Based on interview and record review, conducted during a site visit on 09/05/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 4 of 6 sampled residents whose medication and treatment orders were reviewed (#s 1, 15, 16 and 17). Findings include, but are not limited to:

Facility self-reports for residents 1,15, 16 and 17 dated 05/10/24 indicated the facility had recognized, appropriately investigated, and corrected medication errors for sampled residents.

A review of Resident 1's Physician Orders dated 01/17/23, indicated Resident 1 was to receive 50 unit of Levemir subcutaneously in the morning for diabetes management, notify MD if CBG less that 70 or over 400.

* MARs dated 04/01/24 -04/30/24, indicated that Resident 1's CBG's were not recorded for Levemir administration with missed injections on 04/6/24, 04/14/24 and 04/19/24.

A review of resident 15's Physician Orders dated 03/09/23, indicated Resident 15 was to receive Escitalopram 5MG TAB every morning for a mood disorder.

* MARs dated 04/01/24-04/30/24, indicated the medication was not given on 04/12/24, 04/13/24, 04/15/24 and 04/16/24. The medication was not available on 04/14/24 and 04/17/24.

* Progress Notes dated 04/17/24, indicated the facility called the pharmacy regarding resident's missed medication and the pharmacy said to fax and not call to refill. Medications were reordered on 04/17/24.

A review of Resident 16's Physician orders dated 02/01/23, indicated the injection of Lantus 100-U/ML PEN 3 ML seven units subutaneously every morning, hold for CBG less than 100 and notify PCP if less than 80 or greater than 300 for two days or more in a row greater than 400.

* MARs dated 04/01/024-04/30/24 indicated injections did not occur on 04/15/24, 04/23/24 and on 04/30/24.

* Progress Notes dated 04/15/24 indicated care staff walked past residents room and resident was on the floor.

A review of Resident 17's Physician Orders dated 06/02/23 indicated Metoprolol Extended Release 50 MG tablet for high blood pressure once a day.

* Progress Notes dated 05/01/24 - 05/31/24 indicated the medication was not administered on 05/18/24, 05/19/24, 05/20/24 and 05/21/24.

* Progress notes for Resident 17 dated 05/07/24, indicated the resident was on alert for missed Metoprolol.

In an interview, Staff 1 (Administrator) stated Staff 8 (LPN) was no longer providing consultation services for the facility. Staff 8 could not be interviewed. During the interview Staff 1 confirmed the medication errors had occurred.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Nurse Consultant) and Staff 3 (Nurse Consultant) on 09/05/24.

It was determined the facility failed to carry out medication orders as prescribed.

Verbal Plan of Correction: Facility self-reported all three incidents to the local Seniors and People with Disabilities office as required. Facility to follow up on medications not available and or not given. Med-tech counseling and training on documentation of medication. Timely processing of orders in the third check system. Med Tech meetings every two weeks, next one is scheduled 09/10/2024.

Based on interview and record review, conducted during a site visit on 09/05/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 9). Findings include, but are not limited to:

Resident 9 had a physician order, dated 05/06/24, showed Glipizide 2.5 MG (for high blood sugar) tab one tablet by mouth every morning starting on 05/10/24.

Resident 9's Medication Administration Record (MAR), dated 06/01/24 through 06/30/24, indicated Resident 9 was not administered his/her Glipizide from 06/06/24 through 06/10/24. Notes indicated "Drug not available."

Resident 9's progress notes, dated 06/06/24-06/11/24, indicated the following:

* The pharmacy informed the facility Glipizide 2.5 MG tab would no longer be covered by insurance;

* The resident signed for an immediate delivery that S/he would pay for;

* The pharmacy alleged they did not receive the delivery request faxed by the facility;

* The pharmacy stated they would send medication the night of 06/10/24; and

* The facility faxed a request to the resident's PCP to provide a substitute medication.

Resident 9's physician order, dated 06/12/24, showed:

* Glimepiride 1 MG tab (for high blood sugar) one tablet by mouth every morning to begin on 06/12/24.

