmitted to the facility on [DATE] with a diagnosis of acute cholecystitis (gallbladder inflammation caused by gallstones). Review of Resident #36's electronic health record revealed an After Visit Discharge summary dated [DATE] which indicated a discharge diagnosis of acute cholecystitis and stated she had a cholecystostomy tube (a drainage tube placed into the gallbladder) for symptomatic improvement of acute cholecystitis. The discharge instructions indicated to flush the cholecystostomy tube one time per day, keep the tube in place and keep the area clean and dry. Review of Resident #36's 12/31/23 quarterly Minimum Data Set (MDS) assessment indicated resident was cognitively intact, had an indwelling catheter and an ostomy. Review of Resident #36's January 2024 electronic Treatment Administration Record (TAR) revealed a 1/4/24 entry to apply a dry dressing around the drainage tube on abdomen every three days. Review of Resident #36's 1/24/24 care plan indicated the resident required the use of a colostomy related to history of rectal cancer and a urinary catheter related to urinary obstruction. The cholecystostomy tube was not included in the care plan. Interview with Resident #36 on 1/24/24 at 11:45 AM revealed she had nausea all the time related to her gall bladder. Resident #36 stated the nursing staff checked the drainage tube for her gallbladder sometimes. Resident #36 stated she told the staff how to care for the drainage tube, including using caution with it so it did not get caught on something and to empty it regularly. Interview with Nurse #1 on 1/24/24 at 11:50 AM revealed Resident #36 had a catheter, colostomy, and a drainage tube. Nurse #1 stated she forgot what they called the type of drainage tube Resident #36 had but she thought it had something to do with her bowels. Nurse #1 stated the drainage tube had a button on the side to drain it and sometimes she pressed the button. Interview with the Staff Development Coordinator (SDC) on 1/24/24 at 2:40 PM revealed she normally provided in service education with the staff when a resident was admitted or readmitted with a procedure, device, or equipment that they were not familiar with. The SDC stated a cholecystostomy tube was not something that was seen in the facility often and required special training and education. The SDC stated she was not familiar with what type of drainage tube Resident #36 had and she had not provided education to the staff about it. The SDC stated she did not know why she had not provided education to the staff regarding Resident #36's cholecystostomy tube. The SDC stated she did not know much about a cholecystostomy tube but stated there should be a physician order for the care of the tube and staff should be educated about it. Interview with Nurse #3 on 1/24/24 at 3:50 PM revealed Resident #36 had a drainage tube, but she was not sure what type or what it was for. Nurse #3 stated she squeezed the device and drained it every now and then. Nurse #3 stated she had not received any training regarding Resident #36's drainage tube. Nurse #3 stated she did not know of anything to observe for or any special care required with the drainage tube. Interview with the Nurse Practitioner (NP) on 1/25/24 at 10:30 AM revealed she expected the nurses would be informed of the type of drainage tube and the risks involved. The NP stated the cholecystostomy tube site should be monitored daily for infection and the drainage should be monitored. The NP stated with any tube there was a risk of obstruction, infection, and dislodgement. The NP stated if a cholecystostomy was dislodged the resident would require transport to the hospital for replacement. Interview with Nursing Assistant (NA) #1 on 1/25/24 at 12:25 PM revealed she was familiar with Resident #36's care. NA #1 stated Resident #36 had a Foley catheter, a colostomy, and some other type of tube but she did not know what type of tube it was, had not been instructed regarding any special care or precautions with the tube and had not received in service education regarding it. NA #1 stated the nurse normally took care of Resident #36's drainage tube. NA #1 stated she thought the nurse emptied the drainage tube, but she was not sure. Interview with the Director of Nursing (DON) on 1/25/24 at 1:45 PM revealed there should have been care instructions in Resident #36's electronic health record regarding the cholecystostomy tube. The DON indicated the nurses should have been instructed on how to care for a resident with a cholecystostomy tube. Interview with the Administrator on 1/25/24 at 1:50 PM revealed the staff should have been aware of how to care for a resident with a cholecystostomy tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to secure unused narcotic medications for disposition (the process of returning unused medications to the pharmacy) resulting in possible diversion (the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use). This was for 1 of 1 discharged resident (Resident #256) reviewed for pharmacy services. Findings included: Resident #256 was admitted to the facility on [DATE] and she discharged home with her husband on 8/8/2023. The physician's orders for Resident #256 dated 8/7/2023 revealed she was ordered hydrocodone/acetaminophen 7.5-325 mg, give 1 tablet by mouth every 4 hours as needed for pain for 14 days and hydromorphone hydrochloride oral tablet, give 1 mg by mouth every 4 hours as needed for unspecified abdominal pain for 20 days. She was also prescribed fentanyl patch every 72 hours 25 micrograms (mcg)/hour, apply 1 patch transdermal (on the skin) every 72 hours for pain for 30 days and removed per schedule. The Controlled Drug Administration sheet for Resident #256's hydrocodone-acetaminophen 7.5-325 mg dated 8/8/2023 revealed 30 tablets were dispensed to the facility and no tablets were signed out as administered, and no tablets were returned to the pharmacy. An Initial Allegation report revealed the facility became aware of the possible misappropriation of a controlled substance on 8/9/2023 at 5:00 PM and an investigation was initiated. Narcotic sheets and controlled substances were found in a staff member's unlocked desk drawer. Two of the three sheets with matching controlled substances were found in the unlocked desk drawer. The third narcotic count sheet (hydrocodone 7.5-325 mg) did not have accompanying controlled substances. Resident discharged on 8/8/2023. The police were notified on 8/10/2023 at 10:15 AM. The Investigation Report submitted on 8/16/2023 revealed the accused employee was Nurse #8 for an allegation of diversion of