Health inspection·August 13, 2025

Title 42, F684, Section 483.25 - Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Title 42, F760, Section 483.45(f)(2) - Residents are Free of Significant Med Errors The facility must ensure that its- Section 483.45(f)(2) Residents are free of any significant medication errors. Title 22, Section 72311 - Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. Title 22, Section 72313 - Nursing Service-Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed (6) Medications shall be administered as soon as possible, but no more than two hours after doses are prepared, and shall be administered by the same person who prepares the doses for administration. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. Title 22, Section 72353 - Pharmaceutical Service-General (b) Dispensing, labeling, storage and administration of drugs and biologicals shall be in conformance with state and federal laws. Title 22, Section 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/10/25 at 8 a.m., an unannounced visit was conducted at the facility for the annual recertification survey and the investigation of complaints CA00949363, CA00949369, CA00949421, and CA00949428 regarding medications not being administered timely. The Department determined the facility failed to ensure eight out of 31 sampled residents (Residents 265, 60, 267, 264, 266, 160, 262, and 263) received treatment and care to attain and maintain their highest practical well-being consistent with professional standards of practice and the facility's policy and procedures (P&P). These failures resulted in Residents 265, 60, 267, 264, 266, 160, 262, and 263 not receiving their medications on time. Furthermore, Residents 265, 264, 160, and 266 experienced unnecessary pain and emotional distress due to missed medication doses that negatively affected the residents' level of comfort, activity and sleep. Findings: 1. A review of Resident 265's clinical record indicated Resident 265 was admitted February of 2025 and had diagnoses that included fracture (a break in the continuity of a bone) of left humerus (upper arm bone), neuralgia (pain caused by irritation or damage to a nerve) and neuritis (inflammation of a nerve), and need for assistance with personal care. A review of Resident 265's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns (mental process of acquiring knowledge and understanding)., dated 3/2/25, indicated Resident 265 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15 which indicated Resident 265 had a moderately impaired cognition. A review of Resident 265's MDS Health Conditions, dated 3/2/25, indicated Resident 265 had frequently experienced pain or hurting which frequently made it hard for her to sleep at night, occasionally limited her participation in rehabilitation therapy sessions, and occasionally limited her day-to-day activities. A review of Resident 265's progress notes, dated 2/19/25, indicated Resident 265 arrived at the facility on 2/19/25 at around 11:58 p.m. and had a pain level of "4/10" (numeric pain scale from 1 to 10; 1-3 is mild pain, 4-7 is moderate pain, 8-10 is severe pain). A review of Resident 265's physician's order, dated 2/19/25 at 12:13 p.m., indicated, "MS Contin (Morphine Sulfate) [a strong medication used to treat moderate to severe pain] Oral Tablet Extended Release 30 MG [milligrams- unit of measurement] Give 1 tablet by mouth every 8 hours for Pain management." A review of Resident 265's care plan, initiated 2/19/25, indicated, "At risk for pain or discomfort related to left humeral fracture due to ground fall at home." A review of Resident 265's care plan intervention, initiated 2/19/25, indicated, "Administer pain meds as MD (Medical Doctor) ordered...MS Contin Oral Tablet...for Pain management." A review of Resident 265's Medication Administration Record (MAR- a legal document used to record medications given to the residents), for the month of February 2025, indicated Resident 265's morphine sulfate was scheduled to be administered every 8 a.m., 4 p.m., and 12 midnight, with the first dose scheduled on 2/19/25 at 4 p.m. A further review of the MAR indicated the 4 p.m. of the morphine sulfate on 2/19/25 was marked with a chart code "5", which indicated the medication was held and not given to the resident. A review of Resident 265's "Weights and Vitals Summary", dated 2/19/25 at 8:38 p.m., indicated Resident 265 had a pain level of "8 [severe pain]." During an interview on 3/10/25 at 9:42 a.m., Resident 265 stated she did not receive her morphine medication on the day she was admitted in the