Palm Terrace Healthcare & Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure an accurate medical record for one of eight sampled residents. Facility policy on Nursing Clinical Documentation requires that the clinical record be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition. The resident in question had an H&P indicating no capacity to understand and make decisions. The resident was admitted to the facility and later discharged to the hospital via EMS at 1800 hours on 2/8/26 after becoming very agitated, yelling, and cussing at staff, which led to the sheriff being called and two officers responding. Progress notes for this resident were documented after the resident had already left the facility. One note, timed at 2149 hours on 2/8/26, described the resident’s agitation, involvement of law enforcement, and transfer to the hospital at 1800 hours. Another note, timed at 2303 hours on 2/8/26, documented a head-to-toe assessment under a skilled evaluation by an LVN. During interviews, an LVN verified that these notes were entered after the resident’s discharge and stated that she would not chart on a resident who was no longer in the facility. The MDS Coordinator acknowledged that the 2303 hours progress note should not have been documented after the resident left. The LVN who entered the 2303 hours note stated she was not assigned to the resident, was only helping with documentation, had seen the resident at the start of her shift, and was unaware of the transfer, adding that staff should have checked with nurses and CNAs before writing the notes.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that licensed nurses possessed and demonstrated the competencies required to provide safe and effective care, as evidenced by multiple incidents involving five nurses. For one resident with aspiration pneumonia, respiratory failure, COPD, CHF, chronic atelectasis, and dementia, the care plan required monitoring for respiratory distress and reporting changes to the physician. On the night in question, this resident’s vital signs changed significantly: blood pressure rose to 174/102, respiratory rate increased to 22, oxygen saturation dropped to 83–85% on 2 L O2 via nasal cannula, and temperature fell to 95°F. LVN 8 documented thick white phlegm in the resident’s mouth, performed oral suctioning with 200 ml of phlegm obtained, notified the physician and DON, and left messages for emergency contacts, but did not call 911. LVN 8 stated they believed that because the resident was DNR, 911 should not be contacted and that they were waiting for direction from the MD, RN, and family, despite acknowledging the resident was in distress and still breathing with a heartbeat. Further review of the same resident’s record showed that earlier vital signs that night were within normal limits, and that after the change in condition and suctioning, there was no documented reassessment of vital signs. The MAR showed the resident received levothyroxine and ipratropium bromide inhalation, but there was no documentation of vital sign reassessment after the inhalation treatment. Later that morning, RN 1 assessed the resident and found blood pressure 78/58, respiratory rate 12, oxygen saturation 73%, and disorientation with inability to follow commands. Oxygen was escalated to a non-rebreather at 15 L/min and another nurse was instructed to call 911, and the resident was transferred to the hospital. The DON later stated that LVN 8 focused primarily on breathing and failed to address the abnormal vital signs, and that LVN 8 had not attended the facility’s in-service on LVN scope for respiratory devices. Additional deficiencies in competency were identified in glucometer calibration, medication administration, and GT medication technique. When asked to calibrate a glucometer, LVN 2 stated she had only been shown once, believed NOC shift nurses did it, and was unsure when calibration was needed, stating she would ask an RN supervisor. The glucometer quality control record showed mismatched lot numbers and missing open dates on strips, and control solutions labeled with open dates, while RN 1 performed a control test without entering control mode and stated she relied on box expiration dates rather than the 90-day post-opening limit. Both LVN 2 and RN 1 had competency documents indicating they met glucometer calibration skills. Another resident reported that an LVN repeatedly gave her the wrong medications; on one occasion, RN 2 verified that the resident had been given calcium with vitamin D instead of the ordered calcium alone, and RN 2 told the LVN to follow the physician’s order. In a separate observation, LVN 5 administered medications via GT without flushing the tube with 50 ml water before and after, did not flush between medications, and did not wear appropriate PPE for a resident on EBP, despite documentation that GT and infection control competencies had been signed off. These findings collectively showed that multiple nurses lacked the specific competencies and standard-of-practice skills required for safe care.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and care for a resident with aspiration pneumonia, respiratory failure, COPD, CHF, chronic atelectasis, and dementia when the resident developed thick white phlegm in the mouth and oxygen saturation dropped to 83% to 85%. The record shows oral suctioning was performed and vital signs were obtained, including elevated blood pressure, increased respiratory rate, and low temperature, but the resident was not placed on a non-rebreather mask at that time, was not promptly reassessed, and EMS was not activated in a timely manner. The resident was DNR with selective treatment and no artificial nutrition, but the record and interviews show staff waited for physician and family responses rather than immediately escalating care while the resident still had a pulse and was breathing. The resident’s chart showed continuous oxygen at 2 L/min by nasal cannula and instructions to call the MD if oxygen saturation fell below 92%. After the change in condition was identified, the resident received medications, including ipratropium bromide, but there was no documented reassessment of vital signs after treatment. Later documentation showed the resident was disoriented, unable to follow commands, hypotensive, and had oxygen saturation of 73% on 2 L via nasal cannula, at which point oxygen was increased to a non-rebreather mask at 15 L/min and 911 was called. Interviews with nursing staff and the DON confirmed there was a delay in care, that no assessment was completed when the earlier abnormal vital signs were documented, and that the resident should have been transferred to the hospital based on the condition at that time. The facility also failed to provide a supplemental high-protein shake with a meal for another resident. That resident had recently been cleared to eat by mouth, had tube feedings reduced from five times daily to three times daily, and had an order for a 4-ounce high-protein nourishment shake with meals three times a day. During a meal observation, the shake was not on the tray, and the resident stated the RD had recommended the supplement with every meal. The CNA confirmed the shake should have been served with the meal, and the RD stated the supplement was intended to help meet calorie and protein needs while the resident was being weaned from tube feeding.