Resident #256's drugs. Nurse #8 declined a drug screen and resigned from her position effective immediately. The allegation was not substantiated by the facility. An interview was conducted with the Pharmacist Consultant on 1/24/2024 at 10:06 AM. The Pharmacist stated that all narcotics that are discontinued are supposed to be sent back to the pharmacy for disposal. She further stated that if the resident was discharged the medication should be sent with the resident if their insurance paid for it. The Pharmacist consultant indicated that narcotics were supposed to be kept double locked and should not have been in an unlocked desk drawer. The Pharmacist Consultant stated that she had been the facility consultant since September 2023, and she was unaware of the investigation for diversion. She further stated that during her audits at the facility she had never found any discrepancies. An interview was conducted with the Staff Development Coordinator (SDC) Nurse on 1/24/2024 at 1:29 PM. The SDC Nurse stated that on 8/9/2023 she was looking for a newly admitted resident's narcotic medication and she was unable to find it. She further stated that she remembered that Resident #256 was taking the same medication (hydromorphone) and she went to see if it was accidentally delivered to the wrong medication cart. The SDC Nurse indicated that when she went to the medication cart on the hall where Resident #256's narcotics were kept, the Controlled Medication Administration sheets and the narcotic medications were not there. She stated that the nurse on the cart told her Nurse #8 (the former Assistant Director of Nursing (ADON)) had already removed Resident #256's discontinued narcotic medications from the cart earlier that day. The SDC explained that 3 nurses at the facility had the keys to the discontinued medication cabinet in the Omnicell (automated medication dispensing machine) room and they were the Director of Nursing (DON), the ADON, and herself. She further stated that she had called the pharmacy and the new resident's narcotics had not been delivered to the facility yet. The SDC Nurse indicated that when she looked inside the cabinet, Resident #256's discontinued narcotic medications were not there. The SDC Nurse stated that she immediately informed the DON of the missing narcotic medications, and they began to search the building for them. She indicated that they had gone to Nurse #8's unlocked office on the main hall and found 3 narcotic Controlled Medication Administration sheets with 2 of the corresponding narcotic pill cards in an unlocked drawer. The SDC Nurse stated that Resident #256's hydrocodone 7.5-325mg tablets was the missing medication and the Controlled Medication Administration sheet for the medication indicated there should have been 30 pills. She stated that they had called Nurse #8 to come back to the facility and she did return. The SDC stated that Nurse #8 was unable to produce the missing medication and resigned immediately when asked to take a drug test. She further stated that someone from the pharmacy came to the facility the next day and counted all the narcotics, and no discrepancies were found. The SDC Nurse indicated that the Board of Nursing and the police were notified. An interview was completed with the current ADON on 1/24/2024 at 11:42 AM. The ADON stated that when a resident's narcotic medications were discontinued, they were placed in a locked cabinet in the Omnicell room which was also locked. She further stated that 2 nurses' signatures were required on the return sheet for the discontinued narcotic medications. The ADON indicated that someone from the pharmacy came to the facility monthly to secure the medications and take them back to the pharmacy. An interview was conducted with the DON and the Administrator on 1/24/2024 at 11:52 AM. The DON stated that on 8/9/2023 the SDC Nurse came to her and explained that she could not find Resident #256's narcotic medications. She further stated the SDC Nurse informed her the narcotic medications had been removed from the cart on the hall by Nurse #8 and they were not in the locked discontinued medication cabinet in the Omnicell room. The DON indicated Nurse #8 had left earlier that day, so they went to search in her unlocked office. She stated that when they searched Nurse #8's desk they found 3 Controlled Medication Administration sheets but only 2 pill cards containing narcotic pills in an unlocked drawer. The DON further stated that the missing medications were 30 of Resident #256's discontinued hydrocodone 7.5 -325 mg tablets. She explained they had called Nurse #8 and asked her to return to the facility and she had returned. The DON stated that when Nurse #8 came back to and they recapped what they had found to her, she initially said she didn't know how the medication had gotten in her desk drawer in her office. She further stated that when Nurse #8 was asked if she would take a drug test that she immediately declined and then resigned effective immediately. The DON indicated that Nurse #8 asked if they were going to report her to the North Carolina Board of Nursing. The DON stated they had reported her to the Board of Nursing, and they had called the police. The Administrator stated that she had contacted the Board of Nursing and they had requested further information and signed statements from the other staff involved. The Administrator reported that Nurse #8's nursing license was still active as of 1/24/2024. The Administrator stated a police officer had come to the facility and taken a report, and he had told her an investigator would be assigned to the case. The Administrator indicated the facility had not substantiated the allegation of misappropriation of resident's property against Nurse #8 because she had refused the drug test and she could not be 100% sure. She further stated that she was unsure of what the facility could have done differently to prevent this from happening, because she felt it was an isolated incident. The Administrator indicated the process was still the same as far as how they disposed of discontinued narcotics.

