**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 22 sampled residents, a resident taking an anticoagulant medication received two doses in error on one day. Resident identifier: 109. Findings included: Resident 109 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, persistent atrial fibrillation and long term use of anticoagulants. On 5/12/25 at 3:50 PM, an interview was conducted with resident 109. Resident 109 stated the facility International Normalized Ratio (INR) machines did not work. Resident 109 stated the nurse went through three machines the other day before she could get a reading. Resident 109 stated he was not sure if it was the test strips or the machines. Resident 109's medical record was reviewed. A physician's order dated 5/9/25, documented warfarin 3 milligrams (mg) once a day. The physician's order was dated to start on 5/9/25. A physician's order dated 5/9/25, documented warfarin 2.5 mg once a day. The physician's order was dated to start on 5/10/25. The May 2025 Medication Administration Record was reviewed. On 5/9/25, resident 109 was administered 2.5 mg and 3 mg of warfarin. It should be noted that resident 109 should have only received 3 mg of warfarin on 5/9/25. The INR results were reviewed. a. On 5/9/25, INR 1.7 b. On 5/11/24, INR 3 On 5/14/25 at 10:10 AM, a Nursing progress note documented Pt [prothrombin time] INR is 3.4. [name redacted] NP [Nurse Practitioner] notified. Awaiting new orders. On 5/20/25 at 1:02 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when there was a scheduled dose of the medication they did not discontinue the order completely. The DON stated staff were able to put the dose of medication on hold and order the alternate dosage by however many doses then resume previous order. The DON confirmed that on 5/9/25, there was a medication error where a second dose of warfarin was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 22 sampled residents, a resident had a basic metabolic panel (BMP) and complete blood count (CBC) collected without a physician's order. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, sepsis due to methicillin susceptible staphylococcus aureus, pneumonia, chronic respiratory failure with hypoxia, systolic heart failure, chronic kidney disease, and anemia. Resident 15's medical record was reviewed. An interim lab report was located within resident 15's medical record. A BMP and CBC were collected on 4/20/25 at 7:15 PM. A physician's order for the BMP and CBC were unable to be located. On 5/14/25 at 10:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was trying to get a hold of the provider regarding the physician order for the labs. At 11:04 AM, the DON confirmed that she was unable to locate the physician order. At 11:13 AM, the DON stated staff had put the wrong sticker on the wrong patient for the lab to be drawn. The DON stated that resident 15 should not have had the BMP and CBC drawn. The DON stated the physician order was in and the lab was drawn on both residents when the staff realized what had happened.

Based on observation and interview, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, for 1 out of 22 sampled residents, a nurse did not perform hand hygiene, assisted a pill with their bare finger from the medication bottle to the medication cup, and administered the medications to a resident. Resident identifier: 97. Findings included: On 5/14/25 at 7:56 AM, Licensed Practical Nurse (LPN) 2 was observed to prepare and administer medications to resident 97. LPN 2 was observed to assist a pill with their bare finger from the medication bottle to the medication cup with the other prepared medications. LPN 2 was observed to administer the medications to resident 97. LPN 2 was observed to prepare two resident's medications prior to resident 97 and LPN 2 was observed to not perform hand hygiene before or after the medication administrations. On 5/14/25 at 9:22 AM, an interview was conducted with LPN 2. LPN 2 stated that she would try to hand sanitize as she left the resident room. LPN 2 stated if she thought about it she would also use the hand sanitizer on the medication cart between residents. On 5/14/25 at 12:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff during medication pass should be hand washing often if there hands became soiled. The DON stated that alcohol based hand rub should be used between residents. The DON stated that staff should not be touching medications with their bare hands. The facility Handwashing Policy and Procedure was reviewed. GENERAL INFORMATION Handwashing before and after contact with any patient is the most important measure that can be taken to prevent the spread of infection. POLICY 1. All employees' hands must be washed when visibly dirty or contaminated or visibly soiled with blood or other body fluids. 