Mohun Health Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, staff attestation statements and time clock record review, the facility failed to keep an accurate medical record for one resident. This affected one resident (Resident #5) and had the potential to affect 28 residents (Resident #37, #4, #65, #29, #66, #21, #45, #47, #171, #68, #39, #55, #54, #40, #59, #53, #26, #5, #69, #33, #22, #8, #64, #58, #38, #56, and Former Residents #200 and 201) that were residing on the first and second floors of the facility on 01/9/25.
Findings include:
Review of Resident #5's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN), gastroesophageal reflux disease (GERD), polyarthritis, major depressive disorder, primary osteoarthritis, chronic kidney disease (CKD), Vitamin B-12 deficiency, and Vitamin D deficiency.
Review of Resident #5's physician orders revealed that effective on 03/01/24, she was prescribed Amlodipine Besylate 5 milligrams (mg) one tablet once daily for hypertension, Aspirin 81 mg one tablet once daily for prevention, Diltiazem 24 hour extended release 240 mg one capsule once daily for hypertension, Fluoxetine HCl 40 mg one capsule once daily for major depressive disorder, Omeprazole Delayed Release 20 mg one capsule once daily for GERD, Vitamin B-12 1000 micrograms (mcg) one tablet once daily for Vitamin B-12 deficiency, Vitamin D3 50 mcg one tablet once daily for Vitamin D3 deficiency, Carvedilol 12.5 mg one tablet twice daily for hypertension, Clonidine HCl 100 mg one tablet twice daily for hypertension, Hydralazine 100 mg one tablet twice daily for hypertension, Oysco 500 mg one tablet twice daily, and Tylenol Arthritis Extended Release 650 mg 1 tablet twice daily; Effective 08/21/24, she was prescribed Torsemide, a diuretic, 10 mg one tablet once daily for CKD; Effective 04/19/24, she was prescribed Losartan Potassium 50 mg one tablet once daily for hypertension.
Review of Resident #5's Medication Administration Record (MAR) revealed that on 01/09/25, there was no evidence that the following medications had been administered in the morning: Amlodipine Besylate 5 mg one tablet, Aspirin 81 mg one tablet, Diltiazem 24 hour extended release 240 mg one capsule, Fluoxetine HCl 40 mg one capsule, Omeprazole Delayed Release 20 mg one capsule, Vitamin B-12 1000 mcg one tablet, Vitamin D3 50 mcg one tablet, Carvedilol 12.5 mg one tablet, Clonidine HCl 100 mg one tablet, Hydralazine 100 mg, Oysco 500 mg one tablet, and Tylenol Arthritis Extended Release 650 mg one tablet, Torsemide10 mg one tablet, and Losartan Potassium 50 mg one tablet.
Review of Resident #5's medical record revealed that she had not had any adverse reactions as a result of the medication administration not being administered.
Interview with Resident #5 on 04/03/25 at 9:45 A.M. revealed that she did not recall a time where she was not given her morning medications.
Interview with the Director of Nursing on 04/03/25 at 9:30 A.M. revealed there was no evidence in the medical chart that the medications had been administered to Resident #5 on the morning of 01/09/25.
Review of the time sheets for Licensed Practical Nurse (LPN) #170 for 01/09/25 revealed that she was on duty at the facility on 01/09/25 from 8:20 A.M. until 12:52 P.M.
Review of the attestation statements on 04/03/25 authored by Scheduler #175, Registered Nurse #155, and the Director of Nursing regarding the events of 01/09/25 revealed that on 01/09/25, LPN #170 was the nurse working on the first and second floors of the facility. She left the building on 01/09/25 at 12:52 P.M. after claiming she was too anxious to complete her shift. LPN #170 left the faciity on [DATE] without signing off the medication administration record in its entirety for Resident #5. RN #155, a member of the facility's nursing administration team, completed the duration of LPN #170's shift, and LPN #170 was reported to the nursing board for job abandonment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, financial record review, resident interview, staff interview, facility/resident handbook review, and facility policy review, the facility failed to ensure residents/representatives were aware and agreed to the donation of money from their resident fund accounts. This affected two (Residents #21 and #37) of five resident financial accounts reviewed. The census was 68.
Findings Include:
1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were encephalopathy, Parkinson's disease, sciatica, congestive heart failure, muscle weakness, vitamin D deficiency, polyneuropathy, chronic kidney disease, GERD, hypertension, hyperlipidemia, Alzheimer's disease, hypothyroidism, dysphagia, hypokalemia, Parkinsonism, cognitive communication deficit, lack of coordination, and peripheral vascular disease. Review of her MDS assessment, dated 03/11/25, revealed she had a severe cognitive impairment.
Review of Resident #21's financial/trust statements, dated 01/30/24 to 03/31/25, revealed the following withdrawals from her financial account that were identified as donations: on 07/15/24, a withdrawal listed as checks - per resident's request for $200.
Review of Resident #21's Resident Trust Funding Request Form, dated 07/15/24, revealed a check was made payable to Dominican Sisters of Peace (DSOP) for $200. The form stated it was requested by Resident #21, but Resident Life Director/Sister #450 was the individual who signed the form to authorize the check.