facility. Resident 265 also stated her pain was so awful that day, it went to a level of 9 out of 10 (severe pain). Resident 265 further stated, "Well, It [sleeping] was hard ...I got hard time sleeping ...I was in so much pain." During a concurrent interview and record review on 3/11/25 at 4:22 p.m., Resident 265's MAR for February 2025 was reviewed with Licensed Nurse (LN) 6. LN 6 confirmed that Resident 265's morphine sulfate was not given on 2/19/25 at 4 p.m. LN 6 stated there was a risk for Resident 265 to be in so much pain when the morphine sulfate was not given. During a concurrent phone interview and record review on 3/13/25 at 10:54 a.m., Resident 265's medication orders were reviewed with the Pharmacist from the Facility's Pharmacy (PP). The PP stated they only received Resident 265's medication order for morphine sulfate on 2/19/25 at 7:41 p.m. and had filled and sent it on the next scheduled delivery time which was 10:30 pm. During a concurrent interview and record review on 3/13/25 at 11:46 a.m., Resident 265's medication records were reviewed with the Admissions Coordinator (AC). The AC showed a fax receipt indicating Resident 265's prescription order of morphine sulfate was sent to their pharmacy on 2/19/25 at 5:53 p.m. The AC confirmed the prescription order was faxed after the scheduled administration. The AC stated that sometimes it would take 4 hours for nurses to transcribe medication orders which causes a delay in faxing medication orders. A review of the "Shipping Manifest [receipt]" for Resident 265's morphine sulfate indicated the facility received the medication on 2/19/25 at 10:35 p.m. A review of Resident 265's progress notes did not indicate that Resident 265's attending physician was notified when Resident 265's prescribed medication was not administered timely. 2. A review of Resident 60's clinical record indicated Resident 60 was admitted March of 2025 and had diagnoses that included thrombocytosis (a condition characterized by an abnormally high number of clotting components in the blood) and benign prostatic hyperplasia (BPH- the prostate gland grows larger than normal potentially causing urinary problems). A review of Resident 60's admission "History and Physical", dated 3/5/25, indicated Resident 60 was oriented to person, place and time, but "Does not have the capacity to understand and make medical decisions." A review of Resident 60's progress notes, dated 3/5/25, indicated Resident 60 arrived at the facility on 3/4/25 at 3:05 p.m. A review of Resident 60's physician's order, dated 3/4/25 at 4:40 p.m., indicated, "Tamsulosin HCL(Hydrochloride) [a medication used to treat enlarged prostate] Oral Capsule 0.4 MG... Give 1 capsule by mouth at bedtime related to BENIGN PROSTATIC HYPERPLASIA..." A review of Resident 60's physician's order, dated 3/4/25 at 4:43 p.m., indicated, "Apixaban [a medication used to treat and prevent blood clots and to prevent stroke] Oral Tablet 2.5 MG... Give 1 tablet by mouth two times a day..." A review of Resident 60's MAR for the month of March 2025, indicated Resident 60's Tamsulosin was scheduled to be administered starting 3/4/25 every 9 p.m. and the Apixaban was scheduled every 9 a.m. and 9 p.m., with first dose on 3/4/25 at 9 p.m. A further review of the MAR indicated the 9 p.m. doses for Tamsulosin and Apixaban on 3/4/25 were marked with a chart code, "5", which indicated the medications were held and not given to the resident. A review of Resident 60's progress notes, dated 3/5/25 at 6:56 a.m., indicated, "...f/u [follow up] with pharmacy as medication not delivered.as per pharmacy they did not receive the face sheet and order. Refaxed all the order and face sheet. Requested stat [immediate] delivery of medication. endorsed to next shift..." During an interview on 3/11/25 at 4:08 p.m., Resident 60 stated he could not remember if he got all his medications when he was admitted in the facility. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 60's MAR was reviewed. LN 6 confirmed that the 9 p.m. doses of Resident 60's Tamsulosin and Apixaban on 3/4/25 were not given. LN 6 stated there was a risk for Resident 60 to develop impaired circulation when the Apixaban was not given and a risk to negatively affect Resident 60's health when the Tamsulosin was not given. During a concurrent phone interview and record review on 3/12/25 at 11:51 a.m., Resident 60's medication orders were reviewed with the Pharmacy Technician (PPT) from the Facility's Pharmacy. PPT stated they only received Resident 60's medication orders for Tamsulosin and Apixaban on 3/5/25 at 4:18 a.m. and had filled and sent it on the next scheduled delivery time. A review of the "Shipping Manifest" for Resident 60's Tamsulosin and Apixaban indicated the facility received the medication on 3/5/25 at 10:30 a.m. A review of Resident 60's progress notes did not indicate that Resident 60's attending physician was notified when Resident 60's prescribed medications were not administered timely. 