11. Before passing medications or giving injections; 12. During any medication pass as dictated by professional standards; . 22. Whenever your hands are visibly soiled; . 24. As soon as possible after using waterless or antiseptic hand cleansers or towelettes; . PURPOSE 1. To learn a safe and economical method of Handwashing. 2. To protect yourself and others from harmful microorganisms. 3. To prevent transmission of infection from one patient to another via the health care worker. 4. To remove transient bacteria on hands contaminated after handling patients, objects, and surfaces. 5. To prevent personal illness. Version A10013.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 3 out of 22 sampled residents, five opened insulin injector pens were not labeled with open dates or a discard date, and they were in the medication cart available for resident use. Resident identifiers: 104, 107, and 109. Findings included: On 5/14/25 at 9:29 AM, an observation was conducted of the Hall 3 medication cart with Licensed Practical Nurse (LPN) 1. There were five insulin injector pens in the medication cart that were not labeled with an open date or a discard date. LPN 1 stated that she would date the insulin on the lids with an open date when they were opened and she thought the insulin was good for 30 days after opening. 1. Resident 104 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, metabolic syndrome, and long term use of insulin. Resident 104's insulin lispro pen 100 unit/milliliter (ml) and Novolin FlexPen 100 unit/ml were not labeled with an open date or a discard date and were available for use in the medication cart. 2. Resident 107 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with hypoglycemia and long term use of insulin. Resident 104's Novolin FlexPen 100 unit/ml was not labeled with an open date or a discard date and was available for use in the medication cart. 3. Resident 109 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease, long term use of insulin, and long term use of oral hypoglycemic drugs. Resident 109's insulin lispro pen 100 unit/ml and Lantus Solostar pen were not labeled with an open date or a discard date and were available for use in the medication cart. On 5/14/25 at 12:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when an insulin pen was newly opened the staff should label it with an open date. The DON stated the insulin was usually good for 28 days but it would depend on the insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not consult with the resident's physician and notify when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment. Specifically, the resident had elevated blood sugar levels while waiting for the arrival of their insulin pen and the physician was not notified. Resident identifier 77. Findings included: Resident 77 was admitted to the facility on [DATE] with diagnoses which consisted of type 2 diabetes mellitus (DM), morbid obesity, postprocedural seroma of skin, urinary tract infection, hypothyroidism, hyperlipidemia, depression, hypertension, repeated falls, and long term use of insulin. On 6/27/23, resident 77's medical records were reviewed. Review of resident 77's physician orders revealed the following: a. Tresiba FlexTouch insulin pen, inject 12 units subcutaneously one time a day. Special Instructions: Diagnosis: DM **Pt own supply**. b. Check blood sugar every morning (QAM) & every evening at bedtime (QHS). Special Instructions: If blood glucose (BG) is greater than (>) 250 & sliding scale has not been ordered, notify the Medical Doctor (MD). If BG is less than (<) 60 follow hypoglycemia procedure. c. If BG > 250 & sliding scale has not been ordered, notify MD. If BG < 60 follow hypoglycemia procedure as needed (PRN). Review of resident 77's June 2023 Medication Administration Record (MAR) revealed the following: a. On 6/23/23 at 9:18 PM, the BG was 306. b. On 6/24/23 at QHS, the BG was 335. c. On 6/25/23 at QHS the BG was 329. d. On 6/26/23 at 7:25 PM, the BG was 377. The note documented Pt (patient) still waiting on own supply of insulin s/b (should be) here tomorrow AM On 6/27/23 at 3:27 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that they called the physician for any orders that specified to call or to obtain any new orders. LPN 1 stated that depending on the medication the