Based on record review, observations and staff interviews, the facility failed to date opened multi-dose inhalers and an insulin pen and failed to discard loose pills in the medication cart drawers for 2 of 6 medication carts (300 Hall and 800 Hall carts). Findings included: 1. An observation of the 300 hall medication cart was conducted with Nurse #6 on 1/24/2024 at 9:51 AM. During the observation revealed the following medications were stored on the medication cart: a. An opened box containing an Incruse multidose Ellipta inhaler 62.5 micrograms (mcg) was observed on the cart without an opened date. Incruse Ellipta inhaler is an inhaled medication used to treat chronic obstructive pulmonary disease (COPD). The label on the box revealed it was dispensed from the pharmacy on 9/14/2023 (19 weeks ago) and should be discarded 6 weeks after opening the tray. b. An opened box containing a Serevent inhaler 50 mcg was observed on the cart without an opened date. Serevent inhaler is an inhaled medication used to treat asthma. The label on the box revealed it was dispensed from the pharmacy on 9/23/2023 (18 weeks ago) and should be discarded 6 weeks after opening the foil pouch. c. Six pills (5 various shaped white pills and 1 round purple pill) were found loose in the bottom of a medication drawer. An interview was conducted with Nurse #6 on 1/24/2024 at 09:51 AM. Nurse #6 stated that it was the nurse on the medication cart's responsibility to date and label the medications. She further stated that she was new to the facility and hadn't realized the inhalers expired 6 weeks after opening. Nurse #6 indicated that pills should not be loose in the medication drawers. An interview was conducted with the Director of Nursing (DON) on 1/24/2024 at 12:46 PM. The DON stated that she expected the inhalers to have an open date on them. She further stated that pills were not supposed to be loose in the medication drawers. The DON indicated that it was the nurse on the medication cart responsibility to check for dates on medications. An interview was conducted with the Administrator on 1/25/2024 at 7:20 AM. The Administrator stated that the facility nurses check their carts frequently and check for expired medications and dates. She further stated that the facility had a Pharmacy Consultant that came frequently and checked for expired medications on the carts and in the medication rooms. The Administrator indicated that since the nurse was new to the facility that had the undated inhalers and loose pills in the drawers, maybe they should increase the education during orientation about medication storage and labeling. 2. An observation of the 800 hall medication cart was conducted with Nurse #7 on 1/24/2024 at 11:04 AM. The observation revealed the following medication was observed on the cart: a. An opened Novolog (insulin aspart) injection flexpen 100 units per milliliter (U/ml) was observed on the cart with no open date on it. Novolog (insulin aspart) injection flexpen is a fast-acting insulin used to treat Type I and Type 2 diabetes. The label on the insulin pen read to discard 28 days after opened. An interview was conducted with Nurse #7 on 1/24/2024 at 11:04 AM. Nurse #7 stated that all the insulin pens were supposed to be dated with an opened date. She further stated that she had checked her cart for dates on the insulin pens and stated that maybe the date had rubbed off the pen. Nurse #7 stated it was her responsibility to check the medication carts for dated insulin pens. An interview was completed with the DON on 1/24/2024 at 12:46 PM. The DON stated that she expected insulin pens to be dated the day they are opened. An interview was completed with the Administrator on 1/25/2024 at 7:20 AM. The Administrator stated that the nurses were responsible for checking their medication carts for expired and undated medications. She further stated the facility Pharmacy Consultant came frequently to check for expired medications on the carts and in the medication rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to provide adaptive equipment for 1 of 1 resident reviewed for adaptive devices (Resident #29). Findings included: Resident #29 was admitted to the facility on [DATE] with diagnosis that included poly-osteoarthritis. A review of Resident #29's current physician orders for regular mechanical soft texture diet regular/thin consistency, house nutritional shake, and special instructions food to be put in a scoop dish for all meals, an adaptive two handled cup with straw and lid at all meals dated 04/13/23. Resident #29 was care-planned for potential dehydration and nutritional problems related to arthritis, adult failure to thrive, weakness, a mechanically altered diet, and Alzheimer's. A listed approach for the care area was to provide adaptive equipment, scoop dish and a two handled cup) as ordered. The care plan was last revised on 07/05/23. A review of Resident #29's Annual Minimum Data Set (MDS) dated [DATE] revealed severe cognitive impairment and required set-up assistance with eating. Observations of the breakfast and lunch meal trays on 01/23/24, 01/24/24, and 01/25/24 found Resident #29 had a scoop dish, but did not receive a two handled adaptive cup on her meal trays and was not listed on the meal ticket. The observations revealed there were no two handle adaptive cups at the ready for the meal trays. An observation of Resident #29 and review of her meal ticket was conducted while she was eating lunch in her room on 01/23/24 at 1:00 PM. The resident was not able to pick up any of the three cups on her meal tray with her arthritic hands but was only able to bend her head over the tray and drink from the water cup, which was the only cup with a straw. The observation found her meal tray did not include a two-handle adaptive cup. A review of Resident #29's meal ticket read mechanical soft diet, and scoop dish. Resident #29 stated she never received an adaptive cup with handles, and she said it would be easier for her to drink from. An interview was conducted with Occupational Therapist (OT) on 01/24/24 at 10:30 AM. She said she was not aware Resident #29 should have had a two-handled drinking cup on her meal trays. She did confirm that Resident #29 did have an active order for a two-handle cup, which included a scoop dish dated 04/13/23. She said she did observe the resident's breakfast tray that morning and saw that it only had a scoop dish on it, and no two-handled drinking cup. She said the resident needed the cup and would benefit from having one, due to her arthritis, but no cup was on resident's meal ticket or on her breakfast meal tray and should have. per physician's order. An interview was conducted with the Director of Nursing on 01/24/24 at 12:30 PM. She revealed the dietary department should provide assistive devices including handled cups for residents. DON stated she was not aware that Resident #29 was to have a handled cup and was not getting one for meals. DON stated that she expected residents would be provided with assistive devices for eating and drinking. An