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure several residents were free from unnecessary psychotropic medication use and failed to follow ordered monitoring and documentation requirements tied to those medications. The report identified deficiencies involving alprazolam, mirtazapine, Seroquel, risperidone, and fluoxetine for six sampled residents. The facility’s own policy stated psychotropic medications were not to be used for discipline or convenience and were to be given only after nonpharmacological interventions had been attempted and failed. For one resident, alprazolam was administered twice on the same day even though the order was for daily as needed use for anxiety manifested by verbalization of nervousness. The record did not show documentation of any nonpharmacological interventions before either dose, and it also did not show documentation of the required behavior manifestation at the time the medication was given. For another resident receiving alprazolam, the record showed multiple administrations over several weeks, but the chart did not document nonpharmacological interventions before those doses and did not document the anxiety behaviors that were supposed to justify use of the medication, except on one occasion. The report also found inaccurate or incomplete monitoring tied to psychotropic use. One resident receiving mirtazapine for depression manifested by poor oral intake had meal intake monitoring in the MAR that did not match the CNA documentation in the survey report, and staff stated they could not really identify when intake was less than 50% because the electronic record only showed broad percentage ranges. Two residents receiving antipsychotic medications had orthostatic blood pressure monitoring documented only as three-digit values for lying and sitting positions, without systolic and diastolic readings and without standing measurements. Another resident receiving fluoxetine had no documentation showing what nonpharmacological interventions would be attempted when episodes of sadness occurred. The DON and other staff were interviewed and verified the findings described in the report.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure sanitary requirements were met in the kitchen during observation, interview, and record review. The facility’s sanitation policy required utensils, counters, shelves, and equipment to be kept clean, maintained in good repair, and free from breaks, corrosion, cracks, and chipped areas. During the initial kitchen tour, the DSS observed and verified one stainless steel slotted scoop with a black handle that was discolored and partially melted, three stainless steel scoops with green handles that were peeling and discolored, one stainless steel scoop with a blue handle that was discolored and partially cracked, one stainless steel whisk with a purplish-gray rubber handle that was deformed and broken, and three rubber spatulas with red handles that were chipped, cracked at the edges, and discolored. The facility also failed to keep kitchenware and food-contact surfaces clean. The sanitation policy and USDA Food Code required utensils and food-contact surfaces to be clean to sight and touch and free from residue. During the kitchen tour, the DSS observed a cutting knife with dry, crusted residue on the blade; multiple scoops, spatulas, tongs, measuring cups, measuring spoons, spoons, a ladle, and a peeler with dry residue, watermarks, cloudy film, or paper residue; and one heavy-duty blender used for puree preparation that was dirty and had dry, crusted food residue inside. The DSS acknowledged that the dirty and crusted kitchenware should have been washed thoroughly. The facility also failed to maintain cutting boards in sanitary condition and failed to keep tray line food within the facility’s stated temperature ranges. Two white cutting boards were observed fuzzy, heavily marred, and with deep grooves, and the DSS stated they were changed every month to other month when food got stuck on them and could not be properly cleaned. During tray line observation, multiple hot food items were measured below the facility’s required holding temperatures, including chicken enchiladas, refried beans, fish, chicken breast, broccoli, puree items, and minced and moist items. Milk was 38.6 degrees Fahrenheit and orange juice was 44.3 degrees Fahrenheit. The DSS and RD acknowledged the temperature findings, and the DSS stated the food should have been reheated.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to include ordered non-pharmacological pain interventions for three residents. Facility policies on Pain Recognition and Management and Comprehensive Person-Centered Care Planning require that pain management be consistent with professional standards, include both pharmacological and non-pharmacological interventions, and that the interdisciplinary care plan be reviewed and revised after each assessment. For Resident 4, who had a left femoral fracture, a physician’s order dated 11/26/25 specified non-pharmacological pain interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage as needed. However, the pain care plan initiated on 11/28/25 only included administering medication as ordered and did not incorporate these non-pharmacological interventions. During interviews and concurrent record reviews, LVN 7 and the DON acknowledged that the current plan of care for pain should have reflected these interventions. For Resident 19, who had acute/chronic pain related to UTI, stroke, and seizures, a physician’s order dated 1/21/26 also included the same set of non-pharmacological pain interventions. The care plan for acute/chronic pain initiated on the same date listed interventions such as administering medication as ordered but did not include the ordered non-pharmacological measures. Similarly, Resident 27, who reported on-and-off abdominal and lower back pain and had acute pain related to recent surgery, pressure injuries, medical condition, and impaired mobility, had a physician’s order dated 12/17/25 for the same non-pharmacological pain interventions. The pain care plan initiated on 12/18/25 again only reflected medication administration and omitted the non-pharmacological interventions. LVN 7 and the DON confirmed during interviews and record reviews that the residents’ current pain care plans should have included these non-pharmacological interventions, but they were not incorporated.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide and document non-pharmacological pain interventions prior to administering PRN and scheduled pain medications for three residents. Facility policy titled “Pain Recognition and Management” (revised 4/2025) required staff to manage or prevent pain consistent with the comprehensive assessment and care plan, including both pharmacological and non-pharmacological interventions based on resident needs, preferences, and goals. For each of the three residents, physician orders included specific non-pharmacological pain interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage to be used as needed. For one resident with moderate cognitive impairment, physician orders included scheduled and PRN tramadol for pain, as well as PRN acetaminophen for mild and moderate pain, along with ordered non-pharmacological interventions. Medication administration records for November, December, and January showed multiple administrations of tramadol and acetaminophen; however, the medical record contained no documented evidence that any of the ordered non-pharmacological interventions were provided prior to giving these pain medications. The DON later verified these findings during record review. For a second resident who could make her own medical needs known and reported intermittent abdominal and lower back pain, physician orders included PRN acetaminophen for mild and moderate pain, PRN hydrocodone-acetaminophen for severe pain, and the same set of non-pharmacological interventions. MARs for December, January, and February showed repeated administrations of acetaminophen and hydrocodone-acetaminophen, but the medical record lacked documentation that non-pharmacological interventions were implemented before medication administration. A third resident, with fluctuating capacity but able to make needs known, had multiple sequential PRN Percocet orders for severe pain and corresponding non-pharmacological pain orders. MARs for January and February documented frequent Percocet administration, yet there was no documented evidence that non-pharmacological interventions were provided prior to these doses. LVN 7 stated that non-pharmacological interventions should be used before pain medications and confirmed that such interventions were not provided before administering pain medications to two of the residents, and the DON acknowledged the lack of documentation for all three residents.