pharmacy usually had it delivered within a couple of hours or by the end of the day. LPN 1 stated that if the medication was not available in the facility they would chart it in the MAR and document under the notes the reason for why they did not have that medication. LPN 1 stated that she was not aware of any residents that were still awaiting medication orders. LPN 1 stated that the residents did not usually supply their own medication. The Director of Nursing (DON) joined the interview. The DON stated that sometimes there were medications that the pharmacy did not carry or if it was a high priced medication the resident would use their own supply. Sometimes they will request to bring the medication from home. The DON stated that they were waiting for resident 77's insulin. The DON stated that she had called the pharmacy this morning to request the medication. The DON stated that if resident 77 had an increase in BG and it was far from baseline then that would be considered unstable. The DON stated that the physician should be notified of BG levels over the 350. ON 6/27/23 at 4:01 PM, a follow-up interview was conducted with the DON. The DON stated they should have obtained the insulin sooner and they should have notified the physician. The DON stated that she had provided education to the nursing staff about prompt physician notification when medication was not available within 24 hours after admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident with elevated Blood Glucose (BG) levels did not receive their insulin injection for 4 days after admission. Additionally, the same resident experienced constipation and did not have the bowel protocol orders administered per the standing orders for constipation. Resident identifier 77. Findings included: Resident 77 was admitted to the facility on [DATE] with diagnoses which consisted of type 2 diabetes mellitus (DM), morbid obesity, postprocedural seroma of skin, urinary tract infection, hypothyroidism, hyperlipidemia, depression, hypertension, repeated falls, and long term use of insulin. On 6/27/23, resident 77's medical records were reviewed. 1. On 6/27/23 at 9:23 AM, an interview was conducted with resident 77. Resident 77 stated that she was an insulin dependent diabetic and she had not had any insulin since she was admitted to the facility. Resident 77 stated that she forgot to pack her home insulin with her belongings. Resident 77 stated that at home she took 12 units of insulin daily. Resident 77 stated that her friend was supposed to bring her medication but she had not arrived yet. Review of resident 77's physician orders revealed the following: a. Tresiba FlexTouch insulin pen, inject 12 units subcutaneously one time a day. Special Instructions: Diagnosis: DM **Pt own supply**. b. Check blood sugar every morning (QAM) & every evening at bedtime (QHS). Special Instructions: If blood glucose (BG) was greater than (>) 250 & sliding scale has not been ordered, notify the Medical Doctor (MD). If BG was less than (<) 60 follow hypoglycemia procedure. c. If BG > 250 & sliding scale has not been ordered, notify MD. If BG < 60 follow hypoglycemia procedure as needed (PRN). Review of resident 77's June 2023 Medication Administration Record (MAR) revealed the following: a. On 6/23/23 at 9:18 PM, the BG was 306. b. On 6/24/23 at 8:05 AM, the BG was 167. c. On 6/24/23 at QHS, the BG was 335. d. On 6/25/23 at QAM, the BG was 135. e. On 6/25/23 at QHS the BG was 329. f. On 6/26/23 at 7:48 AM, the BG was 158. g. On 6/26/23 at 7:25 PM, the BG was 377. h. On 6/27/23 at QAM, the BG was 221. Resident 77's June MAR for the Tresiba insulin pen documented the following: a. On 6/24/23 at 9:33 AM, the note documented, Not Administered: Drug/Item unavailable. Comment: pt (patient) family will bring this afternoon. b. On 6/25/23 at 7:51 AM, the note documented, Not Administered: Drug/Item unavailable. Comment: Pt family delivering today 6/25. c. On 6/26/23 at 9:39 AM, the note documented, Not Administered: Other. Comment: Awaiting pt's family to deliver. d. On 6/26/23 at 7:25 PM, the note documented, Pt still waiting on own supply of insulin s/b (should be) here tomorrow AM e. On 6/27/23 at 7:29 AM, the note documented, Not Administered: Other. Comment: waiting for pt's family to deliver. On 6/27/23 at 3:27 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that they called the physician for any orders that specified to call or to obtain any new orders. LPN 1 stated that depending on the medication the pharmacy usually had it delivered within a couple of hours or by the end of