AVIR AT BRADBURN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that residents were free of significant medication errors for 1 of 2 residents (Residents #1) reviewed for pharmacy. The facility failed to ensure oral antibiotic medication was administered to Resident #1 as ordered, resulting in a medication error. As a result of incorrect medication entry, Resident #1 did not receive 6- days of prescribed oral antibiotic, specifically, (Sulfamethoxazole-Trimethoprim oral table 400-80 MG Bactrim), as ordered following hospitalization for sepsis and ureteral stent placement. This failure does not ensure that residents receive necessary treatment to prevent potential decline or worsening of infection. Findings included: A review of Resident #1's face sheet dated 11/20/2024 revealed he was a [AGE] year-old male initially admitted on [DATE] diagnoses of cerebrovascular disease (conditions affecting the blood vessels in the brain), cystostomy (surgery of the bladder to remove bladder stones, clots, tumors, or other obstruction), cystitis with hematuria, mixed incontinence, urinary stents, calculus of kidney, retention of urine, vascular dementia, anxiety, muscle weakness and difficulty in walking. A review of Resident #1's, quarterly MDS section C dated 10/1/2025, revealed a BIMS score of 14 dated 10/02/2025, which indicated he was cognitively intact. A review of Resident #1's medical records revealed that the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE] following treatment for sepsis and the placement of a urethral stent. A review of Resident #1's nurse's re-admission notes dated 09/25/2025 at 7:20 P.M., revealed a clarification of the medication order for Sulfamethoxazole-Trimethoprim oral tablet 400-80 MG, by mouth, twice daily for seven days. The HS (bedtime) dose was administered at the hospital prior to discharge. A Review of Resident #1's physician orders dated 09/25/2025, revealed that the physician order was incorrectly transcribed by LPN A, entering a start date of 10/09/2025 and an end date of 10/02/2025. A review of Resident #1's nurse's notes dated 09/26/2025 during the early morning hours revealed that the resident was sent back to the hospital for replacement of a urinary catheter by a Urologist. The review further indicated that the catheter had not been replaced during the initial emergency room visit. A review of Resident #1's nurse's readmission notes dated 09/26/2025 02:00AM revealed that under Special Care it was documented that the resident was currently on antibiotics, listed as Sulfamethoxazole-Trimethoprim oral tablet 400-80 MG, Bid X7 days. The notes further indicated that the urinary catheter was intact and that the urine appeared clear and yellow in color, with no urinary complaints reported. A further review of the provider's order dated 10/2/2025 revealed: Related diagnosis associated with the antibiotic order: sepsis unspecified organism, urinary retention, and urinary stent placement. A new order for Sulfamethoxazole-Trimethoprim oral tablet 400-80 MG, Bid X 7 days for treatment of sepsis, with a start date of 10/2/205 and an end date 10/9/2025. Documentation indicated that the oral antibiotic was not administered between 09/26/2025 and 10/01/2025. A review of Resident #1's Medication Administration Record (MAR) showed that the antibiotic was scheduled to begin at 9:00PM on 10/02/2025. The Director of Nursing (DON) verified that the staff nurse, LVN A entered an incorrect medication start date, which resulted in a delay in treatment. A review of the facility progress notes assessment dated from 09/26/2025 to 11/20/2025, revealed documentation of no fever, no pain discomfort related to foley, and urine color noted clear since readmission to facility on 09/26/2025. A review of the Hospice Nurse visit documentation on 09/29/25 indicated Indwelling Catheter Assessment: No problems noted or verbalized. Drainage system: Bedside drainage, date last changed 09/26/2025, urine characteristics clear /yellow, odor slight. Clinical Findings: Genitourinary No problems noted or verbalized. On 11/20/2025 at 9:30A.M., observed and interviewed Resident # 1 was in his room seated in a wheelchair watching, the resident is interview able, alert and oriented. Resident # 1 was fully dressed, clean and well groomed, bed in low position, water at bedside, call light was in reach. Resident #1 denied abuse or neglect and said he still had his foley but currently there were no issues with his foley. On 11/20/2025 at 2:00P.M., an interview with the DON revealed that the intent of the provider's order was for the resident to begin the next dose of Sulfamethoxazole-Trimethoprim Bactrim orally upon return to the facility on [DATE]. The DON confirmed that the resident should had started the antibiotic immediately after re-admission from the hospital. The DON further stated, she was unsure of how the medication error was discovered, she revealed she was not the DON at the time of discovery. The DON said she was contacted by the VA case manager for clarification as to why the doctor re-ordered the Bactrim to re-start on 10/2/2025. The DON stated the staff nurse entered the wrong date and the veteran (Resident did not