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves multiple failures in pharmaceutical services, including improper administration of medications via gastrostomy tube (GT), incomplete controlled substance documentation, wrong medication administration, and lack of medication availability. For one resident with GT orders, a nurse crushed several medications (apixaban, Florastor, sennosides, and docusate sodium), mixed each with a small amount of water, and administered them sequentially through the GT without flushing between medications. The nurse also flushed the GT with only 10 ml of water before starting and did not flush with the ordered 50 ml of water before and after medication administration, contrary to the physician’s order specifying 50 ml pre- and post-medication flushes. The nurse later verified she had not followed the ordered flush volumes or flushed between medications, and the DON confirmed awareness of these findings. Another deficiency was identified in the handling and documentation of a controlled medication for a different resident. When the oxycodone 10 mg bubble pack was counted with a nurse, there were 25 tablets remaining, while the Narcotic and Hypnotic Record indicated 26 tablets should be left. The record showed one tablet removed at a specific time, and the MAR showed the resident received oxycodone twice that day at two documented times. The nurse confirmed that the nurse who removed and administered one of the oxycodone doses did not document the removal on the Narcotic and Hypnotic Record, and the DON verified these findings. Additional deficiencies included wrong-medication administration and failure to ensure availability of ordered pain medications. One resident, documented as capable and independent in decision-making, reported that a nurse repeatedly gave her the wrong medications; on one occasion she brought a pill to an RN, who identified it as calcium with vitamin D, while the resident’s order was for calcium only. The RN stated she informed the nurse involved that she must follow the physician’s order and not substitute what was available. In separate observations, two residents with orders for routine topical pain medications (voltaren gel for one resident’s right shoulder three times daily, and a daily lidoderm patch for another resident’s right shoulder) did not receive these medications because they were not available at the time of administration. Nurses stated the medications were out and that refills were being or had just been ordered, despite facility policy and DON expectations that routine medications be reordered several days before the supply is exhausted.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure informed consent was obtained for the use of psychotropic medications for three residents reviewed for unnecessary medications. The facility’s policy stated that informed consent should be obtained before medication use and when a new psychoactive medication was initiated or an existing psychoactive medication dose increased. Surveyors reviewed medical records, medication orders, MARs, and consent forms for Residents 4, 5, and 27 and found that the consent documentation did not match the ordered treatment or was not renewed as required. For Resident 4, who had moderate cognitive impairment, the physician ordered Seroquel 25 mg by mouth in the evening for psychomotor restlessness. The MAR showed the medication was administered from 12/12/25 through 12/29/25 at 1700 hours. The consent form for anti-psychotic medication listed Seroquel 25 mg and the reason for treatment, but it did not specify the frequency or route of administration. For Resident 27, who was able to make own medical needs known, the record showed alprazolam orders for 0.5 mg by mouth as needed for anxiety, including a later order for 0.5 mg every 12 hours as needed for anxiety as manifested by inability to relax. The consent form dated 12/17/25 listed alprazolam 0.25 mg by mouth at bedtime as needed, which did not match the ordered dose, and it did not include the duration. A later consent dated 12/25/25 for Xanax (alprazolam) 0.5 BID as needed also did not include the duration and did not show the correct unit for the dosage and frequency. For Resident 5, the record showed a standing order for Xanax 1 mg by mouth twice a day and an earlier informed consent for anti-anxiety use. Staff verified that the most recent consent had been obtained on 2/2/25, but the consent was not renewed after six months. The DON acknowledged that the informed consents for Xanax had not been renewed and stated that the prescribing physician would call the family or resident representative to obtain consent, while nursing staff would complete the form. The DON and Administrator were informed of and acknowledged the findings.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a homelike environment for Resident 35 by not addressing a loud vibrating noise coming from the room air conditioning unit. The facility policy stated the resident environment would be maintained in a homelike manner, including comfortable sound levels. During an initial tour, Resident 35 was observed awake and sitting on the bed while the loud noise was heard in the room. Resident 35 stated the noise came from the air conditioner and that it was worse when the heater was turned on. Resident 35 stated the noise disrupted sleep, especially at night, because she would be awakened when the noise started again and had difficulty going back to sleep. She also stated the heater took a long time to produce heat and that the noise decreased only when the temperature reached 80 degrees Fahrenheit. Resident 35 reported that the Maintenance Director had come twice the prior month to check the unit and had told her nothing could be done except replacing the old air conditioner, but she had not received an update. Resident 35 was admitted with capacity to understand and make decisions, and her H&P and MDS showed she was cognitively intact. Facility staff confirmed the noise was present. LVN 2 verified the air conditioner was making a loud vibrating noise and stated that having the loud noise was not a homelike environment. The Maintenance Director acknowledged the unit was old and needed replacement, and stated he had told Resident 35 that it needed to be replaced. The Administrator stated the Maintenance Director had not reported the need for replacement to him and said the facility did not need to wait for a resident complaint before replacing an appliance. Review of the maintenance repair log showed the heater issue in the room was documented as resolved, and the air conditioner was ordered electronically after the survey observation.