interview was conducted with the Dietary Manager on 01/24/24 at 1:35 PM. She said the staff who pass the trays to the residents will check residents' meal ticket to make sure the resident had what was listed on the ticket, and she said Resident #29's two-handle adaptive cup was not listed on the meal ticket and should have been per review of physician orders. She said she must have transcribed the physician's order wrong and then failed to order a two-handle cup. An interview was conducted with the Director of Rehab on 01/25/24 at 9:00 AM. He said an adaptive cup was used by residents to prevent spillage and to increase intake. The Rehab Director said if a Nurse Aide (NA) or Nurse identified a resident needed an adaptive cup, it was communicated to rehab department. The Director of Rehab stated Resident #29 had general difficulty getting food and drink to her mouth due to poor range of motion and gripping strength. The Rehab Director stated the adaptive cup would help Resident #29 to get drink to her mouth without spilling it. The Rehab Manager stated he was unaware Resident #29 was ordered a two-handle cup on 04/13/23. The Rehab Manager said the resident would be re-evaluated by Occupational Therapy (OT) and a two-handle cup be provided to the resident per physician order. The Administrator was interviewed on 01/25/24 at 2:20 PM and stated when an order was placed into the electronic health record (EHR) it should be reflected on the meal ticket. The Administrator said the order for a two-handle adaptive cup was not placed on the meal ticket, and that the two-handled cup should have been provided to the resident for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Nurse Practitioner interviews, the facility failed to follow the parameter ordered for administration of a medication used to treat diabetes resulting in 7 doses of insulin Glargine 25 units administered in error for 1 of 1 resident (Resident #47) reviewed for medication error. Findings included: Resident #47 was admitted to the facility on [DATE] with diagnosis which included in part diabetes and Alzheimer's Dementia. Resident #47's 11/1/23 quarterly Minimum Data Set (MDS) assessment indicated resident had severe cognitive impairment with no behaviors noted. The MDS further indicated Resident #47 received Insulin injections daily during the 7 day look back period and had no changes to the insulin orders. Review of Resident #47's electronic medical record revealed a 5/23/23 physician order for insulin Glargine Solution Pen injector 100 units per milliliter. Inject 25 units subcutaneously one time a day related to diabetes. Hold the Insulin if blood sugar reading less than 175. Review of Resident #47's 8/8/23 care plan revealed a focus of diabetes with history of hypoglycemia and hyperglycemia. The goal indicated Resident #47 would have no complications related to diabetes through the next review date. Interventions indicated diabetes medications as ordered by the doctor and to observe and document for side effects and effectiveness. Review of Resident #47's January 2024 electronic Medication Administration Record (MAR) revealed the following documentation: 1/1/24 resident's blood sugar was recorded as 138 and the scheduled insulin Glargine 25 units was administered by Nurse #1. 1/4/24 blood sugar was 83 and the scheduled insulin Glargine 25 units was administered by Nurse #1 at 7:38 AM. 1/6/24 blood sugar was 120 and the scheduled insulin Glargine 25 units was administered by Nurse #2 at 11:19 AM. 1/8/24 blood sugar was 102 and the scheduled insulin Glargine 25 units was administered by Nurse #1 at 8:21 AM. 1/11/24 blood sugar was 71 and the scheduled insulin Glargine 25 units was administered by Nurse #1 at 8:21 AM. 1/18/24 blood sugar was 80 and the scheduled insulin Glargine 25 units was administered by Nurse #1 at 7:58 AM. 1/23/24 blood sugar was 158 and the scheduled insulin Glargine 25 units was administered by Nurse #1 at 7:55 AM. Interview on 1/23/24 at 2:40 PM with Nurse #1 revealed a check mark with the initials on the electronic MAR indicated the dose of medication was administered. The January 2024 electronic MAR was reviewed with Nurse #1 who stated she administered Resident #47's insulin on 1/1/24, 1/4/24, 1/8/24, 1/11/24, 1/18/24, and 1/23/24. Nurse #1 stated she had not read the entire order for the insulin and had not seen the parameter to hold the insulin based on the blood sugar reading. Nurse #1 stated she made a mistake giving the medication and she should have been held Resident #47's insulin when it was below the specified blood sugar level. Attempts made to interview Nurse #2 via phone were unsuccessful. Interview on 1/23/24 at 3:00 PM with the Director of Nursing (DON) revealed Resident #47's Insulin should have been held according to the parameters indicated by the physician and this was a significant medication error. The DON indicated she expected the nurses to read and follow the entire order when they administered medications, especially insulin. The DON stated she would begin education with the nurses immediately. Interview on 1/25/24 at 10:30 AM with the Nurse Practitioner (NP) revealed she expected insulin to be given according to the physician order and the parameter to hold the medication should be followed. The NP stated it was a significant medication error to administer insulin outside of the parameters. The NP stated she was not notified that Resident #47 received doses of insulin outside of the parameter as specified in the physician order. The NP revealed that the administration of insulin Glargine 25 units for a blood sugar less than 175 had the potential for adverse effects but she was not aware of Resident #47 experiencing any of these negative effects.