the day. LPN 1 stated that if the medication was not available in the facility they would chart it in the MAR and document under the notes the reason for why they did not have that medication. LPN 1 stated that she was not aware of any residents that were still awaiting medication orders. LPN 1 stated that they would document in the MAR that the medication was unavailable. LPN 1 stated that the residents did not usually supply their own medication. The Director of Nursing (DON) joined the interview. The DON stated that sometimes there were medications that the pharmacy did not carry or if it was a high priced medication the resident would use their own supply. Sometimes they will request to bring the medication from home. The DON stated that they were waiting for resident 77's insulin. The DON stated that she had called the pharmacy this morning to request the medication. The DON stated that she was informed that resident 77's blood glucose levels were stable. The DON stated that if resident 77 had an increase in BG and it was far from baseline then that would be considered unstable. The DON stated that the physician should be notified of BG levels over the 350. The DON stated that the admission nurse would ask the resident about their baseline BG levels. The DON stated that staff should notify the DON within 24 hours of admission if the medication had not arrived. ON 6/27/23 at 4:01 PM, a follow-up interview was conducted with the DON. The DON stated that she reviewed resident 77's home health documentation and resident 77 was more elevated in the evenings at the facility as opposed to at home. The DON stated they should have obtained the insulin sooner and they should have notified the physician. The DON stated that she had provided education to the nursing staff about prompt physician notification when medication was not available within 24 hours after admission. The DON stated that she had notified the pharmacy to make the medication available. The DON stated that the risks of not administering the insulin were coma, altered mental status, altered wound healing, and exacerbation of other co-morbidities. 2. On 6/27/23 at 9:12 AM, an interview was conducted with resident 77. Resident 77 stated that she had not had a bowel movement (BM) since being admitted to the facility. Resident 77 stated that she was getting an enema today. Resident 77 stated that normally she would have coffee daily and that usually got her bowels moving. Resident 77 stated that she was ill and had been vomiting all morning. Resident 77 stated that the facility had been providing stool softeners. Prune juice was observed at resident 77's bedside. Resident 77 stated that she ordered the prune juice yesterday, but she had not been able to drink any of it yet. Resident 77 stated that she had just thrown up all her breakfast. Resident 77 stated that she was on narcotic pain medication, and she was not receiving a laxative. Review of resident 77's physician orders revealed the following: a. Docusate sodium tablet, give 100 milligrams (mg) by mouth (PO) every 12 hours PRN for constipation. The order was initiated on 6/23/23. b. Hydrocodone-acetaminophen tablet 5-325 mg, give 1 tablet by mouth every 6 hours PRN for pain scores of 4-10/10. The order was initiated on 6/23/23. c. Document Bowel Movement every shift. The order was initiated on 6/23/23. d. Day 3 (Bowel Brigade) = Administer Milk of Magnesia (MOM) 30 ml by mouth in the morning PRN. The order was initiated on 6/23/23. e. Day 4 (Bowel Brigade) = Administer Dulcolax 10 mg by mouth (PO) or per rectum (PR) in the morning PRN. The order was initiated on 6/23/23. f. Day 5 (Bowel Brigade) = Administer Fleets Enema in the morning PRN. The order was initiated on 6/23/23. g. Day 6 (Bowel Brigade) = If no BM in greater than 5 days, notify physician for further orders. The order was initiated on 6/23/23. Review of resident 77's June 2023 Medication Administration Record (MAR) revealed the following: a. On 6/23/23 at 9:04 PM, the Docusate Sodium 100 mg PRN was documented as not administered as the resident requested Milk of Magnesia (MOM) instead. The comments documented that the resident had reported no BM for 3 days. b. On 6/23/23 at 9:10 PM, Day 3 (Bowel Brigade) = Administer Milk of Magnesia 30 ml was administered. The comments documented that it was administered at the resident's request and was not effective, no BM. c. On 6/24/23 at 8:55 PM, Day 4 (Bowel Brigade) = Administer Dulcolax 10 mg PO or PR was administered. The comments documented that it was not effective, no BM. It should be noted