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a new Level 1 PASRR screening was completed after a hospital exemption lapsed for one resident with a diagnosis of psychotic disorder. The resident was admitted and later readmitted to the facility, and the medical record showed a Level 1 PASRR screening dated 4/30/25 that identified the resident had been prescribed psychotropic medications for a serious mental illness. That screening was negative and did not require a Level II mental health evaluation because it was based on an exempted hospital discharge. The same PASRR screening stated that if the resident remained in the facility longer than 30 days, the facility should resubmit a new Level 1 PASRR screening on the 31st day. During interview and record review, the RN verified that the facility did not resubmit a new Level 1 PASRR screening after the resident remained in the facility beyond that timeframe. The RN stated the screening should have been resubmitted to determine whether a Level II mental health evaluation was necessary and to support an accurate plan of care for the resident's mental health services.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive person-centered care plan for Resident 24’s use of a wander guard. Resident 24 was admitted to the facility and was documented in the H&P as unable to make her own medical decisions. A physician’s order dated 1/23/26 directed that a wander guard be placed on the resident’s right wrist to prevent wandering outside unattended due to poor safety awareness secondary to dementia. Review of the care plan showed no person-centered care plan addressing the wander guard, and during the initial tour the resident was observed lying in bed with the wander guard on her right wrist. During interviews, LVN 1 and the DON both verified that no care plan had been initiated for the wander guard use. The facility also failed to implement Resident 53’s bilateral floor mats in accordance with the resident’s fall-risk care plan. Resident 53’s care plan, initiated on 8/21/25, indicated the resident would be free of falls through the review date and included floor mats at the bedside as an intervention, with the mats initiated on 10/25/25. However, during observation the resident was seen lying in bed with only one floor mat in place on one side of the bed, while the opposite side had no floor mat. CNA 2 verified there was no active physician’s order for only one floor mat and stated there had been a past order for one mat. LVN 6 stated the resident was at risk for falls related to weakness and confirmed that, according to the active fall care plan, floor mats should have been placed on both sides of the bed.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Resident 53 remained free from accident hazards by not providing bilateral floor mats in accordance with the resident’s fall plan of care. Resident 53 was admitted and later readmitted to the facility, and the fall risk evaluation dated 1/27/26 identified intermittent confusion, bedbound status, and incontinence as fall risks. The care plan, initiated on 8/21/25, stated the resident would be free of falls through the review date of 2/14/26 and included interventions for a bed and chair alarm to always be in place to alert staff to unassisted transfers. The care plan also included an intervention initiated on 10/25/25 for floor mats at the bedside. On 1/28/26, Resident 53 was observed lying in bed with only one floor mat in place beside the bed, while the opposite side had no floor mat. CNA 2 confirmed the resident was a fall risk and verified there was no active physician order for only one floor mat, stating there had been such an order in the past. LVN 6 later stated that, in accordance with the active fall care plan, floor mats should have been placed on both sides of the bed and were intended to reduce injury if the resident fell from either side.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the necessary care and services to maintain intravenous access for Resident 105, who was admitted with a PICC line in the right upper arm with two lumens. Facility policy titled Central Venous Access Guidelines and Procedures stated that internal catheter length shall be transcribed into the nurse's notes, Peripheral and Central Line Treatment Record, and IV MAR, and that arm circumference shall be monitored and documented on the treatment record. Resident 105's care plan included measuring arm circumference on admission and measuring the external catheter length from end to hub to insertion site into the skin. Review of the medical record showed the admission clinical assessment did not include documentation of the PICC line measurement or arm circumference upon admission. The order summary included physician orders to measure arm circumference on admission and then weekly during dressing changes, and to measure external catheter length weekly, but the record still did not show documented evidence that the PICC line external catheter length and arm circumference were obtained on admission. During interview and concurrent record review, RN 1 verified the measurements were not documented and stated they should have been completed on admission. RN 1 also stated arm circumference measurement would indicate signs and symptoms of infection, such as swelling and blood clots. RN 5 likewise verified the findings and stated the PICC line was measured upon admission to provide the baseline for future complications.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure two residents receiving apixaban were monitored for signs and symptoms of bleeding related to anticoagulant therapy. Resident 4 had moderate cognitive impairment and was ordered apixaban 2.5 mg by mouth twice daily for DVT prophylaxis. The resident received the medication repeatedly across November 2025 through January 2026, and the medical record did not show documented evidence that monitoring for bleeding signs and symptoms was completed. Resident 27 could make her own medical needs known and was ordered apixaban 2.5 mg by mouth twice daily for atrial flutter. The resident received the medication repeatedly across December 2025 through February 2026, and the medical record also did not show documented evidence of monitoring for bleeding signs and symptoms. During interview and record review, an LVN stated residents taking anticoagulants needed to be monitored for bleeding and verified that both residents were not being monitored as required. The DON acknowledged that monitoring anticoagulant residents for bleeding was important and verified the findings.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the medication error rate remained below 5%, and the surveyors calculated a medication error rate of 20%. During an observation for Resident 10, LVN 5 prepared apixaban 5 mg, sennoside 8.6 mg, and docusate sodium 100 mg for administration via GT, but when the medication cups were later checked, there was a significant amount of residue left in all of the cups. The resident’s orders included apixaban 5 mg via GT twice daily, sennosides 8.6 mg two tablets via GT twice daily, and docusate sodium 100 mg two tablets via GT twice daily. During another observation, LVN 10 was preparing medications for Resident 12 but stated the ordered Voltaren topical gel could not be administered because it was not available. The resident had an order for two grams of Voltaren external gel 1% to the right shoulder topically three times daily for pain management. For Resident 45, LVN 9 was observed squeezing diclofenac sodium topical gel into a medicine cup rather than using the dosing card to measure the ordered amount. The resident’s order was for diclofenac sodium 1% topical to the left hip twice daily, with four grams to be applied, and LVN 9 stated she had stopped using the dosing card after the first administration and instead estimated the dose by filling the medicine cup.