Based on observation and staff interviews the facility failed to: a) ensure leftover food items were labeled and dated when stored in the walk-in refrigerator, b) discard an opened, partially used dairy product that had exceeded the shelf life, and c) ensure the temperature of a cold salad on the tray line was 41 degrees Fahrenheit or below. These practices had the potential to affect food served to residents in the facility. Findings included: During the initial tour of the kitchen on 01/22/24 at 11:15 AM the following was observed in the presence of the Dietary Manager: a. The walk-in refrigerator was observed with the following: a plastic bag of tater tots opened and partially used with no opened date and a partially used bag of shredded lettuce with no opened date. b. The walk-in refrigerator was observed with the following: a plastic bag of opened and partially used shredded cheese dated 01/04/24 (the shelf life was 14 days). c. During an inspection of food temperatures on the tray line on 01/24/24 at 12:20 PM the cold chicken salad temperature taken by the Dietary Manager was 69 degrees Fahrenheit. In an interview with the Dietary Manager on 01/24/24 at 12:48 PM she stated any food that was opened and stored in the walk-in refrigerator was to be labeled and dated. She noted the shredded cheese that had been opened on 01/04/24 should have been discarded after 01/18/24 because it had a shelf life of 14 days after opening. The Dietary Manager took the temperature of the cold chicken salad on the tray line. It was 69 degrees Fahrenheit. The salad was immediately discarded. The Dietary Manager commented that cold salad temperatures were usually taken by the cook. In an interview with [NAME] #1 on 01/24/24 at 12:58 PM she stated she had made the chicken salad that morning. She reported she had mixed the ingredients together and placed the salad in the walk-in refrigerator. She noted she normally would have taken the temperature of the salad, but she had not because she was in a hurry to prepare the meal. In an interview with the Administrator on 01/25/24 at 2:00 PM she stated she expected any food that had been opened to be dated and food that had exceeded the shelf life to be discarded. She also expected temperatures of foods on the tray line to be within specifications and recorded accurately in the temperature log for each meal.

Based on record review, observations, Nurse Practitioner interview, and staff interviews, the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint investigation survey completed on 07/19/21, an on-site revisit survey completed on 09/08/21 and a recertification and complaint investigation survey completed on 0929/22. This was for four repeat deficiencies originally cited in the areas of Pharmacy Srvcs/Procedures/Pharmacist/Records (F755), Residents Are Free of Significant Med Errors (F760), Label/Store Drugs and Biologicals (F761), and Food Procurement, Store/Prepare/Serve-Sanitary (F812). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QA program. Findings included: This tag is cross-referenced to: F755: Based on record review and staff interviews, the facility failed to secure unused narcotic medications for disposition (the process of returning unused medications to the pharmacy) resulting in possible diversion (the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use). This was for 1 of 1 discharged resident (Resident #256) reviewed for pharmacy services. During the recertification and complaint investigation survey of 09/29/22 the facility failed to acquire and administer omeprazole, a medication used to treat gastroesophageal reflux disorder. F760: Based on record review, staff and Nurse Practitioner interviews, the facility failed to follow the parameter ordered for administration of a medication used to treat diabetes resulting in 7 doses of insulin Glargine 25 units administered in error for 1 of 1 resident (Resident #47) reviewed for medication error. During the recertification and complaint investigation survey of 09/29/22 the facility failed to perform accuchecks to obtain blood sugar readings and administer the scheduled Lispro insulin 5 units along with Lispro sliding scale insulin. F761: Based on record review, observations and staff interviews, the facility failed to date opened multi-dose inhalers and an insulin pen and failed to discard loose pills in the medication cart drawers for 2 of 6 medication carts (300 Hall and 800 Hall carts). During the recertification and complaint investigation survey of 07/19/21 the facility failed to dispose of a bottle of aspirin with an illegible expiration date on the bottle, dispose of two expired insulin pens, dispose of unidentified loose pills found in the medication cart, and secure an unattended medication cart. During the on-site revisit survey of 09/08/21 the facility failed to discard an expired bulk stock medication and two expired insulin pens and failed to put an opened date on an opened insulin pen. During the recertification and complaint investigation survey 09/29/22 the facility failed to record an opened date for 5 bottles of eye drops, remove an expired insulin pen, and date a bottle of Humalog insulin when opened and to keep unattended medications stored in a locked medication cart. F812: Based on observation and staff interviews the facility failed to: a) ensure leftover food items were labeled and dated when stored in the walk-in refrigerator, b) discard an opened, partially used dairy product that had exceeded the shelf life, and c) ensure the temperature of a cold salad on the tray line was 41 degrees Fahrenheit or below. These practices had the potential to affect food served to residents in the facility. During the recertification and complaint investigation survey of 07/19/21 the facility failed to routinely monitor and document food temperatures on the steam table by not checking and recording food temperatures of the hot and cold foods prior to serving meals to residents, cover food plates on an open food cart during transportation and distribution to residents, and follow the cleaning schedule for the stovetop, front oven, and deep fryer when a buildup of grease and residue was observed on the equipment. In an interview with the Administrator on 01/25/24 at 2:00 PM she stated the citation for significant medication errors was for a different reason this year than it was in the past. She attributed the medication storage citation repetition to the hiring of new staff and the use of pens to label and date medicines that wore off during day to day use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to apply bilateral hand splints for 1 of 1 resident reviewed for positioning (Resident # 9). Findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses which included in part advanced dementia, Parkinson's disease, and abnormal posture. Review of Resident#9's 7/21/21 Occupational Therapy evaluation revealed resident with impaired range of motion (ROM) of bilateral upper extremities. Review of Resident #9's 8/16/21 Occupational Therapy Discharge Summary revealed resident was to have splint to left hand on at or prior to breakfast, remove after 3-4 hours, splint to right hand donned following removal of left hand, remove after 3-4 hours or per patient's tolerance. Review of Resident #9's physician orders revealed an order dated 12/1/21 for left hand splint on at (or prior to) breakfast, remove after 3-4 hours or per patient tolerance