start the antibiotic). The DON stated the doctor was notified of the incorrect transcribe start day and immediately re-ordered the po antibiotic Bactrim. On 11/24/2025 at 1:30 P.M., an interview with the VA RN case manager said, that during a chart review, it was noted that Resident #1 had a new order for Bactrim orally for sepsis dated 10/02/25. The VA case manager said she requested clarification as to why the Doctor had re-ordered the Bactrim PO. The VA case manager said the DON reported that the that the intent of the provider's order was for the resident to begin the next dose of Sulfamethoxazole-Trimethoprim Bactrim orally upon return to the facility on [DATE]. She stated, the DON said that the staff nurse LVN A entered the incorrect start date and failed to initiate the next dose of antibiotic. After notifying the physician, the medication was scheduled to start at 9:00P.M. on 10/2/2025. As a result, Resident #1 missed six days of antibiotic therapy following hospitalization for post-sepsis treatment and ureteral stent placement. On 11/24/2025 1:45 P.M., an attempt was made to contact LVN A, however there was no answer. A message was left requesting a return call to the State Surveyor phone number, but no return call was received during the investigation. On 11/24/2025 at 2:00 P.M., interview with the Hospice RN said, Resident #1 had a history of chronic pain related to a prior electrocution injury, which contributed to ongoing pain and discomfort. The hospice RN said that the resident exhibited no fever or pain associated with the catheter and reported no urinary discomfort. She confirmed that the urinary catheter was intact, and the urine was clear and yellow in color, with no urinary complaints noted. On 11/24/2024 at 2:30 P.M., interview with the DON revealed that the original order received from the hospital, and that the admitting staff nurse is responsible for entering all into orders into the system. The DON stated the facility's process for verifying medication orders upon readmission is the responsibility of ADON and DON, who are expected to review all orders entered. The DON reported that LVN A had been employed at the facility since 11/20/2012 and had no prior disciplinary action in her personnel file. She further stated that nursing staff had been educated, and re-educated on receiving orders, accurate medication transcription, medication administration, documentation, and antibiotic stewardship. The DON added that an Action Plan dated 10/2/2025 had been implemented, with ongoing monitoring by the DON and ADON, and review through QAPI every three months. Review of facility policy for documentation of Medication Administration, Antibiotic Stewardship, and Abuse & Neglect, revealed all seven (7) elements were addressed: Screening, Training, Prevention, Identification, Investigation, Protection and Reporting. There were no concerns with facility policy. In-services were reviewed and were compliant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 7 (Resident #1 and Resident #2) residents reviewed for quality of care. The facility failed to ensure Resident #1's wound care orders were implemented on 9/4/25 Wound Care NP's orders. The facility failed to ensure Resident #1 and Resident #2 received proper wound care to prevent deterioration and infection to their surgical wounds. The facility failed to ensure Resident #2's wound care orders were implemented on 9/11/25 and changed on 9/18/25 per the Wound Care NP's orders. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:20 p.m. on 9/24/25. While the IJ was removed on 9/25/25, the facility remained out of compliance with a scope identified as patterned and a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in residents with surgical wounds of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing.Findings Included: 1. Record review of the face sheet dated 9/23/25 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following surgical amputation (surgical procedure where a body part, such as a limb, finger, or toe is removed), right below the knee amputation, diabetes, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound. Record review of the care plan initiated on 9/16/25 indicated Resident #1 had a recent right below the knee amputation and was at risk for phantom pain (a painful perception an individual experiences relating to a limb or organ that is not physically part of their body), increase in disturbed self-image, increase in depression, and increase in need for assistance with ADLs. The care plan indicated Resident #1 had interventions in place including wound care/dressing changed to be performed to the stump/amputation area per physician orders. Record review of the physician orders which include active, completed, and discontinued order dated 9/23/25 indicated Resident #1 had an order to cleanse the wound on the amputated right knee with wound cleanser, cover with xeroform (a petroleum-based gauze), and cover with dry dressing starting 9/22/25. The physician orders did not indicate Resident #1 had any other wound care orders prior to 9/22/25. The physician orders indicated Resident #1 had an order for Cleocin ((Clindamycin) an