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper storage of medications in one of four medication carts inspected, Medication Cart A. During an inspection on 2/2/26, surveyors observed a box of ondansetron for Resident 63 still on the cart even though the resident had been discharged and a physician order dated 2/2/26 indicated release of the body to the mortuary. Surveyors also observed a bubble pack of amiodarone for Resident 96 with a tear in one of the individual bubbles and a bubble pack of ondansetron for Resident 96 with a tear in one of the individual bubbles. LVN 2 verified these findings during the inspection. Surveyors further observed an opened insulin glargine pen for Resident 108 that did not have an open date. Review of the drug label information for insulin glargine-YFGN showed that an in-use opened pen should be used within 28 days. The DON was informed of the findings during an interview on 2/2/26 at 1116 hours and verified the observations.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure menus and meal tickets were followed for two residents. Resident 14 stated he was supposed to receive two 8-ounce milks with each meal but was often not getting the amount ordered. During lunch observation, his tray contained only one 8-ounce carton of milk. His meal ticket showed a standing order for two 8-ounce milks, and a CNA confirmed he had received only one carton. Resident 85 had a physician order for a CCHO fortified diet with chopped and small portions, and an order for Boost Glucose Control one time a day every Monday and Friday. During lunch observation, Resident 85 stated the meal ticket and tray did not match and items were missing. The tray did not include parslied rice, bread roll with margarine, or the full portion of orange slices, and the meat was not chopped and was chewy. Resident 85 had to dip the meat in soup because there was not enough gravy, and a CNA confirmed the tray was missing several items and that the meat was not chopped. Resident 85 also reported receiving Boost Glucose Control but not drinking it because it was not her preferred flavor. She stated she had told the RD she preferred chocolate. The meal ticket showed Boost Glucose Control chocolate, and the DSS confirmed the facility had chocolate flavor but that Resident 85 was served the wrong flavor and the flavors had to be changed out for her. The RD and facility leadership acknowledged the findings.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure food prepared for residents was cooked in a manner that preserved nutritive value. Survey findings showed that vegetables were cooked more than one hour before meal service and then held in the steam table with the temperature dial set on high. The report specifically identified green peas among the foods observed on the steam table, and the Director of Dietary Services acknowledged that puree preparation had already been completed by the cook before tray line began. Facility documents reviewed included the P&P titled Preparation of Vegetables, which directed that vegetables be cooked in a small amount of water for a short amount of time, and the P&P titled Food and Nutrition Services, which stated that nutritive value should not be compromised or destroyed because of prolonged holding on the steam table. During observation and concurrent interview, the steam table contained Salisbury steak, parslied rice, and green peas covered with foil, and the Director of Dietary Services verified that the vegetables had been prepared more than one hour prior to meal service.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the necessary care and services for one final sampled resident who was receiving hospice services. The deficiency involved the facility not ensuring that hospice skilled nurse visit notes were available and included in the resident’s medical record. The facility’s policy on End of Life Care; Hospice stated that hospice services would be offered as appropriate and ordered by the physician and integrated into the resident’s individualized, interdisciplinary care plan. Resident 13 was admitted to the facility and had an Internal Medicine H&P documenting no capacity to understand and make decisions. The resident also had a physician order for hospice with a primary diagnosis of senile degeneration of brain on routine level of care. Review of the resident’s hospice medical records failed to show any skilled nurse hospice progress notes for December 2025 through February 2026. During interviews and concurrent record review, RN 1 acknowledged the missing notes and stated there should be a copy of the hospice progress notes in the chart for staff awareness of updates in the resident’s status and as a means of communication with the facility; RN 1 also stated medical records should have followed through with hospice.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. During a medication administration observation for Resident 10, who had an order for Enhanced Barrier Precautions due to a GT, an EBP sign was posted outside the room directing staff to wear gloves and a gown for high-contact care activities. LVN 5 performed hand hygiene and donned clean gloves, but did not wear a gown while administering medications via the GT. LVN 5 later verified that the gown was not worn during the procedure, and the DON was informed and verified the finding. The facility also failed to disinfect Resident 24's call light after it had been on the floor. During the initial tour, Resident 24 was observed lying in bed with the call light on the floor. CNA 1 picked up the call light from the floor and gave it back to the resident without disinfecting it first. CNA 1 stated the call light should have been disinfected prior to giving it to the resident, and the IP later stated that call lights on the floor were considered contaminated and should be disinfected before use. The Administrator and DON were informed and acknowledged the finding.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure one of one glucometer was maintained in a safe operating condition. During observation, interview, and record review, the glucometer quality control process was found to be incomplete and not performed correctly. The quality control record for the meter documented a strip lot number and expiration date, but the glucose strip container did not have an open date and did not match the lot number recorded in the quality control record. The normal and high control solution bottles were labeled with an open date of 1/30/26, but the record listed an expiration date of 7/14/27. When LVN 2 was asked to calibrate the glucometer, LVN 2 was not able to perform the calibration. When RN 1 was asked to calibrate the glucometer, RN 1 was also not able to perform the calibration correctly and stated they used the expiration dates printed on the box rather than the number of days after opening the glucose strips and control solution bottles. RN 1 further stated they followed the expiration dates as printed on the control solution box, not when the bottles were opened. The DON was informed and verified these findings.