that Day 5 and Day 6 (Bowel Brigade) was not documented as administered. d. On 6/28/23 at 3:32 AM, Day 3 (Bowel Brigade) = Administer Milk of Magnesia 30 ml's PO was administered. The comments documented that the medication was administered per the resident request and Pt feels it moving but hasn't had a BM yet. e. On 6/28/23 at 9:17 AM, Day 4 (Bowel Brigade) = Administer Dulcolax 10 mg was administered. The comments documented Enemeez to be administered d/t (due to) no BM in days. Review of resident 77's progress notes revealed the following: a. On 6/24/23 at 3:35 PM, the note documented that resident 77's abdomen was soft, non-tender with active bowel sounds in all 4 quadrants. The note documented that resident 77 had not had a BM yet today. b. On 6/24/23 at 11:37 PM, the note documented that resident 77's abdomen was non-tender upon palpation and resident 77 reported no BM today. c. On 6/26/23 at 4:55 PM, the note documented that resident 77 denied discomfort related to bowel or bladder and bowel sounds were present in all 4 quadrants. d. On 6/28/23 at 12:23 AM, the note documented that resident 77 had not had a BM since arrival and had requested an enema and then refused when the nurse brought the supply and requested to wait until a better time. Review of resident 77's point of care tracking for bowel function documented the following: a. On 6/24/23 at 3:22 PM, documented no BM. b. On 6/25/23 at 4:18 PM, documented no BM. c. On 6/25/23 at 6:53 PM, documented no BM. d. On 6/26/23 at 3:41 PM, documented no BM. e. On 6/27/23 at 4:53 PM, documented no BM. On 6/28/23 at 8:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the bowel protocol was a standing order for all residents. On 6/28/23 at 9:16 AM, RN 1 stated that she was going to give resident 77 an enema this morning. RN 1 stated that they had been providing resident 77 with the orders per the bowel protocol. Resident 77 stated she felt full and had just finished vomiting. On 6/28/23 at 9:23 AM, an observation was made of RN 1 administering Enemeez (Docusate Sodium) 283 mg/5 ml PR to resident 77. On 6/28/23 at 9:46 AM, an interview was conducted with RN 1. RN 1 stated that the resident had not had a BM for 6 days. RN 1 stated that the bowel protocol was to administer medications on day 3, 4, 5, and 6 for constipation. RN 1 stated that they were to notify the physician when the bowel protocol was initiated. RN 1 stated that she informed the Physician's Assistant (PA) 1 and that documentation should be in the progress note. RN 1 stated that she was not aware that the resident had been vomiting. It should be noted that RN 1 was present when resident 77 had stated that she had just finished vomiting this morning. RN 1 stated that the monitoring for a BM was done by the Certified Nurse Assistants (CNA) daily. RN 1 stated that she was provided a bowel management report daily that notified her of each resident's BM. RN 1 stated that the report was printed and given to the next shift. RN 1 stated that on Monday, 6/26/23, resident 77 refused the Enemeez and stated that she would like it later in the day or after dinner. RN 1 stated that she did not document that the medication was refused by resident 77. RN 1 stated if it's not documented it's not done. RN 1 stated that she was pretty sure resident 77 had MOM yesterday, but it was not documented. The documented bowel protocol was reviewed with RN 1. RN 1 confirmed that according to the documentation on the MAR the bowel protocol was not followed. Medication was documented as administered on 6/23/23, 6/24/23 and again on 6/28/23. No medication was administered for constipation on 6/25/23, 6/26/23, and 6/27/23 per the bowel protocol. On 6/28/23 at 10:03 AM, an interview was conducted with the DON. The DON stated that they had a bowel protocol standing order that should be initiated after no BM for 3 days. The DON stated that on day 3 the protocol was to administer MOM, day 4 the protocol was to administer a Dulcolax suppository, day 5 was to administer a Fleets enema, and on day 6 staff should notify the physician. The DON stated that if the resident was vomiting the physician should be informed. The DON stated that she would probably obtain a kidney, ureter, and bladder (KUB) X-ray to determine if there was a bowel obstruction. The DON stated that they would conduct a medication evaluation for prevention of constipation to see what opiates were used. The DON stated that monitoring of BM was completed by the CNAs and if the resident was continent then they were to ask the resident if they had a BM that shift. The DON