**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 residents (Resident #26) reviewed for pharmacy services. The facility failed to administer the physician prescribed decreased dose of Amlodipine (a medication used to lower blood pressure) for Resident #26's peripheral edema (swelling of lower legs or hands). This failure could place residents at risk of unwanted side effects and inadequate therapeutic outcomes. Findings include: Record review of Resident #26's face sheet, dated 08/15/2024, reflected an [AGE] year-old who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included spontaneous bleeding in the brain, paralysis affecting right dominant side, stroke, imbalance of blood cholesterol, buildup of fluid around the brain, difficulty speaking and Hypertension (elevated blood pressure). Record review of Resident #26's Physician's Progress Note, date of service 6/17/2024, reflected a diagnosis which included diabetes. Record review of Resident #26's quarterly MDS (a Resident Assessment and Care Screening tool) dated 05/09/2024, reflected a BIMS score of 00 out of 15 ,which indicated severe cognitive impairment. Resident #26 had impairment to one side of the upper extremity and impairment to both sides of the lower extremity. Resident #26 was dependent on staff assistance for all ADLs. Resident #26 had an abdominal feeding tube. Record review of Resident #26's care plan reflected the resident had an ADL self-care performance deficit r/t Stroke with weakness affecting the right dominant side, date initiated was 02/13/2024. The resident had hypertension; date initiated was 2/13/2024. Interventions included to give anti-hypertensive medications as ordered. Monitor for and document any edema and notify MD. Record review of Resident #26's active orders as of 08/15/2024 reflected an order for Amlodipine 5mg, give one tablet via Gastrostomy tube or G-tube (feeding tube inserted into the abdomen) one time a day for Hypertension, dose decreased due to peripheral edema, date ordered 08/14/24 and start date was 08/15/24. Record review of Resident #26's MAR for August 2024 reflected, LVN A documented the administration of Amlodipine 5mg tablet on 08/14/2024 at 8:00 AM. Further review reflected Amlodipine 10mg tablet was started on date 02/01/2024 and discontinued on 08/14/2024. In an observation and interview on 08/15/2024 at 6:50 AM, Resident #26 was alert but did not speak. The head of the bed was elevated. Resident #26's hands, fingers and lower arms were swollen, and her fists were softly clenched. LVN A washed her hands, donned (put on) PPE. LVN A checked Resident #26's blood sugar, it was 193. LVN A checked Resident #26's blood pressure and it was 147/55, with a pulse of 102. LVN A removed the PPE and performed hand hygiene. LVN A prepared Resident #26's medications. LVN A sanitized her hands and placed each of the following medications into individual medicine cups: Amlodipine 10mg tablet, Fenofibrate 145mg tablet, Lisinopril 10mg tablet, Metoprolol 50mg tablet, Famotidine 20mg tablet and potassium chloride 20meq powder packet. LVN A crushed each tablet individually and prepared the NPH (Neutral Protamine [NAME]) insulin (a type of insulin which regulates the amount of glucose in the blood). LVN A washed her hands at the sink and donned PPE. LVN A added 10ml of warmed water from the faucet to each medication cup and added 120ml of water to the cup with the potassium chloride powder. LVN A disconnected the feeding tube from the G-tube and checked Resident #26's G-tube for placement using the stethoscope then checked for residual. There was zero residual. LVN A attached the 60ml syringe barrel to the end of G-tube and poured 30ml of water to flush via gravity. LVN A poured medication from the first cup into the syringe barrel, followed by 10ml of water and repeated the process with the remaining medications. After all medications were infused, LVN A poured 30ml of water to flush and closed the end of the G-tube. LVN A stated she would not connect the tube feeding d/t it was time for the resident to have bowel rest for 4 hours. LVN A removed gloves, performed hand hygiene, donned clean gloves, cleansed Resident #26's skin on the abdomen and administered 12units of NPH insulin to Resident #26's lower right quadrant. In an interview on 08/15/2024 at 10:00 AM, LVN A stated she missed correctly reading the dose for Resident #26's Amlodipine. LVN A stated she should have given 5mg of Amlodipine instead of 10mg. LVN A stated the order was changed yesterday (8/14/2024) d/t peripheral edema. LVN A stated the risk to Resident #26 was edema if the ordered dose was not given. LVN A stated her last in-service on Medication Administration was about one month ago. LVN A stated when she administered medications she should