Penalty

Inspection fine: $33,118

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure garbage was properly stored in two of seven outside garbage dumpsters. During an observation and concurrent interview with the Maintenance Director, two dumpsters were found with lids partially propped open by cardboard boxes, which prevented the lids from fully closing. The facility's Garbage and Trash policy, revised 5/2023, required food waste to be placed in sealed, leak-proof, tightly closed containers and stated that garbage and trash cans must be inspected daily to ensure lids are closed. The Maintenance Director verified the observation and stated the dumpster lids should always be closed for rodents prevention and infection control purposes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.

Plan Of Correction

How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident 1 no longer resides at facility as of 08/11/25. On 08/13/25, 08/14/25, and 08/15/25, all licensed nurses were in-serviced by DON on medication rights of administration and provided with a copy of the medication administration P&P which states correct administration and documentation -- pour, pass, sign. Licensed nurses were also educated on the one-hour medication pass parameter time. 2. Resident 2 no longer resides at facility as of 08/26/25. On 08/13/25, Resident 2 was assessed by DON for adverse reactions related to missed medication. Resident denied any adverse reactions. MD was notified of missed medications by DON immediately, and no new orders were given. On 08/13/25, DON provided 1:1 training to LVN 1 regarding the rights of medication administration. LVN 1 was provided with facility's P&P on medication administration. DON also provided LVN 1 with 1:1 in-service on proper procedure for medication clarification, documentation, and monitoring. On 08/15/25, Resident 2's medications were revisited and reviewed per physician orders based on Medication Administration Schedule. In addition, a review of resident's chart was conducted by DON. On 08/15/25, Resident 2 was interviewed with daughter at bedside by DON regarding complete medication administration as well as timely medication administration. Resident 2 and daughter validated all medication as well as education was provided, and resident received her medications on time. How the facility will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All current residents with physician order for medication have the potential to be affected by this deficient practice. On 08/13/25, designated licensed nurse conducted a check of all current residents who had received their scheduled morning medications late on 08/13/25. A total of 4 residents out of 91 were affected, attending physicians were notified with orders to monitor for adverse reactions. No adverse reaction noted on 4 residents who were affected by this deficient practice. On 08/13/25, designated licensed nurse conducted an audit on LVN 1's residents with physician's orders for medications. Residents were interviewed by designated licensed nurse, 18 verbal residents stated they received all their medications and were educated on medications administered. On 08/15/25, Resident 2's medications were revisited and reviewed per physician orders based on Medication Administration Schedule. In addition, a review of resident's chart was conducted by DON. On 08/15/25, Resident 2 was interviewed with daughter at bedside by DON regarding complete medication administration as well as timely medication administration. Resident 2 and daughter validated all medication as well as education was provided, and resident received her medications on time. How the facility will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All current residents with physician order for medication have the potential to be affected by this deficient practice. On 08/13/25, designated licensed nurse conducted a check of all current residents who had received their scheduled morning medications late on 08/13/25. A total of 4 residents out of 91 were affected, attending physicians were notified with orders to monitor for adverse reactions. No adverse reaction noted on 4 residents who were affected by this deficient practice. On 08/13/25, designated licensed nurse conducted an audit on LVN 1's residents with physician's orders for medications. Residents were interviewed by designated licensed nurse, 18 verbal residents stated they received all their medications and were educated on medications administered. On 08/14/25, 08/15/25, 08/18/25, 08/20/25, and 08/22/25, DON, DSD, and RN conducted a medication observation for 20 residents to validate pour, pass, sign, timely medication administration, and correct documentation. All 20 residents received their medication on time, and licensed nurses followed pour, pass, sign procedures and accurately documented administration. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 08/13/25, 08/14/25, and 08/15/25, DON provided in-services to all licensed nurses regarding rights of medication administration and facility's P&P on medication administration, specifically "pour, pass, sign." Additionally, DON and/or designee will provide in-services monthly for 4 months and as needed to ensure compliance and competency with P&P. Starting 08/14/25, DON and/or designee will perform a random medication observation of 4 residents per week for 12 weeks and as needed to ensure timely medication administration and accurate documentation. Any deficient findings will be reported to the DON and/or designee for follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON and/or designee will report to the QA&A Committee monthly for review and recommendations for 3 months until substantial compliance is achieved. Completion Date: 08/27/25

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff were required to follow the administration process of pouring, passing, and immediately signing the EMAR for safe and accurate documentation of medication administration. When questioned about the acceptability of advance documentation in the EHR for care and services, including medication administration, the DON confirmed that such practice was not acceptable. The DON also acknowledged that any missed medication could significantly impact a resident's health, depending on the medication's indication. During an interview, both the Administrator and DON were informed of and acknowledged these findings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the proper administration and documentation of IV medications for two residents, leading to medication errors. Resident 38 was observed receiving an IV antibiotic, Vancomycin, without the medication bag being dated, timed, or signed by the administering nurse. This lack of documentation was confirmed by RN 1 during an observation and interview. The resident's medical records indicated a physician's order for Vancomycin to be administered every 12 hours for an abdominal abscess, but the absence of