2. Resident #37 was admitted to the facility on [DATE]. Her diagnoses were COPD, venous insufficiency, acidosis,Type II Diabetes Mellitus, hypertension, hyperlipidemia, osteoporosis, hypothyroidism, chronic kidney disease, cognitive communication deficit, anemia, and muscle weakness. Review of her MDS assessment, dated 02/04/25, revealed she had a moderate cognitive impairment.
Review of Resident #37's financial/trust statements, dated 01/30/24 to 03/31/25, revealed the following withdrawals from her financial account that were identified as donations: on 06/30/24, a withdrawal listed as checks - per resident's request for $900.
Review of Resident #37's Resident Trust Funding Request Form, dated 07/12/24, revealed a check was made payable to Dominican Sisters of Peace (DSOP) for $900. The form stated it was requested by Resident #37, and a printed signature of Resident #37's authorized the payment on this form. But, according to Resident #37's medical records, she does not have the cognitive ability to authorize a withdrawal from her account.
Interview with Resident Life Director/Sister #450 on 04/03/25 at 1:59 P.M. revealed donating to the DSOP is an understanding that when the residents have a certain amount of money in their account, that is close to the spend down limit, they will donate it back to the DSOP. When asked how much money each resident is expected to donate, she could not answer. When asked how often the residents have to donate, she could not answer. When asked how much money each resident is permitted to keep in their account before they are expected to donate, she could not answer. She stated the residents know they are expected to give/donate back to the DSOP, but they have no documented procedures or education for the residents or resident representatives to outlines the guidelines. She confirmed there was nothing in hard copy provided to the residents/representatives about these procedures of expected/required donations. She stated the residents sign the donation/financial forms to allow the donating.
Interview with Administrator at 04/03/25 at 3:11 P.M. revealed she was not aware of the donation process and procedures regarding the director of life and the sisterhood. She confirmed there should be information provided to the residents about any donation, and the resident/representative should approve/sign it.
Review of facility Resident Handbook, undated, revealed the facility provides maintenance for individual resident accounts at the facility for the convenience of the resident or responsible party. Residents may use the money in their account for whatever they choose, and are able to withdraw funds from this account at the front desk. The facility is also able to provide checks if the resident prefers. If the resident would like to request a check for a purchase/donation, see the finance manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses osteoarthritis, high blood pressure, and major depressive disorder.
Review of Resident #4's physician orders and medication administration records revealed the resident received Clindimycin HCL, an antibiotic, prior to any dental appointments.
Review of Resident #4's care plan revealed no focus areas, goals, or interventions for the antibiotic medication.
Interview on 04/03/25 at 11:03 A.M. with ADON confirmed Resident #4's care plan did not reflect the antibiotic medications the resident was receiving.
3. Review of the medical record for Resident #65 revealed she was admitted to the facility on [DATE] with diagnoses that included intracranial cerebral hemorrhage, disorder of the urinary system, and need for assistance with personal care.
Review of Resident #65's Bowel and Bladder Program Screener assessment dated [DATE] revealed she was a good candidate for bladder retraining.
Review of Resident #65's Minimum Data Assessment on 02/04/25 revealed that she was frequently incontinent and had not had a trial of a toileting program since urinary incontinence was noted in the facility.
Review of Resident #65's care plan dated 07/12/24 revealed that it was silent for identifying Resident #65 as a risk for bladder incontinence and that it was silent for goals and interventions to prevent further bladder incontinence or improve bladder continence.
Interview with Licensed Practical Nurse #150 on 04/02/25 at 8:54 A.M. revealed that he would normally create a care plan for bladder continence with goals and interventions listed on it if a resident was identified as a good candidate for a bladder retraining program. Interview further confirmed that Resident #65's medical record was silent for a bladder continence care plan.
4. Review of the medical record for Resident #9 revealed an admission date of 01/24/17, with diagnoses of Type II Diabetes Mellitus, hypertension, osteoarthritis, muscle weakness, and difficulty walking.
Review of minimum data set (MDS) 3.0 assessment completed 06/06/24 revealed resident #9 scored a 14 on brief interview for mental status, indicating the resident was cognitively intact. Additionally the resident exhibited no disorganized thinking or altered level of consciousness, and showed no signs of inattention. Additionally, the resident does not reject care.
Review of care plan undated revealed that Resident #9 wears full upper dentures and a partial lower denture and has some of her own teeth. Interventions include continuing to assist with arranging dental appointments, providing transportation, and following up with the dentist as indicated.
Review of lab result collected on 02/04/25 revealed that the resident refused lab work for the day. We will attempt to obtain specimens two more times, and then will discontinue attempts according to the resident's wishes.
Review of active physician orders dated 03/01/25 revealed a standing order for Amoxicillin 500 milligrams, four capsules by mouth as needed prior to dental work.
Review lab result collected on 03/04/25 revealed that the nurse was notified of the lab draw refusal.