In an electronic communication on 10/07/24, Staff 1 (Executive Director) stated the following:

* Med techs reordered medication;

* Medications were to be reordered seven days prior to the last dose;

* Families often purchased medications not covered by insurance; and

* The facility could purchase medication in the event families could not.

On 09/05/24, Staff 1 (Administrator) acknowledged the medication was not administered.

It was determined the facility failed to carry out medication and treatment orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (RN Consultant) and Staff 3 (RN Consultant) on 09/05/24.

Verbal plan of correction: Facility's nurse consultants will follow up on medications not available and or not given. Med-tech counseling and training on documentation of medication. Timely processing of orders in the third check system. Med tech meetings every two weeks; next one is scheduled 09/10/2024.

Based on interview and record review conducted during a site visit on 09/05/24, it was confirmed the facility failed to maintain an accurate MAR for 5 of 5 sampled residents (#s 1, 13, 15,  16, 17) whose MARs were reviewed.  Findings include, but not limited to the following:

A review of Resident 1's MAR dated 04/01/24 -04/30/24, indicated missing signatures for the following medications:

* no CBGs were recorded for Levemir administration with doses missed on 04/06/24, 04/14/24, 04/19/24, and 04/27/24.

A review of Resident 13's MAR dated 04/01/24 -04/30/24, indicated missing signatures for the following medications:

*1. Humalog: No CBG recorded on  04/06/24 am, 04/14/24 am, 04/14/24 pm, 04/15/24 pm, 04/27/24 am

* Humulin 36 units: No CBG recorded on 04/06/24, 04/14/24, 04/27/24

* Humulin 30 units: No CBG Recorded on 04/14/24 and 04/15/24

A review of Resident 15's Progress notes dated 04/25/24 indicated the resident's medication was not available on day shift. Medication was delivered on evening shift.  

A review of resident 15's MAR dated 04/01/24-4/30/34 revealed all morning medications on 4/25/24 were signed for by Med tech.

A review of Resident 16's MAR dated 04/01/24-04/30/24 indicated missing signatures 04/15/24, 04/23/24 and 04/30/34.

*no CBGs were recorded for Lantus on 04/15/24, 04/23/24, and 04/30/24.

A review of Resident 17's progress note dated 05/05/24 indicated the resident was not administered Dapsone from 04/15/24 to 05/07/24.

A review of Resident 17's MAR dated 04/01/24 - 05/31/24 revealed Dapsone was signed as administered on the following dates:

* 04/18/24, 04/25/24 ,04/26/24 04/27/24, 04/28/24 04/29/24,04/30/24,

* 05/01/24, 05/02/24, 05/03/24, 05/05/24, 05/05/24

In an interview on 09/05/24, Staff 1 (Administrator) confirmed the MARs were not accurate.

It was determined the facility failed to maintain an accurate Medication Administration Record.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Nurse Consultant) and Staff 3 (Nurse Consultant).

Verbal plan of correction: Facility self-reported all three incidents to the local Seniors and People with Disabilities office as required. Facility to follow up on medications not available and or not given. Med-tech counseling and training on documentation of medication. Timely processing of orders in the third check system. Med tech meetings every two weeks, next one is scheduled 09/10/2024.

Based on observation, interview, and record review, conducted during a site visit on 09/05/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

The facility's posted staffing plan showed the following:

* Day shift: six care staff;

* Evening: five care staff; and

* Night: four care staff.

A review of the facility's ABST revealed the following:

* Not all residents' profiles had been updated in the last quarter.

* The facility's Posted Staffing Plan did not meet the staffing hours required by the ABST.

In an interview on 09/05/24, Staff 6 (Resident Care Coordinator) stated the following:

* The facility's posted staffing plan had not been updated regularly.

* S/he was unaware of the requirement to save resident profiles who had no changes to their service plans in the last quarter in order to reflect accurate quarterly review dates.

It was confirmed the facility failed to fully implement and update an acuity-based staffing tool.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Nurse Consultant), and Staff 3 (Nurse Consultant) on 09/05/24.