stated that the licensed nurse would conduct an assessment, exchange a bowel management report that would show a history of the BM for the last 7 days, and treat accordingly. The DON reviewed the MAR and confirmed that resident 77 received Docusate 100 mg and MOM on 6/23/23, Dulcolax 10 mg on 6/24/23, no medication on 6/25/23, 6/26/23, or 6/27/23, and then MOM and Enemeez on 6/28/23. On 6/28/23 at 10:40 AM, CNA 1 was heard stating over the radio that resident 77 had not had a BM yet and was requesting another enema. On 6/28/23 at 10:58 AM, a follow-up interview was conducted with the DON. The DON stated that she informed resident 77 that she was contacting the physician regarding her constipation. The DON stated that on Monday resident 77 requested that the DON buy her smoked oysters and prune juice. The DON stated that she bought 2 bottles of prune juice and resident 77 had been drinking them. The DON stated that resident 77 ate the oysters and reported that the oysters usually worked for treating constipation. The DON stated that resident 77 reported that she was nauseated and was vomiting bile, and this was not new for her. The DON stated that resident 77 informed her that she had previously taken Lactulose and this was not something that was currently ordered by the facility. The DON stated that she would inform the physician and get the Lactulose ordered. The DON stated that the physician visited resident 77 on 6/26/23 and was aware of the constipation, but at the time resident 77 had no complaints of nausea and vomiting. The DON stated that they had other bowel protocol orders if the resident had any history of constipation of was status post surgery. The DON stated that the Enemeez was new as a standing order. The DON stated that the Enemeez was a smaller amount and the residents could retain it better than the Fleets Enema. On 6/28/23 at 11:35 AM, the DON stated that resident had a BM. The DON stated that the physician had ordered to start Lactulose 10 mg/15 ml every day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, medications were not administered to a resident due to being unavailable. Resident identifier 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, cerebral infarction, acute bronchitis, acute respiratory failure, chronic obstructive pulmonary disease, gout, hypotension, a-fib, thrombophilia, chronic kidney disease, hyperlipidemia, hypothyroidism, dementia, and back pain. On 6/28/23 resident 15's medical records were reviewed. Review of resident 15's physician orders revealed the following: a. Allopurinol tablet 300 milligram (mg), give one tablet by mouth at bedtime for gout. The order was initiated on 6/9/23. b. Cholecalciferol (vitamin D3) capsule 25 mcg (micrograms) (1,000 unit), give 2 capsules (50 mcg) by mouth at bedtime. The order was initiated on 6/9/23. c. Isosorbide mononitrate tablet extended release 60 mg, give one tablet by mouth one time a day for atrial fibrillation. The order was initiated on 6/9/23. d. Magnesium oxide tablet 400 mg, give one tablet by mouth one time a day. The order was initiated on 6/9/23. e. Metamucil (psyllium husk) powder 3.4 gram/5.4 gram, give 3.4 gm by mouth one time a day between breakfast and lunch. The order was initiated on 6/9/23. Review of resident 15's June 2023 Medication Administration Record (MAR) revealed the following: a. On 6/10/23 at 8:26 PM, the Allopurinol was not administered due to Drug/Item unavailable. b. On 6/10/23 at 8:26 PM, the Cholecalciferol (vitamin D3) was not administered due to Drug/Item unavailable. c. On 6/10/23 at 2:20 PM, the Isosorbide was not administered due to Drug/Item unavailable. d. On 6/10/23 at 2:20 PM, the Magnesium was not administered due to Drug/Item unavailable. e. On 6/10/23 at 11:08 AM, the Metamucil was not administered due to Drug/Item unavailable. f. On 6/11/23 at 10:14 AM, the Metamucil was not administered due to Drug/Item unavailable. On 6/28/23 at 12:14 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that it was night shift's responsibility to check all the medication that needed to be refilled and then request those items from the pharmacy. LPN 2 stated if they really need a medication that was not available they could call the pharmacy. LPN 2 stated that the admissions nurse would send all the prescriptions to the pharmacy and they were delivered the same day as admit, which was usually by 6:00 PM or 7:00 PM. LPN 2 stated that they could request refills from the pharmacy for any missing medication and it would be delivered to the facility at noon or by the 5:00 PM delivery time. LPN 