Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

A review of Resident 5's signed physician orders dated 03/05/24 indicated the following:

·Metformin 500mg "Take one tablet by mouth every day."

A review of Resident 5's 03/01/24 - 03/31/24 MAR indicated the following:

·Metformin (for type 2 diabetes) was discontinued on 03/06/24;

·Resident 5 did not receive 29 doses of Metformin.

No discontinue order was available or provided for Resident 5's Metformin.

In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) were unable explain why Resident 5's Metformin was discontinued.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24.

Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors on 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed.

Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

A review of Resident 3's signed physician orders dated 06/28/24 indicated:

·Alprazolam 0.25 mg oral tablet; "Take 1 tab(s) oral Daily as needed for anxiety; panic disorder" start date of 10/12/23.

A review of Resident 3's 06/01/24 - 06/30/24 MAR indicated:

·06/09/24 staff marked Alprazolam PRN as administered at 14:34.

A review of Resident 3's 06/09/24 progress notes indicated:

·Staff contacted Resident 3's spouse to get permission to administer Alprazolam PRN, Resident 3's spouse gave permission to administer a half dose of medication. Staff administered a half dose of Alprazolam.

In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) stated after the medication error was reported the nurse completed a one-on-one training with the med tech that was responsible for the error.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24.

Facility Verbal Plan of Correction: The facility nurse completed one on one training with the responsible med tech and a med tech training was conducted for physician orders and communicating with outside providers for clarification on orders. The facility staff conducted Consonus Pharmacy training on 10/28/24.

Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:

A review of Resident 6's signed physician orders dated 05/21/24 and 08/12/24 indicated:

·Atorvastatin 80 mg tablet (for heart disease), Take 0.5 tablets by mouth daily;

·Clopidogrel 75 mg tablet (for blood clots), Take 1 tablet by mouth daily;

·Levetiracetam 250 mg tablet (for seizures), Take 1 tablet by mouth 2 times daily;

·Levothyroxine 100mcg tablet (for thyroid), Take 1 tablet by mouth every morning;

·Aspercreme Lidocaine 4% patch (for pain). Place 1 patch onto the skin daily. (apply for 12 hours then remove for 12 hours); and

·Sertaline HCI 50 mg tablet (for depression and anxiety), Give 2 tablets orally in the morning, start date 02/21/24.

A review of Resident 6's 07/01/24 - 07/31/24 MAR indicated:

·07/17/24 and 07/18/24, Resident 6 did not receive two doses of Atorvastatin 80mg, due to medication not available;

·07/12/24 - 07/16/24, Resident 6 did not receive four doses of Clopidogrel Bisul 75 mg, due to medication not available;

·07/07/24 - 07/09/24, Resident 6 did not receive four doses of Levetiracetam 250 mg, due to medication not available;

·07/28/24 - 07/29/24, Resident 6 did not receive two doses of Levothyroxine Sod 100 mcg, due to medication not available;

·07/14/24 - 07/16/24, Resident 6 did not receive three doses of Sertraline HCI 50 mg, due to medication not available; and

·07/01/24 - 07/02/24, Resident 6 did not receive two doses of Aspercreme pad Lid 4%, due to medication not available.

In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) all acknowledged Resident 6 missed several medications throughout July 2024.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24.

Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors on 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed.

Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

A review of Resident 4's signed physician orders dated 02/26/24 indicated the following:

·Apixaban (Eliquis) 5 mg for atrial fibrillation, to "Take ½ tablet by mouth twice daily for 8 days starting 02/26/24. On 03/05/24, resume Take 1 tablet by mouth every 12 hours."

A review of Resident 4's 02/01/24 - 03/31/24 MARs indicated the following:

·On 02/26/24 Resident 4's MAR was updated to reflect physician orders and 0.5 tab of Eliquis was administered for eight days.

·From 03/05/24 - 03/22/24 Resident 4 missed 35 administrations of Eliquis.

In an interview on 10/28/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) were unable explain why Resident 4's Eliquis did not start on 03/05/24 as ordered.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/28/24.

Facility Verbal Plan of Correction: The facility had completed Consonus pharmacy training to reduce errors by end of day 10/28/24 and would be completing Med tech training on following physician orders and communicating with outside providers when clarification was needed.

Based on interview and record review, conducted during a site visit on 10/28/24, the facility's failure to consistently staff to meet or exceed the posted staffing plan 24 hours a day, seven days a week was substantiated. Findings include, but are not limited to:

A review of the facility's posted staffing plan indicated the following:

·Day Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor;

·Swing Shift: One care staff on first floor, two care staff and one med tech on second floor and three care staff and one med tech on third floor; and

·Night Shift: One care staff on first floor, one care staff on second floor, two care staff on third floor and one med tech on shift.

A review of facility's schedule for 10/22/24 - 10/28/24 indicated seven of the 21 shifts reviewed were staffed below the posted staffing plan.

In an interview on 10/28/24, Staff 8 (Caregiver) stated the third floor has had to borrow staff from other floors due to not having enough staff to care for the residents on the third floor.

On 10/28/24, the third-floor swing shift was observed to have two caregivers and one med tech, which was less than the posted staffing indicated.

All other required elements of the Acuity Based Staffing Tool were in compliance.

The facility failed to fully implement and update an acuity-based staffing tool.

All other required elements of the Acuity Based Staffing Tool were in compliance.

The findings were reviewed with Staff 1 (Executive Director) on 11/27/24.

Based on observation and interview, conducted during a site visit on 10/28/24, the facility's failure to ensure all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair was substantiated. Findings include, but are not limited to:

In an interview on 10/28/24, Staff 7 (Med tech) stated there used to be a push bar on the exit door to the first-floor courtyard but believed a resident had broken it and it was never fixed or replaced.

The first-floor exit door to the courtyard was observed to be missing a push bar and screws were visible where the bar connected to the door.

The exit sliding glass doors to patios on the second and third floors were observed to have locks that did not function.

The facility failed to keep all equipment necessary for the health, safety, and comfort of the residents clean and in good repair.

The findings were reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RN) and Staff 4 (RN) on 10/28/24.

Facility Verbal Plan of Correction: The Executive Director was to make maintenance aware of the door locks and missing push bar by 10/29/24 and would get them fixed.