and splint to right hand to be applied following removal of the left-hand splint. Remove right hand splint after 3-4 hours or per patient tolerance. Review of Resident #9's care plan revealed a 12/28/21 focus which indicated resident had an activity of daily living (ADL) self-care performance deficit related to dementia, mobility impairments, and limited range of motion (ROM) with contractures in the bilateral upper and lower extremities. Interventions included to apply splint to left hand on, at or prior to) breakfast, remove after 3-4 hours or per patient's tolerance and right-hand splint to be applied following removal of left-hand splint. Remove after 3-4 hours or per patient's tolerance. Review of Resident #9's 6/23/22 quarterly minimum data set (MDS) assessment revealed resident had severe cognitive impairment, required total assistance with bed mobility, transfers, toileting and eating. Resident #9 had impaired range of motion (ROM) on both sides of her upper and lower extremities. An observation of Resident #9 on 9/26/22 at 11:30 AM revealed no splints were applied. Resident #9 was observed with both hands contracted with left hand tightly closed with thumb across palm and under her fingers. Splints were observed on nightstand in room. An observation of Resident #9 on 9/27/22 at 2:10 PM revealed no splints were applied. Resident #9 was observed with both hands contracted with left hand tightly closed with thumb across palm tucked under the other fingers. Splints were observed on the nightstand in Resident #9's room. An observation of Resident #9 on 9/28/22 at 08:30 AM revealed no splints were applied. Resident #9 was observed with both hands contracted with left hand tightly closed with thumb across palm tucked under the other fingers. Splints were observed on the nightstand in Resident #9's room. An observation of Resident #9 on 09/28/22 at 01:03 PM revealed no splints were applied. Resident #9 was observed with both hands contracted with left hand tightly closed with thumb across palm under the other fingers. Splints were observed on the nightstand in Resident #9's room. An observation of Resident #9 on 09/29/22 at 09:12 AM revealed no splints were applied. Resident #9 was observed with both hands contracted with left hand tightly closed with thumb across palm under the other her fingers. Splints were observed on the nightstand in Resident #9's room. An observation of Resident #9 on 09/29/22 at 12:26 PM revealed no splints were applied. Resident #9 was observed with both hands contracted with left hand tightly closed with thumb across palm and under her fingers. Splints were observed on nightstand in Resident #9's room. An interview was conducted on 09/27/22 at 2:10 PM with Nursing Assistant (NA) #4. NA #4 stated that she worked with Resident #9 regularly. NA #4 stated Resident #9 had not been wearing the splints for a while. NA #4 stated Resident #9's left hand contracture is worse than her right. NA #2 stated that Resident #9's left thumb stays in over her palm and it was not possible to stretch any of her fingers to extend them. An interview was conducted on 9/28/22 at 8:54 AM with the Rehab Manager. The Rehab Manager stated that when a resident was placed on a splinting program, therapy provided copies of the information regarding the splint to the Minimum Data Set (MDS) Nurse, the Director of Nursing (DON) and the Unit Manager. The Rehab Manager stated she was not informed of any changes or problems with the current splint or schedule for Resident #9. An interview was conducted on 09/28/22 at 4:33 PM with Unit Manager #1. Unit Manager #1 stated that no one had reported that Resident #9 had not been wearing the splints. Unit Manager #1 stated the NA assigned to Resident #9 was responsible for applying the splints daily. An interview was conducted on 09/29/22 at 02:19 PM with the Administrator. The Administrator revealed that her expectation is that splints be applied as ordered to all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews with staff and the physician, the facility failed to acquire and administer omeprazole, a medication used to treat gastroesophageal reflux disorder, for Resident #91 during medication pass observation on 9/28/22 at 8:30 AM. The facility also failed to administer the medication omeprazole for Resident #91 for a period of 6 days for 1 of 3 residents whose medications were reviewed. Findings included: Resident #91 was admitted to the facility on [DATE] with medical diagnoses which included in part dementia, hypertension, gastroesophageal reflux disorder, and long-term use of an anticoagulant. Review of Resident #91's medical record revealed a7/12/21 physician order for omeprazole delayed release capsule 20 milligrams give one capsule by mouth one time per day for gastroesophageal reflux disorder. Review of Resident #91's September 2022 Medication Administration Record (MAR) revealed that omeprazole was not administered and was charted by Nurse #8 as see Nurses Notes code 4 on the following dates: 9/19, 9/20,9/21, 9/22, 9/23, 9/24, 9/25, 9/27, 9/28. Review of Resident #91's nurses notes revealed notations regarding pharmacy was to be called regarding medication omeprazole. Review of Resident #91's September 2022 MAR revealed that on 9/28/22 omeprazole was charted by Nurse #8 as not administered and will follow up with pharmacy. An observation of Resident #91's medication administration on 700 Hall was conducted on 9/28/22 at 8:30 AM with Nurse # 8. The ordered omeprazole for Resident #91 was not observed in the medication cup with the other scheduled morning medications. The ordered omeprazole for Resident #91 was not observed on the medication cart and was not administered. An interview with Nurse #8 was conducted on 9/28/22 at 8:45 AM. Nurse #8 stated the omeprazole tablet for Resident #91 was not on the medication cart and she would follow up with the pharmacy. Nurse #8 stated she did not know why the medication omeprazole was not available. An interview was conducted on 09/28/22 at 04:18 PM with Unit Manager #1. Unit Manager #1 stated that the pharmacy was to be called for a medication if not available or check the Omnicell, the machine in the facility that contained emergency medication doses. Deliveries of medications from the pharmacy were received daily. The pharmacy required a prior authorization form to be completed for Resident #91's insurance for the medication omeprazole. Unit Manager #1 further stated that each month she had to call the pharmacy to obtain the medication omeprazole for Resident #91 after it was reordered. Unit Manager #1 