2 stated that Metamucil was delivered by the pharmacy and was not an over the counter (OTC) stock item. LPN 2 stated that for any medication that was not available, if not delivered right away, she would notify the physician or Director of Nursing (DON). LPN 2 stated that the physician notification was documented in the MAR under the comments section. On 6/28/23 at 12:20 PM, an interview was conducted with the DON. The DON stated that the pharmacy main delivery times were 2:00 PM and 7:00 PM. The DON stated that if something was needed they called for a stat delivery. The DON stated that with new admissions they faxed the pharmacy the orders with the estimated time of arrival at the facility. The DON stated that Metamucil and Vitamin D3 were not stock OTC medications and were obtained from the pharmacy. The DON stated that she had been working with the electronic medical records system because they had an ongoing issue with some orders not going through to the pharmacy. The DON stated that if an item was not available staff should notify the pharmacy to see where the medication was located, notify the DON and notify the physician if the medication was not administered. On 6/28/23 at 12:47 PM, the DON stated that resident 15's medications were ordered on the 6/9/23, but the fax did not successfully go through until 6/11/23. The DON stated that the pharmacy was informed that they did not receive the medication the next day. The DON stated that they had to manually send the orders through. The DON stated that the fax would pop up at a random time stating that the fax status failed, and they would have to manually push the fax through. The DON stated that it was not reliable in showing if the pharmacy had received the fax. The DON stated that this was a known and sporadic problem and it was still under investigation. The DON stated that nursing management was responsible for following up on the medication order status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that for 1 of 23 sampled residents the facility did not ensure that its residents were free of any significant medication errors. Specifically, a resident was given an opioid in conjunction with a medication which had orders to not administer with an opioid. Resident identifier: 181. Findings included: 1. Resident 181 was admitted to the facility on [DATE] with diagnoses which included fracture of superior rim of left pubis, chronic kidney disease stage 3b, elevated white blood cell count, panic disorder, depression, insomnia, constipation, muscle weakness, abnormalities of gait and mobility, weakness, and history of falling. On 6/27/23 at 8:45 AM, an interview with resident 181 was conducted. Resident 181 stated that she was upset about the management of her medications. Resident 181 stated that she takes a pain medication and a muscle relaxer. Resident 181 stated that some nurses had given her the pain medication and muscle relaxer at the same time, while other nurses told her that was not allowed. Resident 181's medical record was reviewed. Resident 181's medications were reviewed. • Acetaminophen 325 mg (milligrams) every four hours. • Clonazepam 0.5 mg at bedtime. • Cyanocobalamin 1ml (milliliter) injection once every 14 days. • Hydrocodone-acetaminophen 5-325 mg every four hours PRN (as needed). • Hydrocortisone cream twice a day PRN. • Modafinil 200 mg once a day. • Polyethylene glycol 17 grams twice a day. • Senna-S 8.6-50 mg twice a day. • Tizanidine 4 mg every four hours PRN. • Trazodone 150 mg at bedtime. The order for clonazepam was reviewed. Clonazepam 0.5 mg was ordered on 6/15/23 with special instructions that stated, Do not administer with opioids d/t [due to] risk of respiratory suppression. A documented titled Controlled Drug Record for the medication clonazepam 0.5 mg was reviewed along with a documented titled Controlled Drug Record for the medication hydrocodone. The documents revealed the actual time that the medications were administered. A review of both documents revealed that, on two occasions, the clonazepam and the hydrocodone-acetaminophen were administered within minutes of each other. • On 6/20/23 the hydrocodone-acetaminophen was administered at 2143 (9:43PM) and the clonazepam was administered at 2142 (9:42PM). • On 6/21/2023 the hydrocodone-acetaminophen was administered at 2129 (9:29PM) and the clonazepam was administered at 2123 (9:23PM). On 6/28/23 at 10:51 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that it was best practice to separate clonazepam and hydrocodone due to the risk of respiratory suppression.