proper labeling posed a risk for medication errors. Similarly, Resident 587 had a PIV line that was not dated or labeled, as observed during a room visit. The physician's order required the PIV site to be changed every 72 hours or as needed, but the lack of labeling made it difficult to track the duration of the PIV line. RN 1 confirmed the oversight, acknowledging that the PIV sites should be dated and labeled to comply with the physician's orders. Both the Administrator and Interim DON were informed of these findings and acknowledged the deficiencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary respiratory care for several residents, as evidenced by multiple deficiencies in the administration and management of oxygen therapy. For Resident 686, the facility did not adhere to the physician's order for oxygen administration, providing oxygen at a higher rate than prescribed. Observations revealed that the resident was receiving oxygen at 5 liters per minute instead of the ordered 3 liters per minute. This discrepancy was not documented, and there was no evidence that the physician was notified of the change or the resident's subsequent difficulty in breathing and decreased oxygen saturation. Additionally, the facility did not ensure proper labeling and dating of oxygen tubing for Residents 28 and 438. Resident 28's nasal cannula tubing was dated incorrectly, and Resident 438's tubing was undated, contrary to the facility's policy that requires tubing to be changed weekly and dated. These lapses in protocol were confirmed through interviews with staff, who acknowledged the oversight in labeling the tubing. Furthermore, Resident 436's nebulizer tubing was also found to be undated, which is a deviation from the facility's policy. The lack of proper documentation and adherence to procedures for respiratory equipment management could potentially impact the residents' medical conditions. These findings highlight the facility's failure to maintain consistent and accurate respiratory care practices for its residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors during a medication administration observation. The facility's policy requires that medications be administered as prescribed by the attending physician, including checking specific parameters before administration. On the specified date, a Licensed Vocational Nurse (LVN) prepared hydralazine for a resident, which is used to treat high blood pressure. The medication's instructions required the nurse to hold the medication if the resident's systolic blood pressure (SBP) was less than 110 mmHg or if the pulse rate was less than 60 beats per minute. Although the LVN checked the resident's blood pressure, they did not initially check the pulse rate before preparing to administer the medication. Upon being reminded of the requirement, the LVN checked the resident's pulse rate, which was 69 beats per minute, and then administered the medication. The resident's medical records confirmed the physician's order to hold the medication under the specified conditions. The LVN acknowledged the oversight during an interview, and the facility's Administrator and Interim Director of Nursing were informed of the findings. This oversight in following the medication administration protocol had the potential to negatively impact the resident's health outcomes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the pureed food recipes and menu were followed for eight residents receiving pureed diets. Specifically, the pureed recipe for potatoes was not adhered to, as cold milk and vegetable broth were used instead of warm milk, contrary to the facility's documented recipe. This deviation was confirmed during an observation and interview with a dietary staff member, who acknowledged the discrepancy in the preparation of pureed red potatoes. Additionally, the facility did not follow the prescribed serving size for pureed wheat rolls. The menu specified the use of Scoop #16, equivalent to 1/4 cup, but instead, Scoop #12, equivalent to 1/3 cup, was used. This was observed during a tray line observation and confirmed by the Dietary Supervisor Assistant. The facility's Administrator, DON, and CDM acknowledged these findings, indicating a failure to adhere to the established dietary guidelines and menu specifications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. Several deficiencies were noted, including the poor condition of food preparation utensils and equipment. A large pot was heavily marred with black discoloration, and cutting boards were observed with significant wear and discoloration. A can opener had brown discoloration, and other kitchen tools such as a measuring cup, spatula strainer, and ice cream scoopers were found with residues and chipped handles. These conditions were verified by the Certified Dietary Manager (CDM) and other kitchen staff, who acknowledged the risk of food contamination. Additionally, the facility did not adhere to its policy on labeling and dating food items. Unlabeled and undated food items were found in the freezer and refrigerator, including containers of solid food substances and various beverages. The CDM confirmed these findings and admitted to not knowing why certain food items were not stored properly. Furthermore, the kitchen staff failed to wear appropriate hair restraints, as observed with the Dietary Supervisor Assistant, which was acknowledged as a requirement by the Dietary Resource. These failures had the potential to cause foodborne illnesses to the residents consuming food prepared in the kitchen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop baseline care plans to address the administration of oxygen for two residents, which had the potential for their care needs not being met. Resident 686, who was admitted with a history of acute respiratory failure secondary to congestive heart failure, had a physician's order for oxygen administration at 3 liters per minute via nasal cannula. However, during an observation, it was noted that the resident was receiving oxygen at 4 liters per minute, and there was no baseline care plan in place to address this discrepancy. This was confirmed by both an LVN and an RN during interviews and medical record reviews. Similarly, Resident 438 had a physician's order for continuous oxygen at 3 liters per minute via nasal cannula, but the resident's plan of care did not document the administration of supplemental oxygen. An observation confirmed that the resident was receiving oxygen as ordered, but the lack of documentation in the care plan was verified by the IP during an interview and medical record review. These oversights in care planning could potentially lead to unmet care needs for the residents involved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the proper accounting and safeguarding of controlled medications, specifically narcotics, which posed a risk for loss or diversion. The deficiency was identified through a review of the facility's policies and