stated she would follow up with the pharmacy regarding the prior authorization form for Resident #91. An interview was conducted on 9/28/22 at 4:50 PM with the physician for Resident #91. The physician revealed that she was not informed of omeprazole not being available for Resident #91. The physician stated Resident #91 should not experience any adverse effects from not receiving omeprazole as ordered for a few days. An interview was conducted on 9/28/22 at 5:15 PM with the Director of Nursing (DON). The DON revealed that the nurse was to call the pharmacy and the physician if a medication was not available on the med cart. DON further stated that a medication was not to be omitted due to not available. A follow up interview was conducted on 09/29/22 at 11:05 AM with the DON. The DON stated she was aware a prior authorization form was required by the pharmacy for the medication for Resident #91, but she did not know the status of the form for his current reorder. The DON stated she would follow up regarding the prior authorization form for Resident #91. The DON stated she had completed education with Nurse #8, a new nurse, regarding obtaining medications. An interview was conducted on 09/29/22 at 02:18 PM with the Administrator. The Administrator revealed that her expectation is that all residents receive medications as prescribed and there will be no omissions of medications due to not available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and physician interview the facility failed to perform accuchecks to obtain blood sugar readings and administer the scheduled Lispro insulin 5 units along with Lispro sliding scale insulin on 3 occasions (9/21/22, 9/22/22, and 9/23/22) and failed to administer scheduled Lispro insulin 5 units and Lispro sliding scale insulin on 1 occasion (09/27/22) for a blood sugar reading of 305 mg/dl (milligrams per deciliter) for 1 of 2 residents reviewed for insulin administration (Resident #247). Findings included. Resident #247 was admitted to the facility on [DATE] with a diagnoses of diabetes, and long-term use of insulin. A physician's order dated 09/08/22 revealed Insulin Lispro Solution 100 units/ml (milliliter). Inject 5 units subcutaneously three times a day for diabetes. Take before meals. A physician's order dated 09/08/22 revealed Insulin Lispro Solution 100 units/ml per Sliding Scale. Inject subcutaneously before meals for diabetes and long-term use of insulin. A care plan dated 09/09/22 revealed Resident #247 had diabetes. The goal of care was the resident would have no complications related to diabetes. Interventions included to administer diabetes medications as ordered, and to perform fasting serum blood sugars as ordered. A review of the Medication Administration Record (MAR) dated September 2022 for Resident #247 revealed to Administer 5 units of Lispro insulin three times a day. The scheduled administration times were 8:00 AM, 12:00 PM, and 4:00 PM. Further review of the MAR revealed on 09/21/22, 09/22/22, and 09/23/22 at 12:00 PM each day Nurse #11 documented NA (not applicable) for the 12:00 PM scheduled dose of 5 units of Lispro insulin. Review of the MAR dated September 2022 for Resident #247 revealed Lispro Insulin inject per sliding scale: for blood sugars of 150 - 200 give 2 units, 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units. Call physician for blood sugars greater than 400. The scheduled administration times were 7:30 AM, 11:30 AM, and 4:00 PM. Further review of the MAR revealed on 09/21/22, 09/22/22, and 09/23/22 no blood sugar was recorded for the 11:30 AM reading each day and no documentation that Lispro sliding scale insulin was administered to Resident #247 at 11:30 AM. During the survey on 09/27/22 at 2:30 PM further review of the MAR revealed no documentation of the 11:30 AM blood sugar reading for today 09/27/22 and no documentation of administration of Lispro 5 units at 12:00 PM and no sliding scale insulin was documented as administered. An interview was conducted on 09/27/22 at 2:33 PM with Nurse #11. She stated CMA #1 (certified medication aide) was the person that checked Resident #247's blood sugar at 11:30 AM today with a result of 305 mg/dl. She stated she did not recall CMA #1 reporting to her to administer sliding scale insulin to Resident #247. She stated Resident #247 never received her lunchtime (11:30 AM) dose of Lispro insulin 5 units or any sliding scale insulin today. She stated she was orienting a new nurse and was the nurse in charge of CMA #1 and stated she was busy and had not had the chance to go administer the resident's lunchtime dose of Lispro insulin. She stated it was an oversight. Nurse #11 also stated she was the assigned nurse to Resident #247 on 09/21/22, 09/22/22, and 09/23/22. She stated she documented NA on the residents MAR because she never gave the Lispro 5 units of insulin to Resident #247 for the lunchtime (11:30AM) dose on those dates. She stated her lunchtime (11:30 AM) blood sugar was not checked until after 4:00 PM on those dates so the 12:00 PM dose of Lispro 5 units was never given and stated no sliding scale insulin was administered at 11:30 AM on those dates because the blood sugars were not checked at the scheduled time. She stated it was an error on her part. An interview was conducted on 09/27/22 at 2:43 PM with CMA #1. She stated she checked Resident #247's blood sugar at 11:30 AM today which resulted in 305. She stated she usually checked all blood sugars on her assignment then when done with her medication pass, she would tell the nurse unless the blood sugar was high then she would report to the nurse right away. She stated she thought she had reported Resident 247's blood sugar reading of 305 to the nurse earlier today. A follow up interview was conducted on 09/27/22 at 3:00 PM with Nurse #11. She stated she just informed the physician of the missed insulin dose today and was instructed not to cover Resident #247 at this time since it was so late and to be sure to administer the dinner time insulin. An interview was conducted on 09/27/22 at 3:05 PM with Resident #247. She was lying in bed with her eyes closed. She was easily aroused and was alert and oriented. She stated she could not remember if she received any lunchtime insulin and stated she felt okay today. An interview was conducted on 09/27/22 at 3:14 PM with the Director of Nursing (DON). She stated there needed to be better communication between the nurse and the CMA. She stated if Nurse #11 was getting behind with her assignment she would be expected to reach out and let someone know that she needed help. She stated typically the CMA collected the blood sugars and notified the nurse at that time to administer the insulin. She stated Resident #247's blood sugars should have been checked on the dates it was omitted, and insulin should be administered as ordered. An interview was conducted on 09/27/22 at 4:24 PM with the Administrator. She stated she was made aware of the missed doses of insulin. She stated blood sugars should be checked and insulin administered as ordered. A phone interview was conducted on 09/28/22 at 4:30 PM with the physician. She stated Resident #247 not getting the lunchtime blood sugars checked and Lispro insulin not administered on 3 occasions and not getting sliding scale coverage for a blood sugar reading of 305 was a medication error. She indicated not getting the ordered insulin could potentially cause Resident #247 harm due to the resident's blood sugar fluctuations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews with staff, the facility failed to 1) record an opened date for 5 bottles of eye drops, remove an expired insulin pen and date a bottle of Humalog insulin when opened for 2 of 3 medication carts (East Wing and 700 hall). 2) failed to keep unattended medications stored in a locked medication cart for 1 of 4 medication carts observed (400 hall medication cart). Findings included: 1) Observation of East Wing Medication Cart on 9/27/22 at 1:22 PM with Nurse #1 in attendance revealed the following bottles of ophthalmic drops with no opened dates: Resident #299's Travoprost , Resident #299's Alphagan, Resident #80's Brimonidine, and Resident #80's Latanoprost 0.005%. A bottle of Refresh tears was observed in the drawer of the medication cart with room [ROOM NUMBER] B and Resident #20's name written on it and no opened date. An opened and accessed multi use vial of Humalog insulin for Resident #302 was observed in the medication cart with no opened date or discard date recorded. Interview conducted on9/27/22 at 1:30 PM with Nurse #1 revealed that insulin and eye drops should be labeled with an opened date. Observation of the 700 Hall Medication Cart on 9/27/22 at 3:37 PM with Nurse #2 in attendance revealed the following: Resident #47's opened bottle of Fluorometholene eye drops with no opened and no discard date, and Resident #18's Novolog insulin pen with a beyond use date sticker with the date recorded as 9/12/12 and no opened date recorded. Interview conducted on 09/27/22 at 03:35 PM with Nurse #2 revealed that bottles of eye drops, and Insulin should always be dated when opened. She further revealed that it was important to label the bottles with the date, so you know when they were to be discarded. Nurse #2 stated that the date recorded as the beyond use date of 9/12/2012 on Resident #18's Novolog insulin pen was invalid and therefore it should have been discarded. Nurse #2 stated she thought audits of the medication carts were completed but she did not know when or by whom. Interview conducted on 09/27/22 at 03:40 PM with Nurse #3 revealed that the date when opened should have been recorded on the bottles of eye drops and insulin. Nurse #3 stated that Resident #18's Novolog insulin pen should have been discarded due to the invalid beyond use date recorded. Interview conducted on 9/28/22 at 4:22 PM with Unit Manager #1 revealed that she had been in the position a few months. Unit Manager #1 further revealed that she and Unit Manager #2 completed monthly medication cart audits to check for labels and expired medications. Interview conducted on 9/28/22 5:15 PM with the Director of Nursing (DON) revealed that nursing staff were expected to date insulin and bottles of eye drops when opened. The DON acknowledged that the insulin pen and insulin vial were not dated properly and should have been discarded. The DON further stated that audits of the carts were to be completed but there was no ongoing monitoring regarding medication labeling and storage. 2) An observation of an unattended medication cart (400 Hall medication cart) was made on 09/27/22 at 4:05 PM. The medication cart was located in a common area near the nurse's station. The cart was noted to be unlocked without a staff member present at the cart or at the nurse's station. During the observation period staff members were observed coming out of the locked unit and walking by the unlocked medication cart. An interview was conducted with Nurse #4 on 09/27/22 at 4:10 PM. She stated she was the assigned nurse for the 400 hall and was responsible for the 400-hall medication cart. She acknowledged the medication cart was unlocked when she returned to the cart. She stated she left the medication cart to go check a resident's blood sugar and forgot to lock it. She stated it was an oversight on her part and stated she usually locked the cart before leaving it unattended. An interview was conducted with the Director of Nursing on 09/27/22 at 5:00 PM. She stated the nurse was responsible for keeping the medication cart locked and secured when unattended. She indicated Nurse #4 should have made sure the medication cart was locked before leaving it unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions put into place following the [DATE] recertification and complaint investigation survey and the [DATE] revisit survey. This was for a recited deficiency in the area of Label/Store Drugs and Biologicals (F761). The continued failure of the facility during three federal surveys of record demonstrated a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F761: Based on observation and interviews with staff, the facility failed to record an opened date for 5 bottles of eye drops, remove an expired insulin pen and date a bottle of Humalog insulin when opened for 2 of 3 medication carts (East Wing and 700 hall). The facility also failed to secure/lock an unattended medication cart for 1 of 4 medication carts. During the [DATE] recertification and complaint investigation survey the facility was cited for failing to: a) dispose of a bottle of aspirin with an illegible expiration date on the bottle, insulin pens, and unidentified loose pills in the medication cart; and b) secure an unattended medication cart. During the [DATE] revisit survey the facility was cited for failing to: a) discard expired bulk stock medication and insulin pens; and b) put an opened date on an opened insulin pen. An interview with the Administrator on [DATE] at 2:16 PM revealed that the expectation was that medications be labeled and stored appropriately. The Administrator stated that further education of the nursing staff and monitoring was needed.