Review of behavioral monitoring from 03/05/25 through 04/02/25 revealed that Resident #9 exhibited no concerning behaviors.
Review of lab result collected on 04/01/25 revealed that Resident #9 refused the blood draw.
Review of care plan dated 04/03/25 revealed that Resident #9 had refused lab draws, exercising her right to make decisions. Interventions include providing encouragement as needed, enlisting the resident's preferences, and re-approaching later if necessary.
Interview on 04/02/25 at 2:13 P.M. with the infection preventionist #200 confirmed that the resident has a standing order for as-needed Antibiotics. This was ordered due to the presence of hardware in her right hip and femur. The infection preventionist was unaware whether this hardware was documented in her medical record or if antibiotic use related to dental visits had been included.
Interview on 04/03/25 at 11:11 A.M. with the Minimum Data Set (MDS) 3.0 nurse #150 confirmed that Resident #9's care plan did not include refusals of lab work or the use of Antibiotics.
Interview on 04/03/25 at 11:13 A.M. with the Social Worker (SW) #205 confirmed that, according to Resident #9 's laboratory reports, she frequently refuses blood draws. SW #205 denied knowledge of Resident #9's consistent refusal of lab work and confirmed it should be addressed in her care plan.
Interview with MDS nurse #150 on 04/03/25 at 11:11 A.M. confirmed that Resident #9 does not have a care plan addressing mobility or infection risks related to the hardware in her right hip and femur.
Based on medical record review, staff interview, and facility policy review, the facility failed to initiate care plans as needed. This affected five residents (#44, #67, #65, #9, and #4) of 18 resident care plans reviewed. The census was 68.
Findings Include:
1. Resident #44 was admitted to the facility on [DATE]. Her diagnoses were Type II Diabetes Mellitus, functional urinary incontinence, blepharitis, hypothyroidism, hyperlipidemia, osteoporosis, vitamin D deficiency, anemia, dysphagia, venous insufficiency, kyphosis, hypo-osmolality and hyponatremia, anxiety disorder, cognitive communication deficit, lack of coordination, depression, shortness of breath, diarrhea, and GERD. Review of her minimum data set (MDS) assessment, dated 02/20/25, revealed she was cognitively intact.
Review of Resident #44 physician orders, dated 12/24/24, revealed an order for Amoxicillin (antibiotic) 500 milligrams (mg), one time a day for prophylactic regarding osteonecrosis of jaw.
Review of Resident #44 current care plans found no care plan for the use of an antibiotic and/or treatment for an infection to her jaw.
Interview with Licensed Practical Nurse (LPN) #403 on 04/03/25 at 9:00 A.M. confirmed he is not aware of any antibiotic care plan for Resident #44. He confirmed the care plan would be in the electronic medical record if there was one.
Interview with Assistant Director of Nursing (ADON) #200 on 04/03/25 at 3:01 P.M. confirmed Resident #44 did not have an antibiotic care plan, but should have it.
2. Resident #67 was admitted to the facility on [DATE]. Her diagnoses were hemiparesis and hemiplegia, acromegaly and pituitary gigantism, morbid obesity, hyperlipidemia, hypertension, dysphagia, muscle weakness, need for assistance with personal care, dysarthria, and edema. Review of her MDS assessment, dated 02/13/25, revealed she was cognitively intact.
Review of Resident #67's current physician orders found the following pain medications ordered: Tramadol 50 mg every six hours as needed for pain, which was started on 10/31/24; Tramadol (opioid) 100 mg every 24 hours as needed for severe pain, which was started on 03/18/25, Acetaminophen (analgesic) 500 mg, two tabs every six hours as needed for pain, which was started on 11/08/24, and Ibuprofen (nonsteroidal anti inflammatory) 400 mg every six hours as needed for pain, which was started on 11/04/24.
Review of Resident #67 current care plans found no care plan for pain or the use of pain medication.
Interview with LPN #403 on 04/03/25 at 9:00 A.M. confirmed a care plan would be in the electronic medical record if there was one.
Interview with LPN #150 on 04/03/25 at 10:38 A.M. confirmed Resident #67 had no care plan for pain; they added it today. He confirmed there should have been a care plan for pain or pain management.
Review of facility Pain Management policy, dated 09/10/24, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included, major depressive disorder, polyoteoarthritis and hypertension. Review of the comprehensive Minimum Data Set assessment, dated 03/25/25, revealed the resident's cognition was intact.
Review of a physician order, dated 03/20/24, revealed Resident #4 was ordered Nortriptyline (an antidepressant medication) three capsules daily at bed time for neck pain.
Review of the Resident #4's Medication Administration Record (MAR) revealed the resident received Nortriptyline, as ordered, beginning 03/20/24.
Review of Resident #4's medical record revealed there was no monitoring the resident for depressed and withdrawn behaviors.
Interview on 04/03/25 at 3:09 P.M. with LPN #50 confirmed behavior monitoring was not being tracked and/or documented for Resident 's depression and behaviors.