procedures, which require a physical inventory of all controlled medications to be conducted by two licensed nurses at each shift change. This inventory is to be documented on an audit record or accountability record. However, the Narcotic Count Sheet for Medication Cart B showed multiple instances of missing signatures from incoming and outgoing licensed nurses on specific dates, indicating that the required inventory checks were not properly documented. Interviews with facility staff, including an LVN and the Interim DON, confirmed the missing signatures on the Narcotic Count Sheet. The LVN explained that the purpose of the Narcotic Count Sheet log is to ensure that narcotic medication counts are reconciled and accounted for at the end of each shift. The Interim DON acknowledged the missing signatures and stated that failing to account for controlled medications poses a risk for narcotic diversion. This lack of proper documentation and accountability for controlled substances represents a significant deficiency in the facility's pharmaceutical services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper medication storage, as observed during an inspection of Medication Cart A. Open packages of wound care supplies, including Skin Closure Strips and calcium alginate dressing, were found in the medication cart. These items were not stored in a manner that maintained their sterility, as they were open and partially used. The Licensed Vocational Nurse (LVN) acknowledged these findings and confirmed that all wound care supplies should be single-use to ensure sterility. Additionally, the facility did not adhere to its policy of storing orally administered medications separately from externally used medications. During an inspection of Medication Room A, it was observed that Latanoprost eye drops and nitroglycerin tablets were stored together in the same tray inside the refrigerator. Furthermore, various over-the-counter and house supply medications, including earwax softener drops, nasal spray, calamine lotion, artificial tears, nicotine patches, and pain reliever patches, were stored side by side without separation. The Interim Director of Nursing (DON) acknowledged these findings and confirmed that internal and external medications should be stored separately.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their care. For Resident 85, the medical records inaccurately documented vital signs and urinary output after the resident had been discharged and transferred to an acute hospital. This discrepancy was confirmed during an interview with the Interim Director of Nursing (DON), who acknowledged that such documentation should not have occurred once the resident was no longer at the facility. For Resident 44, the facility did not accurately document the blood pressure access site in the resident's medical record. Despite a care plan and physician's order specifying that no blood pressure readings should be taken from the left arm due to an AV shunt, the records showed multiple instances where blood pressure was measured from the left arm. This was verified by the MDS Coordinator and acknowledged by the Administrator and Interim DON. These documentation errors had the potential to impact the residents' care needs due to the inaccuracies in their medical information.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors. A licensed nurse, identified as LVN 6, did not properly check and identify the resident before administering medication. The facility's policy and procedure for medication administration, dated January 2019, required the use of at least two identifiers to confirm resident identity before medication administration. However, LVN 6 administered levothyroxine 25 mcg to a resident who did not have a history of hypothyroidism, without verifying the resident's identity using the required methods. The incident occurred in the early morning when LVN 6 administered the medication to the resident, who was able to make self-understood and understand others, as indicated by a BIMS summary score of 14. The resident informed LVN 6 that she did not take medications in the early morning, but LVN 6 proceeded to administer the medication and later returned to acknowledge the error. The Director of Nursing confirmed the medication error and verified that the facility's policy was not followed, resulting in the resident receiving the wrong medication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary pharmacy services to two residents, resulting in medications not being administered within the prescribed time. The facility's policy and procedure (P&P) for medication administration requires medications to be given within 60 minutes of the scheduled time, except for those ordered before or after meals. However, observations and interviews revealed that medications scheduled for 0800 hours were administered late to both residents. For Resident 1, an interview and observation on 9/3/24 showed that medications due at 0800 hours were administered late because the nurse assigned to administer them did not show up. LVN 2, who was observed administering the medications, confirmed the delay and stated that he had to cover for the absent nurse, resulting in late administration for other residents as well. Similarly, LVN 3 confirmed that she finished administering the 0800 hours medications at 0954 hours, indicating a consistent delay in medication administration. Resident 2's medical records showed multiple medications scheduled for 0800 hours, including atenolol-chlorthalidone, fish oil, gabapentin, and Prozac. On 9/3/24, LVN 4 administered these medications late due to attending to a resident with a change in condition. The Director of Nursing (DON) stated that medication administration should not be interrupted and expected other staff to handle residents with changes in condition, highlighting a failure in staffing and task delegation that led to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that meals were served at the desired temperatures, which could potentially lead to decreased oral intake and undesirable weight loss for residents. During interviews, two residents expressed dissatisfaction with the temperature of their meals. One resident stated that the hot food items on their meal tray were not hot enough and expressed a preference for warm food. Another resident mentioned that the food could be improved and noted that it was often cold. A test tray inspection was conducted to assess the temperature of the food being served. The inspection revealed that the egg omelet, bacon, and oatmeal were served at temperatures significantly below the desired level, with readings of 105.6, 86.1, and 108.6 degrees Fahrenheit, respectively. Additionally, the milk was found to be at 51.2 degrees Fahrenheit. A taste test confirmed that the egg omelet, oatmeal, and bacon were cold, and the Dietary Services Supervisor (DSS) verified the temperature drop, acknowledging that the food items were indeed cold.