check for the right person, right medication, right dose, this time she did not see the right dose and she should check for the right time. LVN A stated she would let the DON know of the medication error. In an interview on 08/15/2024 at 10:15 AM, the DON stated she expected the nurses to be looking at the physician order, compare the blister pack to the MAR, if the medication required a blood pressure, then it should be explained to the resident and then the nurse would sign for the medication. The DON stated she would start a medication error report. The DON stated she instructed LVN A to notify the MD and RP and to always check the MAR when administering a medication. When asked what the risks were to the resident, the DON stated she did not have the lab results in front of her but assumed the labs were better than what they were, and the MD wanted to reduce the dose of the Amlodipine. When asked how she ensured the nurses and medication aides were administering medications per policy and procedures, the DON stated she conducted end of the month in-services for reminders on medication pass, which included to make sure they told the alert residents what medications they were given. Record review of the facility's policy on Administering Medications through an Enteral Tube, revised April 2007, read in part: The purpose of this procedure provide guidelines for the safe administration of oral medications .General Guidelines, follow the medication administration guidelines in the policy entitled Administering Medications .Steps in the Procedure .6. Check the label on the medication and confirm the medication name and dose with the MAR. 7. Check the expiration date on the medication .8. Check the medication dose. RE-check to confirm the proper dose

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an irregularity noted by the pharmacist was acted upon for 1 (Resident #4) of 6 residents reviewed for pharmacy review. The facility failed to ensure: 1. The pharmacist's Physician Notification Letter dated 03/07/2023 reflected Resident #4 had a routine order for a medication (Robitussin Nighttime DM [Dextromethorphan]) that was not recommended for routine use in the elderly. 2. The pharmacist's Physician Notification Letter dated 05/09/2023 reflected Resident #4 was still receiving the medication routinely as of 6/14/23. The physician signed the 05/09/2023 letter, agreeing to discontinue the routine administration of the medication . These failures could place residents at risk for complications resulting from receiving a medication contraindicated for routine use. Findings Include: Record review of the admission Record (printed 06/15/2023) revealed Resident #4 was 84-years-old, admitted to the facility on [DATE]. Diagnoses included muscle weakness, asthma (breathing difficulty), insomnia (difficulty sleeping), and chronic respiratory failure (breathing difficulty). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed she scored 15/15 on the BIMS, indicative of intact cognition. She required limited assist for bed mobility and transfers. She used a wheelchair for mobility. The MDS reflected Resident #4 received a hypnotic (medication to help sleep) for all seven days of the seven-day look-back period. Record review of Resident #4's Care Plan dated 05/16/2023 read in part . Resident #4 receiving a sedative or hypnotic . Goal: the resident will be free of any discomfort or adverse side effects. Intervention: Administer sedative/hypnotic medications as ordered by the physician . Record review of Resident #4's Medication Regimen Review note dated 03/07/2023 read in part that a Physician Notification Letter was sent on 03/07/2023 . Record review of Resident #4's pharmacy Physician Notification Letter dated 03/07/2023 read in part that Resident #4 was receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. The letter reflected .Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula) . Accept/decline' and physician signature areas were blank. Record review of Resident #4's Medication Regimen Review note dated 04/12/2023 read in part Check for response to 3/7/2023 letter to PCP to stop routine Robitussin Nighttime cough. Follow up: change the medication to PRN . Record review of Resident #4's Medication Regimen Review note dated 05/09/2023 read in part . Re-send the letter to discontinue the routine Robitussin Nighttime DM. Nurse Follow-Up: Noted . Record review of Resident #4's pharmacy Physician Notification Letter dated 05/09/2023 read in part . Receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula). Accept/decline' and physician signature areas marked 'accept' and scribed D/C Robitussin Nighttime DM by Nurse Practitioner (05/11/2023) . Record review of Resident #4's Medication Regimen Review note dated 