3. Review of Resident #40's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included depressive disorder, cognitive communication deficit and vascular dementia.
Review of Resident #40's Minimum Data assessment dated [DATE] revealed that she received antidepressant medication.
Review of Resident #40's physician' orders dated 12/19/24 revealed that she received an antidepressant medication, Sertraline HCL, 100 milligrams in the quantity of one tablet by mouth once daily.
Review of Resident #40's Treatment Administration Record (TAR) revealed there was no documentation present for monitoring for side effects of an antidepressant medication and there was no documentation present for monitoring for signs and symptoms of depression.
Review of Resident #40's tasks in the medical record revealed that they were silent for monitoring for side effects of an antidepressant medication and silent for monitoring for signs and symptoms of depression.
Review of Resident #40 care plan dated 03/12/21 revealed that she was at risk for the potential for a therapeutic regiment due to her antidepressant medication. Her goal was listed as to be free from discomfort for adverse reactions related to her antidepressant therapy through the review date. Her care plan goals included being monitored and documented for ongoing signs of depression and that she would be monitored for side effects and effectiveness of the medication and that these would be documented.
Interview with Licensed Practical Nurse (LPN)# 160 on 04/03/25 at 1:36 P.M. revealed when a resident is on an antidepressant medication, nursing would monitor for signs of depression and signs and symptoms of side effects from the medication.
Interview with Director of Nursing on 04/03/25 at 1:34 P.M. revealed that if a resident is on an antidepressant medication, nursing is expected to monitor for signs and symptoms of depression and side effects of the medication. Further interview revealed that these would be documented in the medical record under the tasks documentation in the medical record or in the TAR.
Interview with LPN #150 on 04/03/25 at 2:37 P.M. confirmed that Resident #40's medical record did not contain documentation of the resident being monitored for signs and symptoms of depression and for side effects of her antidepressant medication since 12/01/24.
2. Review of the medical record for Resident #3, admitted on [DATE], revealed diagnoses of basal cell carcinoma of the skin, age-related osteoporosis, rheumatoid arthritis, bilateral arm pain, and a wedge compression fracture of T11-T12.
Review of the Minimum Data Set (MDS) 3.0 assessment, completed on 02/05/25, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The health conditions section of the MDS indicated that the resident receives scheduled pain medication, as well as as-needed (PRN) medication and non-medication interventions for pain management.
Review of the medication administration record for March 2025 revealed Resident #3 has an order for as needed Aspercreme Lidocaine 4% patch for pain, this medication was not utilized in March 2025.
Review of the medication administration record for March 2025 revealed Resident #3 has an order for as needed acetaminophen 500 milligram (mg) capsule every four hours as needed for mild pain, this as needed medication was not utilized March 2025.
Review of the medication administration record for March 2025 revealed Resident #3 received as needed Tramadol (narcotic) mg for pain it was administered on 03/04/25 for pain at three out of 10, on 03/09/25 for pain at three out of 10, On 03/13/25 pain at two out of 10, 03/17/25 for pain at three out of 10, and on 03/22/25 for pain at three out of 10.
Review of the medication administration record for March 2025 revealed Resident #3 received scheduled Tramadol 50 mg at 8:00 A.M. on 03/05/25 for pain of 0/10, on 03/14/25 for pain at 0/10, and on 03/19/25 for pain at 0/10.
Interview conducted on 04/02/25 at 2:33 PM with Registered Nurse #210, the nursing staff, confirmed that PRN pain medication is administered based on the resident's reported pain level and location. The resident is asked to rate their pain, and the appropriate medication is administered based on the pain level. Lower-strength medications are given for pain levels of one to five, while higher-strength options are given for pain levels 6-10. If pain medication is administered outside of these prescribed parameters, a progress note is required to explain the deviation. RN #210 further confirmed that medication selection is influenced by the location of the pain and that clear guidelines should be established for selecting the appropriate medication based on these factors.
Interview with Registered Nurse #210 on 04/03/25 at 10:14 AM revealed that Resident #3 does not have specific parameters for when pain medication should be administered. It was noted that on some occasions, narcotic medications are administered even when the pain level is reported as low or 0/10, as reflected in the medical record. She confirmed that the resident typically follows a scheduled regimen for pain medication, often requesting Tramadol at night, though no formal pain parameters are currently in place for the administration of these medications.
Based on medical record review, staff interview, and facility policy review, the facility failed to have proper pain parameters for residents using as needed pain medication. This affected two (Residents #67 and #3) of three residents reviewed for pain management. Also, the facility failed to monitor medication side effects for residents prescribed psychotropic medications. This affected two (Resident #4 and #40) of five residents reviewed for unnecessary medications. The census was 68.
Findings Include:
Resident #67 was admitted to the facility on [DATE]. Her diagnoses were hemiparesis and hemiplegia, acromegaly and pituitary gigantism, morbid obesity, hyperlipidemia, hypertension, dysphagia, muscle weakness, need for assistance with personal care, dysarthria, and edema. Review of her minimum data set (MDS) assessment, dated 02/13/25, revealed she was cognitively intact.
Review of Resident #67's current physician orders found the following as needed pain medications ordered: Tramadol (opioid) 50 milligrams (mg) every six hours as needed for pain, which was started on 10/31/24; Tramadol 100 mg every 24 hours as needed for severe pain, which was started on 03/18/25, Acetaminophen (analgesic) 500 mg, two tabs every six hours as needed for pain, which was started on 11/08/24, and Ibuprofen ( non steroidal anti inflammatory) 400 mg every six hours as needed for pain, which was started on 11/04/24. Review of these medications found there were no parameters or guidelines as to when each medication should be administered.
Review of Resident #67's medication administration records, dated November 2024 to March 2025, revealed the following as needed pain medications that were ordered, administered, and the pain levels that were documented for each administration in totality from November 2024 to March 2025: Acetaminophen had 22 total administrations for pain levels that varied between one and seven; Ibuprofen had 116 administrations for pain levels that varied between zero and six; Tramadol 50 mg had 81 administrations for pain levels that varied between zero to ten, and Tramadol 100 mg was administered two times for pain levels between two and six. Ibuprofen was administered a total of five times for a pain level of zero, and Tramadol 50 mg was administered a total of two times for a pain level of zero.
Review of Resident #67's care plans revealed no care plan regarding the use of pain medication or pain management. This also included no parameters as to when each pain medication should be administered.
Review of Resident #67's progress notes, dated November 2024 to March 2025, revealed no progress notes to justify the reasons as to why as needed pain medication was given based on their pain levels, and no justification as to why as needed pain medication was given for a pain level of zero.
Interviews with Registered Nurse (RN) #302 and RN #210 on 04/02/25 at 2:05 P.M. and 2:10 P.M. stated as needed pain medication is given based on the pain level and location of pain. They stated they will ask the resident what their pain level is, and then ask the resident which pain medication they would like to have. Typically, they will provide lower strength pain medication (ibuprofen or acetaminophen) for pain levels of one to five, then higher strength pain medication (Tramadol) for pain levels of six to ten. If they provide pain medication outside of those parameters or guidelines, there will be a progress note to support it. But, they confirmed there should be specific parameters for which pain medication to give, when there is more than one as needed pain medication prescribed.
Review of facility Pain Management policy, dated 09/10/24, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (IDT), may necessitate gathering the following information, as applicable to the resident: current prescribed and pain medications dosage and frequency. Factors influencing the course of treatments include: the cause, location, and severity of resident's pain, the resident's current medical condition, the resident's current medications, the resident's desired level of relief and tolerance for adverse consequences, potential benefits, risks, and consequences of medications, and available treatment options. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has a potential for pain. The following are general principles the facility will utilize in prescribing analgesics: use lower doses of medication initially and titrate slowly upward until comfort is achieved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure medications were properly stored to ensure medications did not exceed the expiration date on stock medication supplies. This affected 28 residents living on the first and second floor. The facility census was 68.
Findings include:
Observation of the second floor medication room on [DATE] at 1:35 P.M. revealed a single medication cabinet in which nursing staff stores over the counter medication for residents of the first and second floor. The cabinet also stores medications residents have in possession prior to admission, to be held until the residents are discharged . The cabinet had various scattered medications and empty boxes. Pulls of medication revealed Ferrous Gluconate (iron replacement) 240 mg with an expiration date of 05/2024. Additionally pulled from the cabinet were Systane drops (ophthalmic lubricant) with an expiration date of 11/24.
Interview on [DATE] at 1:37 P.M. with Licensed Practical Nurse (LPN) #160 confirmed the two medications were expired and they should be disposed of.
A medication storage policy was requested from the facility however there was none provided.

2. Observations on a tour of the facility's kitchen on 03/31/25 between 8:35 A.M. and 8:59 A.M. revealed a red and black substance inside the white plastic backboard of ice machine which was easily removed with a cleansing towel. A crate of bananas on floor of the dry storage room. A fuzzy gray and brown substance on the walk-in refrigerator's ceiling, near the internal fans. In the walk-in freezer there were opened and undated packages of crinkle carrots. There was also an unlabeled and undated cup of a brown substance. On the freezer floor there were two crates of bread loaves, a package of fire roasted sweet potatoes and a bag of tater tots. In the walk-in freezer ceiling there were icicles present, and evidence of ice formed on one package of frozen cheese manicotti.
On 03/31/25 at 8:37 A.M. [NAME] #374 revealed that she opened the undated frozen carrots but could not recall the date that she opened them. She stated that the brown substance was a chocolate milkshake but unsure when it was made. She also confirmed the food items sitting on the freezer floor. She acknowledged the ice on the cheese manicotti and added that ice should not be on the packaging.
On 03/31/25 at 8:47 A.M. Dietary Aide #388 confirmed the presence of the red and black substance inside the ice machine that it is easily removed by wiping it.
On 03/31/25 at 9:03 A.M. during an interview Dietary Manager confirmed the undated opened food in the freezer, the items found on floor and the presence of the icicles on the ceiling and dripping on to the manicotti box.
Based on observations, staff interviews, review of facility policies and review of food safety guidelines recommended by the Centers for Disease Control and Prevention, the facility failed to serve and store food in a safe and sanitary manner. This had the potential to affect all 68 residents in the facility that ate food from the kitchen and 35 residents who ate in the dining room on 04/01/25 (Residents #58, #4, #53, #36, #29, #271, #60, #64, #45, #59, #39, #66, #68, #54, #56, #55, #57, #2, #27, #42, #12, #15, #25, #44, #51, #46, #50, #62, #67, #23, #34, #6, #16, #52, and #28) . The facility census was 68 residents.
Findings include:
1. Observations on 04/01/25 at 12:17 P.M. in the dining room of the temperatures of the seafood salad on the buffet serving line revealed that the seafood salad was being stored on the buffet serving line was being held at a temperature on the buffet line from 49 to 51 degrees Fahrenheit.
Director of Dietary Services #165 took the holding temperatures of the seafood salad on 04/01/25 at 12:17 P.M. in two locations of the container that held the seafood salad. The first temperature that registered in the seafood salad was 51 degrees Fahrenheit. The Director of Dietary Services #165 was observed stirring the seafood salad and obtained a second temperature from the middle of the seafood salad. The observed temperature that registered was 49 degrees Fahrenheit.
Interview with the Director of Dietary Services #165 on 04/01/25 revealed that the seafood salad had been on the food service line since 11:45 A.M. Further interview on 04/02/25 at 9:55 A.M. revealed that the holding temperature should be at 40 degrees or lower for the seafood salad.
Review of facility policy titled Food Safety Requirements dated 2023 revealed that foods and beverages shall be maintained at the proper temperature and out of the danger zone.
Review of the Centers for Disease Control and Prevention's website on Food Safety revealed that bacteria can multiply rapidly if it is in the danger zone between 40 and 140 degrees fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with hyperglycemia, nonexudative age-related macular degeneration, Rhabdomyolysis and nonrheumatic aortic valve stenosis.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #61's cognition was intact. Resident #61 was independent with set up help only for personal hygiene and eating. Resident #61 utilized a walker for mobility assistance. Further review of the quarterly MDS assessment dated [DATE] indicated Resident #61 was on insulin.
Review of Resident #61's physician's orders dated 05/12/22 revealed an order for Ozempic (hyperglycemic medication) 0.25 milligram (mg) subcutaneously every week on Tuesday. There was no order for the resident to receive insulin.
Interview on 01/26/23 at 11:23 A.M. Director of Nursing #297 verified the Ozempic was coded on the MDS assessment as insulin.
4. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to encephalopathy, bipolar, metabolic syndrome, and diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #44's cognition was intact and the resident required extensive assistance with one staff for activities of daily living. Further review of the quarterly MDS assessment indicated Resident #44 was on insulin.
Review of Resident #44's physician's orders dated 06/26/22 revealed an order for Trulicity (hyperglycemic medication) 0.5 milliliter (ml) subcutaneously every week on Saturday. There was no order for Resident #44 to receive insulin.
Interview on 01/26/23 at 11:10 A.M. with MDS Licensed Practical Nurse (LPN) #309 verified that Trulicity was coded as insulin.
5. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified dementia, diabetes mellitus, unspecified psychosis, and Alzheimer's disease. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident required extensive assistance with one staff for activities of daily living except eating was coded for supervision with two staff.
Interview on 01/26/23 at 8:11 A.M. with MDS Licensed Practical Nurse (LPN) #309 verified Resident #13 required one staff for supervision of eating, not two.
Based on medical record review and staff interview, the facility failed to have accurate Minimum Data Set (MDS) assessments for four (Resident #3, #36, #44, and #61) of 10 residents who received injectable hyperglycemic medication and for one (Residents #13) of 20 residents whose records were reviewed that required assistance for eating. The census was 67.
Findings include:
1. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included displaced fracture of the second vertebra, major depression, high blood pressure, osteoarthritis, diabetes, and repeated falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3's cognition was intact. Resident #3 was independent with set up help only for bed mobility and eating. Resident #3 required extensive assistance of one staff member for dressing. The quarterly MDS assessment dated [DATE] also indicated Resident #3 was on insulin.
Review of the physicians orders dated 08/12/21 revealed an order for Ozempic (hyperglycemic medication)1 milligram (mg) every week on Thursday, Resident #3 did not receive insulin.
Interview on 01/25/23 at 4:00 P.M. of Licensed Practical Nurse (LPN) #309 verified the Ozempic was coded on the MDS assessment as insulin.
2. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute embolism and thrombosis (05/11/21), diabetes and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #36's cognition was intact. Resident #36 was independent with set up help only for bed mobility and eating and supervision with one staff physical assistance for personal hygiene. Resident #36 received antidepressant and anticoagulant daily. Further review of the quarterly MDS assessment dated [DATE] indicated Resident #36 received insulin.
Review of Resident #36's physicians orders dated 07/24/21 revealed an order for Ozempic 1 mg every Sunday.
Interview on 01/25/23 at 4:00 P.M. of Licensed Practical Nurse (LPN) #309 verified the Ozempic was coded on the MDS assessment as insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve food at the proper portion size to meet the nutritional needs of residents who received the alternate entrée. This affected two residents (#13 and #24) out of eleven (Residents #6, #13, #21, #24, #33, #37, #46, #51, #52, #56 and #119) who selected to receive a full portion of the alternate. The facility census was 67.
Findings include:
Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified dementia, diabetes mellitus, unspecified psychosis, and Alzheimer's disease. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident required extensive assistance with one staff for activities of daily living.
Review of the physicians' orders for January 2023 revealed Resident #13 was on a regular diet with no restrictions.
Review of Resident #13's diet ticket revealed a five-ounce chicken Caesar wrap.
Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, diabetes mellitus, and major depressive disorder. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with one staff for activities of daily living and for meals required supervision for set up only.
Review of the physicians' orders for January 2023 revealed Resident #24 was on a consistent carbohydrate no added salt diet.
Review of Resident #24's diet ticket revealed a five-ounce chicken Caesar wrap.
Observation of tray line on 01/25/23 at 11:40 A.M. revealed Resident # 13 and Resident #24 received a half portion (1/2) of a Caesar chicken wrap instead of the whole Caesar wrap (5 ounce) alternative which was identified on the meal ticket. Interview with [NAME] #277, at the time of the observation, revealed she has always served 1/2 of a wrap to residents.
Interview on 01/25/23 at 11:43 A.M. with Registered Diet Technician (DTR) #289 verified Residents #13 and #24 should have been given a full Caesar wrap.
Interview on 01/25/23 at 3:00 P.M. with DTR #289 revealed the following residents ordered full wrap sandwiches (Residents #6, #13, #21, #24, #33, #37, #46, #51, #52, #56 and #119). Residents #12 and #49 were to receive 1/2 portions of the chicken Caesar wrap.
Interview on 01/26/23 at 8:24 A.M. with DTR #289 revealed the facility was having trouble printing recipes with the program and tray line was audited as needed for accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #41) of one resident reviewed for advanced directives. The facility census was 67.
Findings include:
Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, chronic kidney disease, generalized anxiety disorder, depression hyponatremia, hypokalemia, and iron deficiency anemia.
Review of the signed documents section of Resident 41's medical record revealed a signed do not resuscitate comfort care- arrest (DNRCC-A) consent dated [DATE].
Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #41 was cognitively intact and required extensive assistance with one-person physical assistance for activities of daily living.
Review of Resident #41's care plan dated [DATE] revealed the resident was a DNRCC-A code status signifying that cardiopulmonary resuscitation (CPR) was not to be conducted in case of cardiac or respiratory arrest.
Review of the [DATE] to [DATE] physician orders for Resident #41 revealed an ordered dated [DATE] for Full Code status signifying that CPR measures were to be conducted in case of cardiac or respiratory arrest.
Observation on [DATE] at 8:14 A.M. revealed Resident # 41's physician's orders for [DATE] to [DATE] indicated the resident was a Full Code. The hard chart had a face sheet and on the stem of the hard chart was a sticker that indicated DNR-CCA. This was verified by Registered Nurse (RN) #203 on [DATE] at 8:20 A.M.; RN #203 stated that they should both match.
Review of the facility policy dated 11/2022 titled, Residents' Rights Regarding Treatment and Advanced Directives revealed during the care planning process, the facility would identify, clarify, and review with the resident or legal representative whether they desired to make any changes related to any advanced directives. Any decision making regarding the resident's choices would be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, the facility failed to obtain a physician order for a resident's hand splint (Resident #28). The deficient practice effected one (Resident #28) of two residents (Resident #7 and Resident #28) reviewed for limited range of motion. The facility census was 62.
Findings include:
Review of Resident #28's medical record revealed an admission date on 07/30/07 with diagnoses including Alzheimer's Disease, aphasia, macular degeneration, other specified diseases of anus and rectum, osteoarthritis, hypothyroidism, other iron deficiency, stiffness of left knee, disorder of bone, hyperlipidemia, persistent vegetative state, hypertension, contracture of right and left knees, Vitamin B12 deficiency, major depressive disorder, leiomyome of uterus, unspecified psychosis not due to a substance or known physiological condition, pain in joints of hand, contracture of unspecified hand, abnormal posture, muscle weakness and dysphagia.
Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was never or rarely understood. Per staff assessment, the resident had severely impaired cognition. The resident required extensive assistance from one to two staff to complete bed mobility, dressing, eating, toileting and personal hygiene. The resident was totally dependent on staff assistance to complete bathing, mobility and transfers. The resident was always incontinent of bladder and bowel. The resident was on a turning and repositioning program.
Review of the progress notes for Resident #28 dated 12/18/19 revealed the resident continued to maintain flexible joints with the restorative maintenance program which included splint or brace and passive range of motion.
Review of Resident #28's care plan dated 01/05/2012 revealed the resident had altered functional range of motion of bilateral hands related to contractures with an interventions that included: bilateral elbow, wrist and shoulder and lower extremity passive range of motion exercise program once a day, six to seven days per week for at least fifteen minutes per day and use of supportive devices such as splints, braces, canes, crutches, etcetera as recommended by occupational therapy.
Review of Resident #28's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the past three months revealed no documentation of the use of a hand splint.
Review of Resident #28's current physician orders revealed there was not a physician order for the use of hand splints.
Observations of Resident #28 on 03/10/20 at 9:14 A.M. and 6:10 P.M. revealed the resident had a splint on her left hand.
Observations of Resident #28 on 03/11/20 at 10:04 A.M., 12:24 P.M., and 4:35 P.M. revealed the resident was up in her custom wheelchair without the hand splint in place at the times of each of the observations.
Interview with the Assistant Director of Nursing (ADON) on 03/11/20 at 3:03 P.M. confirmed there should be a physician order in place for any kind of adaptive equipment, including a splint.
Interview with State Tested Nurse Aide (STNA) #152 on 03/11/20 at 4:40 P.M. revealed Resident #28 wore a splint on her hand in the morning and then once the resident was out of bed, the splint was removed. STNA #152 confirmed the resident was not wearing a splint due to the resident being up in her wheelchair. STNA #152 stated the physical therapist provided instructions on when the resident should have the splint on and when it should be taken off. Resident #28 did not sleep with the splint on. The aide was not aware whether a physician order was in place for the splint.
Interview with Registered Nurse (RN) #150 on 03/11/20 at 4:53 P.M. revealed physical therapy provided an in-service to staff regarding Resident #28's restorative nursing program and recommended the use of the splint. RN #150 stated the resident should have the splint on her hand when she is out of bed and it should be taken off when the resident was in bed. RN #150 stated the resident's physician approved the use of the splint, but there should also be an order with instructions in the resident's chart. RN #150 confirmed there was not a physician order in the resident's chart for the use of the hand splint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician provided a rational for declining a gradual dose reduction of psychotropic medications for Residents #30 and #33. This affected two of five residents reviewed for unnecessary medications. Facility census was 62.
Findings include:
1. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including major depressive disorder and dementia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. The MDS also revealed the resident received an antidepressant.
Review of pharmacy note dated 12/18/19 revealed a pharmacy recommendation was made for an updated progress note for the continued need of Resident #30's Prozac (antidepressant).
Review of the pharmacy consultation report dated 12/18/19 revealed a recommendation for an annual review to update the progress note regarding the continued need for Prozac 20 milligram (mg) daily. The Centers of Medicare and Medicaid (CMS) required an annual consideration for a gradual dose reduction (GDR) for residents that received antidepressant medications. If the medication was to continue at the current dose, a resident-specific rational was to be provided describing why a dose reduction was clinically contraindicated.
On 01/03/20, the physician marked the box to decline the recommendation because the GDR was clinically contraindicated as indicated below. There was a note to check option #1 or #2 AND provide a patient-specific rationale. The physician checked option #1 which indicated the medication was to be continued, and a GDR was likely to impair the individual function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW. The physician signed the form but did not provided a patient-specific rationale to describe why a GDR attempt would likely impair function or cause psychiatric instability for Resident #30.
Review of March 2020 physician orders revealed Resident #30 had received Prozac 20 mg daily for depression since 03/10/05.
Interview on 03/12/20 at 5:17 P.M. Director of Nursing (DON) verified the physician did not provide a patient-specific rationale by a GDR should not attempted for Resident #30.
2. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses including dementia, psychosis, anxiety and depressive disorder.
Review of the quarterly MDS dated [DATE] revealed Resident #33 had severe cognitive impairment. The MDS also revealed the resident received antipsychotic and antidepressant medication.
Review of pharmacy note dated 05/22/19 revealed a pharmacy recommendation was made for an updated progress note for the continued need of Resident #33's Abilify (antipsychotic) 2.5 mg daily and Zoloft (antidepressant) 25 mg daily. CMS required an annual consideration for a GDR for residents that received antipsychotic and antidepressant medications. If the medication was to continue at the current dose, a resident-specific rational was to be provided describing why a dose reduction was clinically contraindicated.
On 06/06/19, the physician marked the box to decline the recommendation because the GDR was clinically contraindicated as indicated below. There was a note to check option #1 or #2 AND provide a patient-specific rationale. The physician checked option #1 which indicated the medication was to be continued and a GDR was likely to impair the individual function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW. The physician signed the form but did not provided a patient-specific rationale to describe why a GDR attempt would likely impair function or cause psychiatric instability for Resident #33.
Review of March 2020 physician orders revealed Resident #33 had received Zoloft 25 mg daily since 06/27/17 and Abilify 2.5 mg daily since 10/18/18.
Interview on 03/12/20 at 5:17 P.M., the DON verified the physician did not provide a patient-specific rationale why a GDR should not attempted for Resident #33.