3. A review of Resident 267's clinical record indicated Resident 267 was admitted March of 2025 and had diagnoses that included asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe) and gastro-esophageal reflux disease (GERD- a condition where stomach acid flows back up into the esophagus causing symptoms like heartburn and regurgitation). A review of Resident 267's admission "History and Physical", dated 3/5/25, indicated Resident 60 was oriented to person, place and time, and "Has the capacity to understand and make medical decisions." A review of Resident 267's progress notes, dated 3/4/25, indicated Resident 267 arrived at the facility at around 3 p.m. A review of Resident 267's physician's order, dated 3/4/25 at 4:40 p.m., indicated, "Fluticasone-Salmeterol Inhalation [a combination medication used to treat asthma] ...500-50 MCG/ACT [unit of measurement] ...1 puff inhale orally one time a day for asthma..." A review of Resident 267's physician's order, dated 3/4/25 at 6:29 p.m., indicated, "Pantoprazole Sodium [a medication used to treat GERD] Oral Capsule 100 MG... Give 1 capsule by mouth two times a day for GERD..." A review of Resident 267's MAR for the month of March 2025, indicated Resident 267's Fluticasone-Salmeterol inhalation was scheduled to be administered starting 3/5/25 every 9 a.m. and the Pantoprazole was scheduled every 6:30 a.m. and 4:30 p.m., with first dose on 3/5/25 at 6:30 a.m. A further review of the MAR indicated the 9 a.m. dose of Fluticasone-Salmeterol inhalation and 6:30 a.m. dose of Pantoprazole for Resident 267 on 3/5/25 were marked with a chart code, "5", which indicated the medications were held and not given to the resident. A review of Resident 267's progress notes, dated 3/5/25 at 4:19 p.m., indicated, "Fluticasone spray unable to give, waiting for pharmacy delivery..." During an interview on 3/10/25 at 11:10 a.m., Resident 267 stated she did not receive some of her medications when she was admitted in the facility. Resident 267 also stated it was upsetting for her to wait that long for her medications. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 267's MAR was reviewed. LN 6 confirmed the 9 a.m. dose of Fluticasone-Salmeterol inhalation and 6:30 a.m. dose of Pantoprazole for Resident 267 on 3/5/25 were not given. LN 6 stated there was a risk for Resident 267 to develop gastric acidity when the Pantoprazole was not given and a risk to develop difficulty breathing when the Fluticasone-Salmeterol inhalation was not given. During a concurrent phone interview and record review on 3/12/25 at 11:51 a.m. with the PPT, Resident 60's medication orders were reviewed. PPT stated they only received Resident 267's medication orders for Fluticasone-Salmeterol inhalation and Pantoprazole on 3/5/25 at 12:35 p.m. and had filled and sent it in on the next scheduled delivery time. A review of the "Shipping Manifest" for Resident 267's Fluticasone-Salmeterol inhalation and Pantoprazole indicated the medications were received by the facility on 3/5/25 at 3:20 p.m. 4. A review of Resident 264's clinical record indicated Resident 264 was admitted February of 2025 and had diagnoses that included osteoarthritis (OA- a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet), pain in right hip, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body), chronic pain syndrome (condition that involves persistent pain that lasts for weeks to years), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 264's MDS Cognitive Patterns, dated 2/26/25, indicated Resident 264 had a BIMS score of 15 out of 15 which indicated Resident 264 had an intact cognition. A review of Resident 264's MDS Health Conditions, dated 2/26/25, indicated Resident 264 had frequently experienced pain or hurting which frequently made it hard for her to sleep at night, frequently limited her participation in rehabilitation therapy sessions, and frequently limited her day-to-day activities. A review of Resident 264's physician's order, dated 2/19/25 at 3:06 p.m., indicated, "Pregabalin [a drug used to treat nerve and muscle pain] Oral Capsule 150 MG... Give 1 capsule by mouth two times a day related to PAIN IN RIGHT HIP..." A review of Resident 264's MAR, for the month of Februa