06/13/2023 read in part . Routine Robitussin Nighttime DM medication to be discontinued . Record review of Resident #4's MAR dated June 2023 read in part . Routine Robitussin Nighttime Cough DM . The MAR reflected Resident #4 received the medication every night up to 06/13/23 . Observation and interview on 06/14/2023 at 3:40 p.m., the DON said per the facility protocol for pharmacy reviews, she was responsible for reviewing the Medication Regimen Review notes, then on the following day she gave the Physician Notification Letters to the physician. She said the recommendations were to be implemented within seven days. The Surveyor presented Resident #4's pharmacy review note scribed in nurse's follow-up notes on 4/12/23. The DON said the note scribed in the 04/12/2023 Nurse Follow-Up area for the medication to be changed to PRN was her writing. This Surveyor asked if Resident #4 was still receiving the routine Robitussin medication. The DON pulled up the electronic MAR dated June 2023. She verbally acknowledged Resident #4 was still receiving the routine Robitussin Nighttime Cough DM nightly. Interview on 06/14/2023 at 3:50 p.m., the DON said she had spoken to Resident #4, and the resident wanted to receive the medication every night. When asked if the physician had been informed, the DON said she would notify the physician at this time. Interview on 06/15/2023 at 3:15 p.m., the DON said the Charge Nurse was responsible to update the orders when a pharmacy recommendation was received. She said the order for Resident #4 had just been overlooked. Record review of the facility policy Medication Regimen Review (revised 04/07/2022) revealed .The Director of Nursing will be responsible in assuring that each resident's Medication Review Record is reviewed and follow-up actions to recommendations are documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #4) of 6 residents reviewed for pharmacy services had a drug regimen that was free from an unnecessary drug, which was administered for an excessive duration. The facility failed to ensure: 1. The pharmacist's Physician Notification Letter dated 03/07/2023 reflected Resident #4 had a routine order for a medication (Robitussin Nighttime DM [Dextromethorphan]) that was not recommended for routine use in the elderly. 2. The pharmacist's Physician Notification Letter dated 05/09/2023 reflected Resident #4 was still receiving the medication routinely as of 6/14/23. The physician signed the 05/09/2023 letter, agreeing to discontinue the routine administration of the medication. 3. The MAR for Resident #4 for March, April, and May 2023 reflected the medication was administered to the resident nightly. 4. The June 2023 MAR for Resident #4 reflected the medication was administered to the resident nightly until 06/13/2023. 5. The surveyor inquired about the medication on 06/14/2023. The routine order was discontinued that day. These failures could place residents at risk for complications resulting from receiving a medication contraindicated for extended routine use. Findings Include: Record review of the admission Record (printed 06/15/2023) revealed Resident #4 was 84-years-old, admitted to the facility on [DATE]. Diagnoses included muscle weakness, asthma (breathing difficulty), insomnia (difficulty sleeping), and chronic respiratory failure (breathing difficulty). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed she scored 15/15 on the BIMS, indicative of intact cognition. She required limited assist for bed mobility and transfers. She used a wheelchair for mobility. The MDS reflected Resident #4 received a hypnotic (medication to help sleep) for all seven days of the seven-day look-back period. Record review of Resident #4's Care Plan dated 05/16/2023 read in part . Resident #4 receiving a sedative or hypnotic . Goal: the resident will be free of any discomfort or adverse side effects. Intervention: Administer sedative/hypnotic medications as ordered by the physician . Record review of Resident #4's Medication Regimen Review note dated 03/07/2023 read in part that a Physician Notification Letter was sent on 03/07/2023 . Record review of Resident #4's pharmacy Physician Notification Letter dated 03/07/2023 read in part that Resident #4 was receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. The letter reflected .Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula) . Accept/decline' and physician signature areas were blank. Record review of Resident #4's Medication Regimen Review note dated 04/12/2023 read in part Check for response to 3/7/2023 letter to PCP to stop routine Robitussin Nighttime cough. Follow up: change the medication to PRN . Record review of Resident #4's Medication Regimen Review note dated 05/09/2023 read in part . Re-send the letter to discontinue the routine Robitussin Nighttime DM. Nurse Follow-Up: Noted . Record review of Resident #4's pharmacy Physician Notification Letter dated 05/09/2023 read in part . Receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula). Accept/decline' and physician signature areas marked 'accept' and scribed D/C Robitussin Nighttime DM by Nurse Practitioner (05/11/2023) . Record review of Resident #4's MARs dated March. April, and May 2023 revealed the order for routine Robitussin Nighttime Cough DM was in place, and the facility administered the medication nightly for those three months. Record review of Resident #4's Medication Regimen Review note dated 06/13/2023 read in part . Routine Robitussin Nighttime DM medication to be discontinued . Record review of Resident #4's MAR dated June 2023 read in part . Routine Robitussin Nighttime Cough DM . The MAR reflected Resident #4 received the medication every night in June 2023 up to 06/13/23 . Observation and interview on 06/14/2023 at 3:40 p.m., the DON said per the facility protocol for pharmacy reviews, she was responsible for reviewing the Medication Regimen Review notes, then on the following day she gave the Physician Notification Letters to the physician. She said the recommendations were to be implemented within seven days. The Surveyor presented Resident #4's pharmacy review note scribed in nurse's follow-up notes on 4/12/23. The DON said the note scribed in the 04/12/2023 Nurse Follow-Up area for the medication to be changed to PRN was her writing. This Surveyor asked if Resident #4 was still receiving the routine Robitussin medication. The DON pulled up the electronic MAR dated June 2023. She verbally acknowledged Resident #4 was still receiving the routine Robitussin Nighttime Cough DM nightly. Interview on 06/14/2023 at 3:50 p.m., the DON said she had spoken to Resident #4, and the resident wanted to receive the medication every night. When asked if the physician had been informed, the DON said she would notify the physician at this time. Interview on 06/15/2023 at 3:15 p.m., the DON said the Charge Nurse was responsible to update the orders when a pharmacy recommendation was received. She said the order for Resident #4 had just been overlooked. Record review of the facility policy Medication Regimen Review (revised 04/07/2022) revealed .The Director of Nursing will be responsible in assuring that each resident's Medication Review Record is reviewed and follow-up actions to recommendations are documented.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure: -Previously opened frozen foods were not sealed or labeled with the date they were opened. -Previously opened refrigerated foods were not sealed or labelled with the date they were opened. -Non-perishable foods in the pantry were not labelled with the date they were opened. The failure placed residents at risk for food-borne illness associated with improper food storage. Findings include: Findings include: Observation on 06/13/2023 at 8:00 a.m., revealed the facility was part of a campus that included assisted and independent living. All three entities were serviced by the same kitchen. Observation and interview on 06/13/2023 at 8:22 a.m., revealed the DM accompanied the surveyor to tour the kitchen area. Observation of the walk-in freezer revealed an unsealed box of frozen cookies. There was no label to indicate the date it was opened. Observation revealed an open and unsealed box of Beyond Burgers plant-based patties. There was no label to indicate the date it was opened. Observation revealed an opened/resealed box of flat bread. There was no label to indicate the date it was opened. The DM said they do not date the packages when they open them. Observation on 06/13/2023 at 8:25 a.m., of the walk-in refrigerator revealed a five-pound bag of Zesty Peeled Garlic was open on the shelf. It was a resealable bag, but it was not sealed. There was no label to indicate the date it was opened. Observation on 06/13/2023 at 8:29 a.m., revealed the dry pantry contained a previously opened large bag of uncooked ziti. It was sealed with transparent plastic wrap. There was no label to indicate when the bag was opened. The bag was in a box with sealed ziti. Interview on 06/13/2023 at 8:30 a.m., the DM said if the foods were in the original containers, they do not date them because they have a year shelf life. He said they should have dated them. Record review of the facility policy Food Storage Policy (no date) provided by the facility on 06/15/2023 revealed .When item is removed from stock and opened for use and subsequent storage, an open on date should be placed on the package. The United States Public Health Service Food Code, 2013, page 92, reflects .at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .