Azalea Health And Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and facility policies titled, Medication Storage in the Care Center and Multi-dose of Medication Storage Conditions and Expiration Date Factsheet, the facility failed to ensure that medications, biologicals, and supplies were stored properly following manufacturers' recommendations or those of the suppliers, including expiration dates for two of two medication carts. This deficient practice has the potential to place residents at high risk for potential clinical, psychosocial, and mental harm.Findings included:A review of policy titled Medication Storage in the Care Center with a last review date of [DATE], revealed that the facility was to facilitate safe, secure, and proper storage of medications and biologicals following the manufacturer's recommendations or those of the supplier. Bullet point 13 revealed that medications requiring refrigeration are kept in a refrigerator with a thermometer to allow for temperature monitoring.An observation and interview with Certified Medication Assistant (CMA) AA on [DATE] at 11:39 AM on B hall medication cart revealed lubricated jelly dated [DATE] and diclofenac sodium topical gel 1% expired in [DATE]. CMA AA admits that the lubricated jelly and diclofenac sodium topical gel 1% had expired. She stated that the lubricated jelly should have been discarded. She states that the lubricated jelly was used for Foley insertion and to check the rectum for impactionAn interview with Licensed Practical Nurse (LPN) BB admits that the diclofenac sodium topical gel 1% had expired in [DATE]. She states the lubricated gel expired in [DATE]. Subsequent interview on [DATE] at 4:29 pm revealed that it is a joint effort with night shift, but night shift was ultimately the one to manage the medication cart.An interview with LPN CC on [DATE] at 4:41 pm revealed that the expectation was that medication carts are clean and everything labeled, and medication is to be discarded timely.An interview with the Assistant Director of Nursing (ADON) revealed that the expectation is that nurses and CMAs must check the cart when coming on and as they give out medications for expiration dates.A review of the factsheet Multi-dose Packages of Medication Storage Conditions and Expiration Dates revealed that Rocklanta unopened should be stored at two to eight degrees or 36-46 degrees Fahrenheit.An observation and interview with Registered Nurse (RN) FF on A hall medication cart on [DATE] at 1:46 pm revealed that the medication eye drops that were unopened required refrigeration before use. There was a label on the box that stated to refrigerate before use. She is unsure how long the box was in the cart. RN FF admits that eye drops were not refrigerated and admits that they should be refrigerated.An interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:46 pm revealed that the eye drops were not open and required refrigeration.An interview with the Director of Nursing (DON) and the Facility Regional nurse on [DATE] at 2:50 pm revealed that the eye drop medication should be refrigerated until it opens. An interview with a Pharmacy Consultant on [DATE] at 11:36 am revealed that the Rocklanta eye drops are to be refrigerated until opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled Patient's Plan of Care, the facility failed to ensure the care plan was followed for two (R) (R78 and R31) of 37 residents related to Activities of Daily Living Care for R78 and R31 related to medication parameters. Harm was identified to have occurred on 12/13/2024 when Certified Nursing Assistant (CNA) EE was providing ADL care alone, resulting in R78 falling out of bed and sustaining a sub-capital fracture of the femoral neck.Findings included:1. A review of the Patient's Plan of Care dated 12/29/2023, revealed each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs.A review of the medical record for R78 revealed the resident was initially admitted to the facility on [DATE] with the following diagnosis's not limited to fracture of unspecified part of neck of right femur, initial encounter of closed fracture, Parkinson's disease without dyskinesia without mention of fluctuations, unspecified dementia severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic obstructive pulmonary disease, unspecified, and schizoaffective disorder, unspecified.A review of Quarterly Minimum Data Set (MDS) dated [DATE] (MDS at time of fall) revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of four, indicating severe cognitive impairment. Section GG (functional abilities and goals) revealed the resident was dependent on staff for self-care and mobility (required 2 persons).A review of the care plan dated 6/10/2024 revealed the resident is a fall risk. Interventions included but are not limited to two-person assist with bed mobility.An interview on 9/10/2025 at 8:45 am with the Director of Nursing (DON) revealed that the fall with injury occurred when CNA EE provided care to the residents. The DON confirmed that the resident was a two-person assist for bed mobility and that the CNA was the only staff providing care. The DON stated she expects that staff follow care plans and provide a two-person assist when requiredAn interview with Registered Nurse (RN) MDS Coordinator on 9/11/2025 at 11:37 am revealed that care plans are developed as a team. She is responsible for completing the MDS assessment. She confirmed that the resident was coded as a two-person assist for bed mobility in the MDS and care plan at the time of the fall. She stated the resident should have had two staff assisting her and that the staff are aware of a resident's care level because it is listed in their charting system. 2. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R31 had presented with a Brief Interview for Mental Status (BIMS) score of 00, indicating that R31 was totally dependent on activities of daily living (ADL) care.A review of the care plan dated 8/19/2025 revealed that R31 was at risk for Phenytoin (Dilantin) Toxicity related to Dilantin and Levetiracetam. The goal was for the R31 will be free of any discomfort or adverse side effects and will be injury-free during the review period. The interventions include, but are not limited to, holding g-tube feeding one hour before and one hour after Dilantin administration.A record review for R31 revealed that the resident's tube feeds were to be held one hour before and one hour after the administration of phenytoin (Dilantin).During an interview with RN FF on 9/11/2025 at 1:07 pm revealed that the care plan states to hold tube feeds one hour before and one hour after administration of phenytoin (Dilantin). She admits that she did not hold the medication. She admits that she did not realize that she needed to hold the medication. She states that the parameters should she added to the physician's orders. She admits that she only reviews care plans if there is a change in a resident's condition.An interview with the Minimum Data Set (MDS) coordinator on 9/11/2025 at 1:15 pm states that parameters for medication are found in the medication administration record. Everyone on the interdisciplinary team is responsible for the care plan. The care plan does include medication parameters. In the electronic record, that is a tab with recommendation parameters for staff to follow.An interview with the Director of Nursing (DON) on 9/11/2025 at 1:25 pm reveals that the expectation is that the nurse follows the care plan. Parameters for medications are in order. The nurses have access to the care plan for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of policy titled Falls Management, the facility failed to provide care by two staff members for one of two residents (R) (R78) reviewed for falls. Harm was identified on 12/13/2024 when resident R78 fell from bed during care, resulting in a right hip fracture.Findings included: A review of the facility policy dated 12/29/2023 titled Falls Management revealed upon admission/readmission, the nurse will complete the Falls Risk Assessment and address the risk factors related to the patient on the plan of care and implement appropriate interventions as identified.A review of the medical record for R78 revealed the resident was initially admitted to the facility on [DATE] with the following diagnosis's not limited to fracture of unspecified part of neck of right femur, initial encounter of closed fracture, Parkinson's disease without dyskinesia without mention of fluctuations, unspecified dementia severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic obstructive pulmonary disease, unspecified, and schizoaffective disorder, unspecified. A review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] (MDS at time of fall) revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of four, indicating severe cognitive impairment. Section GG (functional abilities and goals) revealed the resident was dependent on staff for self-care and mobility (required two persons). A review of a progress note dated 12/13/2024 at 6:55 am revealed the resident rolled out of the bed onto the floor during patient care. The fall was observed by Certified Nurse Assistant (CNA) EE, the CNA who was assisting the resident with patient care. The resident complained of pain in the right knee. The resident's granddaughter and physician were notified, and the resident was transferred to the emergency room by rescue.A review of the hospital emergency room report on 12/13/2024 revealed an X-ray report that listed a subcapital fracture of the femoral neck. Attempts were made to contact the resident's representative, but were unsuccessful.During an interview on 9/11/2025 at 9:10 am with CNA EE confirmed she was the only CNA providing care to the resident when the resident required a two-person assist. CNA EE revealed she received a corrective action and was given a verbal/written warning. She was provided with education on bed mobility.During an interview on 9/10/2025 at 8:45 am with the Director of Nursing (DON) revealed that the fall with injury occurred when CNA EE provided care to the resident without the assistance of another staff member. The DON confirmed that the resident was a two-person assist for bed mobility and that the CNA was the only staff providing care. The DON revealed CNA EE received a corrective action and revealed CNA EE, along with all clinical staff, including CNA's were provided education on bed mobility. The DON completed nurse aide competency checklists on turning and repositioning a patient in bed, as well as audits/monitoring. A review revealed a facility document titled on-site in-service, dated 12/13/2024, documented that all nursing staff were provided education by the DON. The topic, Subject: adl plan of care/care plan, bed mobility. The fall management policy was attached. Staff signed their name as an acknowledgement of attending the in-service. A review revealed A corrective action that was given to CNA EE on 12/13/2024. She received a verbal and written warning. It was signed by the CNA.A review revealed a written statement by CNA EE on 12/13/2024---I, CNA EE was doing patient care on R78. I was changing her brief and bed. I turned her over to her right side, pointing towards the door. As I rolled the sheet over to the other side of the bed, R78 fell out of the bed to the floor. Immediately, I called for help. If you have any questions, please call me.A review revealed competency checklists on repositioning and bed mobility were completed with staff. Verified by DON on 9/11/2025 at 2:00 pm, and with staff interviewed. During an interview on 9/11/2025 at 11:30 am with Certified Medication Assistant (CMA) AA revealed she has been working for one year. She revealed she received training on bed mobility and following care plans. She stated she is aware of what a resident's care level is by looking at the medical chart. She stated that all staff should know a resident's care level before completing care with a resident to ensure safety. During an interview on 9/11/2025 at 11:43 am with CMA GG revealed she has been with the facility for five months. She stated she had training on bed mobility and care plans.During an interview on 9/11/2025 at 11:45 am with Registered Nurse FF, revealed that they have been employed for a year. She confirmed she had training on bed mobility and care plans. She stated that all staff have access to the resident's level of care, and that is how they know if a resident requires a two-person assist. During an interview on 9/11/2025 at 11:48 am with CMA HH revealed she has been employed with the facility for a year. She confirmed she had training on bed mobility and care plans. She stated that the medical chart has the resident care level.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled Pharmacy Services, the facility failed to ensure one of 37 sampled residents (R) (R40) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility. Findings included:A review of the facility policy titled Pharmacy Services: dated 12/31/2024 revealed that the facility will facilitate a process for safe self -administration of medications by patients when appropriate each patient who desires to self administer medication is permitted to do so if the nursing center's interdisciplinary team has determined that the practice would be safe for the patient and other patients of the nursing center and that the patient can accurately self-administer. A review of clinical records for R40 revealed the following diagnoses, but not limited to, vascular dementia, paroxysmal atrial fibrillation, hypertension, and chronic obstructive pulmonary disease. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R40 presented with a Brief Interview Mental Status Score (BIMS) of five, indicating severe cognitive impairments. An observation on 9/9/2025 at 12:28 pm revealed the following over-the-counter medications: a bottle of antacid tablets and a small tube of sterile lubricant eye ointment (style) lying on a nightstand.A review of clinical records for R40 revealed an omission of a completed assessment to determine whether or not the resident was capable of Self-Administration of Medications.During an interview at the time of observation of R40's room on 9/9/2025 at 4:01 pm, with Certified Medical Assistant (CMA) HH, CMA HH reported being unaware of medications in the resident room. She reported receiving prior in-services to monitor for unauthorized medications in resident rooms. CMA described R40 's cognition as having periods of confusion, which would make her incapable of self-administering medications without supervision During an observation of R40's room on 9/9/1025 at 4:13 pm, with Licensed Practical Nurse (LPN) LPN BB, LPN BB confirmed the unauthorized medication in the resident room. She removed the medications from the room. LPN BB reported R40 was not assessed to self-administer medications and described her mental status as being very confused. LPN BB reported that most likely the resident's family brought the meds into the room. She reported that her expectations are for the nursing staff and certified medical assistant (CMA) to monitor the residents' rooms for medications. During an interview on 9/10/2025 at 10:20 am, the Director of Nursing (DON) reported being unaware of medications in R40's room. She reported that the IDT (Interdisciplinary Team) determines the patient's ability to self-administer medications, and at this time, the IDT had not assessed any residents to self-administer medication. The DON reported that after the deficient practice was brought to her attention yesterday, she and her staff did a scan of all residents' rooms for unauthorized meds and conducted an in-service on unauthorized meds with staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure vents were free from dust and grime buildup in five resident rooms on one of two halls (Hall B).Findings included:An observation on 9/9/2025 at 12:04 pm revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 11:32 am revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 11:11 am revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 10:16 am observed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 10:43 am revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].During an interview on 9/10/2025 at 2:02 pm, the Maintenance Director revealed that he is responsible for cleaning the filters. He confirmed that the filters were dirty and possibly last cleaned in August 2025. An additional interview at 2:52 pm with the Maintenance Director revealed that it takes days to clean the filters and that he takes them outside he places a purple cleaning solution on the filters, and then cleans them off with a water hose. He attempts to clean one hall at a time. He reports that the last time they were cleaned was on 8/13/2025.During an interview on 9/10/2025 at 2:02 pm, the Environmental Services Director confirmed that the air filters were dirty. She stated that the cleaning is tracked in Telles' maintenance system. The subsequent interview at 2:52 pm revealed that the facility does not have a policy for the cleaning or maintenance of air filters or air conditioning units. The facility just tracks the information in its maintenance system. During an interview on 9/10/2025 at 2:02 pm, the Administrator confirmed that the observed air filter in room [ROOM NUMBER] was dirty. Subsequent interviews with the Administrator on 9/11/2025 at 10:51 am revealed that he expected that when they are dirty, like the observation of the filter, the filter should be cleaned immediately.

Based on observations, record reviews, staff interviews, and a review of the facility policy titled, Medication Administration - General, the facility failed to ensure the medication error rate was not 5% or greater. Observation of medication administration revealed there were two errors out of 35 opportunities observed for 2 of 3 residents (R) (#33 and #6), which resulted in a medication error rate of 5.71 percent (%).
Findings included:
A review of the facility's undated policy titled, Medication Administration - General, dated 2019 revealed, Prior to medication administration: The nurse should read the administration directions on the MAR (medication administration record) and verify correct medication, dose and direction for use.
1. During a medication administration observation and interview on 01/31/2023 at 7:34 a.m., Licensed Practical Nurse (LPN) 4 prepared medication for R#33 to administer orally and in the eyes. The following medications were prepared and given to the resident:
- CertiVite, one tablet
- baclofen 20 milligrams (mg), one tablet
- citalopram hydrobromide 20 mg, one tablet
- famotidine 20 mg, one tablet
- levetiracetam 500 mg, one tablet
- medroxyprogesterone 10 mg, one tablet
- docusate sodium 100 mg, one capsule
- vitamin D3 1000 international units (IU)/25 micrograms (mcg), one tablet
- polyvinyl alcohol 1.4 % eye drops, one drop in each eye
Prior to administering the medication, LPN 4 verified there were eight pills in the medication cup.
A record review of the EMAR (electronic medication administration record) and active physician's orders for R#33 revealed that during the 8:00 a.m. medication administration, the resident was to receive the following medications:
- multivitamin with minerals. Give one tablet by mouth one time a day as a supplement.
- baclofen 20 mg tablet. Give one tablet by mouth three times a day for muscle spasm.
- citalopram hydrobromide 20 mg. Give one tablet by mouth once a day for depression.
- famotidine 20 mg. Give one tablet by mouth two times a day for reflux.
- levetiracetam 500 mg. Give one tablet by mouth two times a day for seizures.
- polyvinyl alcohol 1.4 % eye drops. Instill one drop in both eyes four times a day for dry eyes.
- Provera (Medroxyprogesterone Acetate) 10 mg. Give one tablet by mouth one time per day for sexual inappropriate behaviors.
- Colace (docusate sodium) 100 mg capsule. Give two capsules by mouth two times a day for constipation.
- Vitamin D3 25 mcg (1000 units) tablet. Give one tablet by mouth once a day for vitamin D deficiency.
The record review revealed that docusate sodium was not administered to R#33 as ordered.
Interview on 01/31/2023 at 10:26 a.m., LPN 4 stated that the resident should have received two capsules of docusate sodium and that she probably didn't drop two in there. That was an error on my part.
2. During a medication administration observation and interview on 01/31/2023 at 7:52 a.m., Licensed Practical Nurse (LPN) 5 prepared medication for R#6 to administer orally and subcutaneously. The following medications were prepared and given to the resident:
- Lantus pen, 30 units
- amlodipine 10 milligrams (mg), one tablet
- clopidogrel 75 mg, one tablet
- escitalopram oxalate 20 mg, one tablet
- furosemide 40 mg, one tablet
- hydralazine 25 mg, one tablet
- lisinopril 40 mg, one capsule
- metoprolol tartrate 25 mg, one tablet
- Vitamin B complex, one tablet
- Vitamin D3 5000 international units (IU)/125 micrograms (mcg), one tablet
- Januvia 50 mg, one tablet
- calcium 600 mg/Vitamin D3 10mcg, one tablet
- loratadine 10 mg, one tablet
- aspirin 81 mg chewable, one tablet
Prior to administering the medication, LPN 5 verified that there were 13 pills in the medication cup.
A record review of the EMAR (electronic medication administration record) and active physician's orders for R#6 revealed that during the 8:00 a.m. medication administration, the resident was to receive the following medications:
- amlodipine 10 mg. Give one tablet by mouth once a day for high blood pressure.
- aspirin 81 mg delayed release (DR/EC). Give one tablet by mouth once a day for coronary artery disease. Do not crush.
- B Complex-Vitamin B12 (Vitamin B Complex). Give one tablet by mouth one time a day as a supplement.
- calcium carbonate 600 mg/Vitamin D3 10mcg. Give one tablet by mouth one time a day as a supplement.
- cholecalciferol (vitamin D3) 125 mcg (5,000 units). Give one tablet by mouth once a day for vitamin D deficiency.
- clopidogrel 75 mg. Give one tablet by mouth one time a day for stroke.
- furosemide 40 mg. Give one tablet by mouth once a day for congestive heart failure.
- hydralazine 25 mg. Give one tablet by mouth three times a day for high blood pressure.
- Januvia 50 mg. Give one tablet by mouth once a day for diabetes.
- Lantus Solostar U-100 insulin (100 unit/mL (milliliter) 3mL) subcutaneous pen. Inject 30 units subcutaneously one time a day for diabetes.
- Lexapro (escitalopram oxalate) 20 mg. Give one tablet by mouth one time a day for depression.
- lisinopril 40 mg. Give one tablet by mouth one time a day for high blood pressure.
- loratadine 10 mg. Give one tablet by mouth once a day for allergies.
- metoprolol tartrate 25 mg. Give one tablet by mouth two times a day for high blood pressure.
The record review revealed that the aspirin 81 mg delayed release (DR/EC) was not administered to R#6 as ordered.
Interview on 01/31/2023 at 4:01 p.m., LPN 5 stated R#6 should have received an 81 mg aspirin. LPN 5 then reviewed the resident's physician's orders and stated that the resident should have received a delayed release aspirin. She stated she gave the resident a chewable aspirin because it was the only aspirin on the medication cart. LPN 5 went to the medication cart and looked for a delayed release aspirin and was unable to locate any in the cart. She then went to the medication room and came out with a bottle of enteric coated 81 mg aspirin.
Interview on 02/02/2023 at 2:21 p.m., the Director of Nursing (DON) stated that medications should be given as ordered. The DON stated that if the medication was not located in the medication cart and it was an over-the-counter medication, the facility should have the medication in stock, and the nurse should check the medication storage areas to make sure the medication was in the building. If the medication were not in the building, the DON would request that the pharmacy deliver the medication.
Interview on 02/02/2023 at 4:56 p.m., the Administrator stated that the nurse should follow the facility policy regarding medication administration and should follow the physician's orders. The Administrator stated that if a medication was not located in the medication cart, the nurse should check the emergency kit or call the pharmacy to have the medication delivered. If the pharmacy could not deliver, the nurse should contact the facility's backup pharmacy. For over-the-counter medications, the nurse should look to see if the medication was in stock.

Based on observation, staff interviews, record review, and a review of the facility policy titled, Pharmacy Services Medical Administration - General, the facility failed to store medications properly for 3 of 22 residents (R) (#14, #21, #30) on Hall B's medication cart.
Findings included:
Review of the policy titled, Pharmacy Services Medical Administration - General, dated 2019, revealed Medications should be prepared immediately prior to administration. Medications should not be pre-poured.
1. Review of the most recent quarterly Minimum Data Set (MDS) for R#14, dated 12/27/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.
A review of the physician's orders for R#14's dated 01/2023 revealed the resident was receiving the following medication:
- calcium acetate (a calcium supplement) 667 milligrams (mg), one capsule by mouth twice daily;
- cholecalciferol (vitamin D3 supplement) 125 microgram (mcg) capsule, one capsule by mouth every day;
- clopidogrel (a blood thinner) 75 mg, one tablet by mouth every day;
- Lexapro (treats depression)10 mg, one tablet by mouth every day; ferrous sulfate (iron supplement) 325 mg, one tablet by mouth every day;
- folic acid (vitamin B supplement) 1 mg, by mouth every day;
- Lasix (diuretic/water pill) 80 mg, one by mouth every day;
- gabapentin (treats nerve pain and seizures) 300 mg, one by mouth every day;
- oxycodone-acetaminophen (a narcotic pain medication) 10 mg-325mg, one tablet by mouth every day; and
- sodium bicarbonate (treats heartburn) 650 mg, give two tablets by mouth three times every day.
Interview with R#14 on 02/02/2023 at 2:08 p.m., the resident stated the nurse brought the medications to the resident's room in the morning, and the resident did not go to the desk for medications.
2. Review of the most quarterly Minimum Data Set for R#30, dated 11/08/2022, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact.
A review of the physician's orders for R#30 dated 01/2023 revealed the resident was receiving the following medication:
- Lasix (diuretic/water pill) 40 mg, one by mouth every day;
- potassium chloride ER (extended-release potassium supplement) 10 milliequivalent (mEq) one by mouth every day;
- Prozac (antidepressant) 20 mg, one by mouth every day;
- Senna Plus (treats constipation) 8.6 mg-50 mg tablet, give two tablets by mouth every day; and
- Vraylar 3 mg, one capsule by mouth for bipolar disorder.
Interview on 02/02/2023 at 2:09 p.m. with R#30, the resident stated the nurse brought medications to their room in the morning.
3. Review of the most recent quarterly Minimum Data Set assessment for R#21, dated 12/06/2022, revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact.
A review of physicians orders R#21 dated 01/2023 revealed the resident was receiving the following medication:
- amlodipine 5 mg, one tablet by mouth every day;
- Cholecalciferol (vitamin D3) 125 mcg capsule, one capsule by mouth every day;
- clopidogrel (a blood thinner) 75 mg, one by mouth every day;
- Colace (a stool softener) 100 mg, one capsule by mouth twice daily;
- Eliquis (a blood thinner) 5 mg, one by mouth twice daily;
- ferrous sulfate (an iron supplement) 325 mg, one by mouth every day;
- losartan (treats high blood pressure) 25 mg, one by mouth every day; and
- multivitamins, one by mouth every day.
Interview on 02/02/2023 at 2:06 p.m. with R#21, the resident stated that when they received their medications in the morning, the nurse brought the medications to the resident's room.
During an observation on 01/30/2023 at 8:47 a.m. with Licensed Practical Nurse (LPN) 17, revealed that the LPN 17 opened the second drawer of the medication cart to begin a medication pass. An unlabeled medication cup that contained medications was observed sitting in the far-left divided area of the drawer. R#30's name was observed on pre-dispensed medication packets behind the unlabeled medication cup. The nurse then closed the drawer and opened the third drawer. Two additional unlabeled medication cups were observed pre-filled with medications in the divided areas. R#14 and R#21's pre-dispensed packets of medications were observed behind each unlabeled medication cup in the divided areas.
Further observation on 01/30/2023 at 8:47 a.m. revealed that the medication cart had divided areas in the second and third drawers, with room numbers on each divided area. There were no resident names alongside the room number. Each divided area contained pre-packaged medications. R#30's medication was in the second drawer labeled B7A (R#30 did not reside in that room), R#21's medication was in the third drawer labeled B16B (R#21 did not reside in that room), and R#14's medication was in the third drawer labeled B15A (R#14 did not reside in that room).
Interview on 01/30/2023 at 8:47 a.m. with LPN 17, she stated the residents were coming to the main desk for their medications, so she pulled the medications, which made them easier to give.
Interview on 02/02/2023 at 2:22 p.m. with LPN 4, she stated the medications were in the drawer according to the order the residents appeared on the EMAR (electronic medication administration record). The first resident on the EMAR screen would be the first medication in drawer one to the far left, and the medications for residents moved to the right in the drawer according to the next resident name on the screen. LPN 4 confirmed that the numbers on the dividers did not necessarily coordinate with the resident's room number.
Interview on 01/31/2023 at 10:17 a.m. with the Director of Nursing (DON), she stated medications should be given when the nurse approached the resident's room or the location of the resident and given immediately. The DON stated nursing 101 spoke to never pulling medications ahead of time.
Interview on 02/02/2023 at 11:06 a.m. with the Consultant Pharmacist, she stated that as a pharmacist, she did not recommend pulling medications early as a mistake could be made, and another resident could receive the incorrect medication. She further stated that the facility had pre-packaged medications for each resident, and the package could be opened and placed in the medication cup when the nurse was ready to administer the medication to a resident.
Interview on 02/02/2023 at 1:37 p.m. with the Administrator, he stated his expectation would be that policy would be followed and the nursing staff would administer medications immediately after placing them in the medication cups. He stated that no medication cups should be pre-filled to be given later.

Based on staff and resident interviews, record review, and review of the facility policy, Changes in a Patient's Condition, review, the facility failed to notify the resident's physician in a timely manner when there was a change in condition for 1 of 3 sampled residents (R) (#46) reviewed for change of condition. Specifically, Resident R#46 complained of weakness and an unsteady gait, and the right lower leg was bothering the resident. The resident requested that their physician order a scan, but the facility failed to immediately notify the resident's physician, and the physician did not see the note and order a scan of R#46's leg until two days later. The scan was not completed until four days after the resident requested a scan.
Findings included:
A review of the facility's Changes in a Patient's Condition, dated 2020, revealed it was the intent of this center to notify the patient, his/her attending physician, and responsible party/patient representative of changes in the patient's condition and/or status. Nursing services should be responsible for notifying the patient's attending physician when: There is a significant change in the patient's physical, mental, or emotional status; Deemed necessary or appropriate in the best interest of the patient. Further review revealed, Notification, other than for medical emergency, should be made as soon as practical, but should not exceed twenty-four (24) hours.
A review of the Face Sheet for R#46 revealed that the facility admitted the resident with diagnoses that included peripheral vascular disease (PVD).
A review of the most recent quarterly Minimum Data Set (MDS) for R#46, dated 08/05/2022, revealed that R#46 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. R#46 was independent and required no physical assistance for bed mobility, transfers, or walking in the room and/or corridor. The MDS indicated the resident was steady at all times while walking and used a walker.
A review of the Care Plan R#46, initiated on 02/11/2022, indicated the resident was taking an anticoagulant for peripheral vascular disease and a heart attack. The facility developed interventions to administer medications as ordered and to notify the doctor as indicated. The care plan also indicated care areas related to an infection and/or cellulitis, antiplatelet use, cognitive deficit, limited mobility, manipulative behaviors, smoking, decreased cardiac output, pain risk, and the resident planned to discharge home with a caregiver.
Review of a Nurses Note, dated 02/10/2022 at 11:43 a.m., revealed the facility admitted R#46 to the facility with a history of cellulitis of the right lower limb. According to the note, the resident was admitted to the facility with a dressing on the right lower leg where there had been a previous infection.
Review of a Progress Note for R#46, completed by the Advanced Practice Registered Nurse (APRN), indicated that on 08/11/2022, R#46 was seen for a follow-up for PVD and suspected cellulitis to the right leg. The APRN indicated that the previous cellulitis to the resident's right lower leg had healed. The resident had PVD with a previous right femoropopliteal bypass (surgery to bypass an area of the artery and create a new route for blood flow to the leg), with patency (open, not blocked), which was verified in March by the vascular center. The APRN indicated that the resident reported erythema (redness), edema (swelling), and pain to the resident's right lower extremity (RLE) that started approximately 72 hours before. Per the APRN, the resident suspected an infection in the leg again and asked for something to treat it, as well as additional pain medication. The APRN indicated the RLE was mildly edematous from the knee distally (below the knee) and had nonpitting edema (does not respond to applied pressure). The APRN's plan was to start Bactrim DS (an antibiotic), one tablet twice a day for seven days.
Review of a Nurses Note for R#46 dated 08/13/2022, at 5:44 p.m. indicated Licensed Practical Nurse (LPN) 10 noted R#46 complained of weakness and an unsteady gait and requested to work with therapy for walking/strengthening. The resident told LPN 10, My right leg has been bothering me lately. Can the dr (doctor) order a scan for it? According to the note, LPN 10 completed an MD (medical doctor) Communication form and placed it in the doctor's box. LPN 10 indicated in the note that she would continue to observe the resident.
Review of the Fax Form for Physician Communication, dated 08/13/2022, revealed R#46 complained of weakness, an unsteady gate, and the resident's leg was bothering the resident lately. The resident wanted the doctor to order a scan. According to the form, a therapy referral was submitted related to weakness. Further review revealed that the doctor responded to the fax request on 08/15/2022 and ordered a venous doppler ultrasound of the resident's right lower extremity. The fax was noted on 08/16/2022 by Licensed Practical Nurse (LPN) 5.
Review of a Nurses Note, dated 08/16/2022 at 4:32 p.m., revealed the APRN ordered a venous doppler ultrasound (US) to the right lower extremity.
Review of Care Plan Conference notes completed on 08/17/2022 with R#46, and the resident's representative revealed updates regarding the resident's care were provided, and the resident was to have a doppler of his/her leg completed that day (08/17/2022).
Review of a Nurses Note, dated 08/17/2022 at 11:10 a.m., revealed there was redness noted to the resident's right leg, and the resident complained of pain in the right leg. The note also indicated that the resident was able to walk on the leg without difficulty.
Review of a Patient Report on 08/17/2022 at 11:35 a.m., R#46 had a duplex scan of extremity veins related to right lower extremity pain. The impression indicated there was no evidence of deep venous thrombosis (DVT or blood clot) visualized in the right lower extremity veins.
Telephone interview on 02/02/2023 at 7:36 p.m. with LPN 10 stated R#46 always complained of pain in the right leg. She stated that the resident had voiced that the pain had increased. She stated she assessed the resident's leg and asked where the pain was located. LPN 10 stated that the resident then pointed to the spot where the resident previously had cellulitis. She stated there were no open areas in the skin and no redness. She stated she wrote the communication form to the physician, voicing the resident's complaint. She stated she did not call the physician because the resident always complained of pain in the right leg. She stated that the resident usually complained of pain about the time the resident's pain medication was due, and she believed that was why she did not call the physician. LPN 10 further stated that R#46 requested to work with therapy and complained of pain. Subsequently, she filled out the communication form and placed it in the doctor's box for the physician to address.
Interview on 02/02/2023 at 8:50 a.m., LPN 5 stated she could not remember when the resident first complained of pain in the right leg. She stated she did not remember much about the incident. LPN 5 stated she could not answer why the Fax Form for Physician Communication dated 08/13/2022 was not noted by her until 08/16/2022. LPN 5 stated that communication forms went into the doctor's box in the fax room at the facility. When the doctor arrived at the facility, the doctor checked the box and signed off on the form. LPN 5 further revealed that the doctor would then place the fax in a basket in the hall where the resident resided or bring the form to the nurse's desk and give it to the nurse.
Interview on 02/02/2023 at 10:09 a.m. with, Licensed Practical Nurse (LPN) 1, stated she could not remember when R46 first complained of pain in the right leg. LPN 1 stated that if the resident had a change in condition, staff would notify the physician via telephone. If the concern was not urgent, the staff would notify the doctor through written communication, which was placed in the doctor's box in the copy room. The APRN came to the facility twice a week, and the doctor came once a week. LPN 1 stated that if the concern happened over the weekend, the facility used the on-call service.
Interview on 02/02/2023 at 12:28 p.m., the APRN stated the resident was being followed by the vascular clinic for PVD and was seen by the APRN on 08/11/2022. The APRN stated the resident had cellulitis that he thought had healed, but the resident suspected the leg had become infected again. The APRN stated he started the resident on Bactrim. The APRN stated that the resident had also requested an increase in pain medication, and the APRN wanted to talk to the MD about the request for an increase in pain medication. He stated that the facility staff did not call him regarding the resident's complaint that was documented on the 08/13/2023 communication form. He stated in the note that the resident did not complain of pain, just that the resident's leg was bothering them. He stated that if the facility had called the APRN or noted that it was swollen and hot to touch, then a phone call would have been appropriate, but the facility staff wrote the concern as weakness and unsteady gate, which was not urgent. The APRN stated he felt like he did everything he could and got the doctor involved, who escalated the concern. The APRN stated that the resident's right leg was an ongoing, chronic issue.
Interview on 02/02/2023 at 2:21 p.m., the Director of Nursing (DON) stated that the resident was admitted to the facility with a mobility issue. The DON stated that the facility staff used the communication form depending on the resident concern. The DON stated that if the concern was something the APRN or MD could see the resident for later, staff completed a communication form and placed it in the APRN/MD box. When the APRN/MD arrived at the facility to see residents, they reviewed the communication forms. The DON stated that the APRN was at the facility twice a week, and the MD was at the facility once a week. The DON could not explain why she was not notified of the resident's concern until 08/15/2022. The DON stated it was a possibility that the nurse who wrote the communication form on 08/13/2022 should have contacted the APRN via telephone instead of the communication form. The DON stated there was a delay in treatment because the communication form was completed over the weekend, and she would have expected the nurse that completed the form to call the APRN. She stated if the pain was more severe, the nurse should have contacted the physician or contacted the on-call physician. She stated that if the nurse was unable to contact the physician or on-call physician, the nurse should have monitored the resident's pain and possibly sent the resident out to the hospital.
Interview on 02/02/2023 at 4:52 p.m., the DON stated that if a resident voiced concerns about an issue with their leg, she would expect staff to assess the leg and determine how severe the concern was. She stated that if the level was different from the resident's normal, staff should notify the APRN or MD.
Interview on 02/02/2023 at 3:40 p.m., the Medical Director (MD) stated the resident's leg pain was gradual, and the resident had chronic pain and complained of pain everywhere, including the hand, shoulder, foot, and jaw. The MD stated that the facility completed the communication forms and placed them in their folder, and the APRN or MD reviewed the forms once to twice a week. She stated it would be the nurse's perception of the resident if the communication form needed to be completed or if the concern warranted the need to notify someone immediately.
Interview on 02/02/2023 at 5:09 p.m., the Administrator stated he expected staff to assess, evaluate, and follow up with the APRN and/or the MD if the resident voiced new concerns. He stated that the staff was allowed to complete communication forms and place them in the APRN or MD's box, but the staff should still call the APRN or MD regarding the concern.