antibiotic to treat infection) 150mg 2 capsules 3 times a day related to acquired absence of right leg below the knee. Record review of the TAR dated 9/2025 indicated Resident #1 had not received any wound care in the month of September 2025. The TAR indicated on 9/22/25 Resident #1 did not receive wound care due to being hospitalized . Record review of the Wound Care NP's progress note dated 9/4/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing 3 times a week and as needed. Record review of a picture dated 9/4/25 indicated Resident #1's surgical amputation site was well approximated with minor bruising. Record review of the Wound Care NP's progress note dated 9/11/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing every other day and as needed. Record review of a picture dated 9/11/25 indicated Resident #1's surgical wound site was well approximated with redness up the leg from the site to the knee. Record review of the Wound Care NP's progress note dated 9/18/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing every other day and as needed. Record review of a picture dated 9/18/25 indicated Resident #1's surgical wound site was well approximated with eschar (thick, black, adherent crust of dead tissue) in several different areas near the surgical incision. Record review of the Vascular Surgery NP's progress note dated 9/19/25 indicated Resident #1 had an order for Clindamycin (Cleocin) 300mg three times a day for 10 days with diagnosis of right below the knee amputation. During an interview on 9/23/25 at 12:35 p.m. the DON said she did not know why wound care on Resident #1 was not performed or documented. The DON said the wound care was being done and just because it was not documented, or the orders were not put in does not mean it was not being performed. The DON said the importance of ensuring wound care was performed as ordered was patient care. The DON said she was unsure whether not following the wound care orders would have contributed to Resident #1's wound deterioration due to his other comorbidities including being a smoker, diabetes, hypertension, and peripheral vascular disease. The DON said the negative effect of not performing the ordered wound care or starting the antibiotic on Resident #1 would be the infection to his wound growing. During an interview attempt on 9/23/25 at 2:13 p.m. in the hospital Resident #1 was sleeping. During an interview on 9/23/25 at 2:15 p.m. the Hospital Nurse said Resident #1 was admitted for a non-healing surgical wound following a below the knee amputation and infection to the surgical wound. The Hospital Nurse said Resident #1 was given the option to have a surgical revision performed on his BKA to remove the infection to his wound or to have an AKA performed. The Hospital Nurse said Resident #1 had chosen to move forward with and AKA and it was scheduled for 9/24/25. The Hospital Nurse said per the hospital physician's progress note Resident #1 reported he had been seen by the wound care doctor on 9/18/25 at the facility and was told his wound looked good. The Hospital Nurse said per the hospital physician's progress note Resident #1 said he had a follow-up with his surgeon on 9/19/25 and was informed his wound did not look good and was infected. During an interview attempt on 9/24/25 at 10:28 a.m. the surveyor left a message with office staff for the Vascular Surgery NP with no return phone call received. During an interview on 9/24/25 at 11:00 a.m. LVN A said she had performed wound care on Resident #1 (unknown date). LVN A said the wound care she had performed was wrapping the surgical site with a bandage. LVN A said wrapping the surgical site with a bandage was the only order for wound care for Resident #1. 2. Record review of the face sheet dated 9/24/25 indicated Resident #2 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including fracture of the upper and lower end of the right fibula (thin outer bone of the lower leg that runs from the knee to the ankle), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), osteoarthritis, hypertension, and diabetes. Record review of the MDS dated [DATE] indicated Resident #2 understood others and was understood by other. The MDS indicated Resident #2 had a BIMS score of 09 and was moderately cognitively impaired. The MDS indicated Resident #2 did not have any ulcers, wounds, or skin problems. Record review of the care plan last revised 7/15/25 indicated Resident #2 was at risk for impaired skin integrity. Record review of the physician orders which include active, completed, and discontinued order dated 9/24/25 indicated Resident #2 had an order to cleanse wound with wound cleanse, apply xeroform, and cover with dry dressing ordered 9/20/25 and with an unknown discontinue date. The physician orders indicated Resident #2 had an order to cleanse the right later low leg wound (wound #1) with wound cleanser, apply xeroform, and cover with a dry dressing starting 9/25/25. The physician orders indicated Resident #2 had an order to clean the right lower leg wound (wound #2) with wound cleanser, apply medical honey and calcium alginate, and cover with a dry dressing starting 9/25/25. The physician orders indicated Resident #2 had an order for Doxycycline (an antibiotic used to treat infections) 100mg twice a day for 10 days for wound infection. Record review of the Wound Care NP's progress note dated 9/11/25 indicated Resident #2 had a closed surgical wound to her right lower leg with 40% granulation (pink or red tissue that forms in the [NAME] stages of wound healing) and 60% scab. The Wound Care NP's progress note indicated Resident #2 had an order to cleanse the surgical wound with wound cleanser, apply xeroform, and cover with border dressing daily and as needed. Record review of the Wound Care NP's progress note dated 9/18/25 indicated Resident #2 had two surgical wounds to the right lower leg. The progress note indicated the wound to the right lateral lower leg (wound #1) had 80% granulation and 20% slough (non-viable, dead tissue)/ The progress note indicated Resident #2 had an order for wound #1 to cleanse the surgical wound with wound cleanser, apply xeroform, and cover with border dressing daily and as needed. The progress note indicated the wound to the right lower leg (wound #2) had 20% granulation, 40% slough, and 40% scab. The progress note indicated Resident #2 had an order for wound #2 to cleanse surgical wound with cleanser, apply medical honey and calcium alginate, and cover with a dry bordered dressing daily and as needed. During an interview on 9/24/25 at 9:45 am the DON said she did not know why Resident #2's wound care orders for 9/11/25 were not implemented until 9/20/25 or why Resident #2's wound orders for 9/18/25 were not implemented. The DON said the importance of ensuring wound care orders were implemented was patient care. The DON said the antibiotic order for Resident #2's wound was requested by the facility for prophylaxis due to her wound being open and fear of the wound becoming infected. The DON said she had not been able to access the wound care provider's progress notes until last week. The DON said she had emailed the wound care provider on 9/4/25 regarding not being able to access the progress notes and the wound care provider was supposed to have the issue resolved. The DON said the issue was not resolved until last week. During an interview on 9/24/25 at 11:30 a.m. Resident #2 said her surgical wound was doing well and healing nicely. Resident #2 said the facility had reached out to the community consultant regarding her wounds. Resident #2 said the community consultant had ordered her an antibiotic due to part of the wound not healing like the other part. Resident #2 said her surgical wound was not infected. During an interview on 9/24/25 at 12:13 p.m. the Wound Care NP said she was not aware her wound care orders on Resident #1 were not being followed. The Wound Care NP said she had seen him 3 times in the facility. The Wound Care NP said on the initial visit she gave orders to cleanse the wound with wound cleanser, apply Xeroform, and cover with rolled gauze. The Wound Care NP said on her 2 subsequent visits Resident #1 did have Xeroform in place. The Wound Care NP said when she rounded with the nurses she gave her treatment plan verbally at bedside, had a conference with the DON prior to leaving, and sent her progress notes to the facility. The Wound Care NP said she was aware of the facility not being able to access her progress notes electronically and had sent them over manually. The Wound Care NP said due to Resident #1 vascular issues not receiving proper wound care would not have contributed to the deterioration of his wound. The Wound Care NP said it was possible that not receiving proper wound care led to Resident #1's surgical wound infection. The Wound Care NP said she was not aware her wound care orders on Resident #2 had not been followed or implemented until 9/20/25. The Wound Care NP said Resident #2's wound care orders could have led to the deterioration of her wounds. The Wound Care NP said she did not order an antibiotic for Resident #2, but the primary care team may have. The Wound Care NP said she could not determine whether Resident #2's wound was infected but that there was redness surrounding the wound with minimal serous (thin, watery pale yellow, clear liquid) drainage. The Wound Care NP said she expected the facility to follow the orders she gave for wound care. The Wound Care NP the goal of wound care was to reduce the chances of infection, prevent deterioration of wounds, and to heal wounds. During an interview on 9/24/25 at 1:04 p.m. the NP said she had ordered an antibiotic for Resident #2 due to wound infection. The NP said the facility had sent her a picture of Resident #2's wound and due to the redness and slough the wound appeared infected leading her to ordering an antibiotic. The NP said not implementing the proper wound care as ordered by the Wound Care NP possibly led to the infection in Resident #2's wound. Record review of the facility's Wound Care policy revised October 2010 indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure.The following information should be recorded in the resident's medical record: 1. The date wound care was given, 2, The initials of the individual performing the wound care. 3. Any change in the resident's condition. The Administrator was notified on 9/24/25 at 2:37 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/24/25 at 2:46 p.m. The facility's Plan of Removal was accepted on 9/25/25 at 9:13 a.m. and included: Plan of RemovalAction: Director of Nursing and Assistant Director of Nursing have been educated by the Regional Nurse Consultant on: 1. Notification of MD and resident responsible party of Change of condition, specifically notification of any new or deteriorated wounds.2. Transcribing physician ordersPerson(s) Responsible: Regional Nurse ConsultantDate/Time: 09/24/25Action: Licensed Nurses have been educated by the Director of Nursing on: 1. Notification of MD and resident responsible party of Change of condition, specifically notification of any new or deteriorated wounds.2. Transcribing physician ordersLicensed nurses and newly hired licensed nurses will be educated prior to working their next scheduled shift. Person(s) Responsible: Director of NursingDate/Time: 09/24/25 Action: DON/ADON will review all current wounds during Standards of Care meeting and ensure:a. Wound assessments are completed weekly.b. Care plans are completed and updated with new interventions.c. Orders from Wound practitioners are transcribed correctly.d. MD is notified of any new or deteriorating wounds.e. Wound log is updated. Person(s) Responsible: Director of NursingDate/Time: 09/24/25 On 9/25/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of 6 of 9 residents currently receiving wound care confirmed all wound care orders were entered in each residents' physician orders and on each resident, TARs as ordered by the wound care provider as of 9/25/25. Record review of the facility's wound log dated 9/25/25 indicated all wound orders and wound assessments were up to date. During an observation on 9/25/25 at 9:15 am Observed LVN A perform wound care on Resident #2. LVN A provided privacy before starting and explained procedure to Resident #2. LVN A performed appropriate hand hygiene and glove changes during the wound care. LVN A performed wound care per the most current orders from the Wound Care NP using aseptic technique. There was no concern with the wound care performed. Record review of in-services dated 9/23/25 indicated 4 LVNs had been in-serviced regarding weekly skin and wound assessments, notifying the physician or NP regarding wound deterioration, ensuring all residents with wounds had orders in place, and ensuring all treatment orders showed up on each resident's TAR. Staff interviewed (LVN A, LVN B, and LVN C) on 9/25/25 between 9:10 a.m. and 10:03 a.m. said they had been in-serviced regarding the importance of weekly skin and wound assessments, ensuring all wounds had a treatment order in the EMR and that the treatment order was on the resident's TAR, obtaining treatment orders for new residents or residents with new wounds, and reporting changes in condition including wound deterioration. During an interview on 9/25/25 at 10:09 a.m. the DON and ADON said they would be monitoring the residents' plan of care to ensure any new orders including wound care orders were entered. The DON and ADON said they would be reviewing wound care orders against the Wound Care NP's progress notes to ensure accuracy. The DON and ADON said they would be checking the EMR to ensure all residents had weekly skin assessments performed. On 9/25/25 at 10:18 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as patterned and a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 9 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure Resident #1's antibiotic (Cleocin) was started on 9/19/25 when ordered from the Vascular Surgery NP instead waiting 2 days until 9/21/25 to initiate the antibiotic. The facility failed to ensure the nurses had access to the Pyxis (a machine used to safely and efficiently dispense medications) to obtain available medication such as antibiotics while waiting for pharmacy to deliver medications. The facility failed to ensure Resident #1's antibiotic was initial dosed when delivered from the pharmacy on 9/20/25 instead initiating the antibiotic on 9/21/25 and Resident #1 required hospitalization due to infection on 9/22/25. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:20 p.m. on 9/24/25. While the IJ was removed on 9/25/25, the facility remained out of compliance with a scope identified as isolated and a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents with an order for an antibiotic at risk for spread of infection leading to hospitalization, need for intravenous antibiotics, or sepsis (a life-threatening complication of infection). Findings Include:1. Record review of the face sheet dated 9/23/25 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following surgical amputation (surgical procedure where a body part, such as a limb, finger, or toe is removed), right below the knee amputation, diabetes, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound. Record review of the care plan initiated on 9/16/25 indicated Resident #1 had a recent right below the knee amputation and was at risk for phantom pain (a painful perception an individual experiences relating to a limb or organ that is not physically part of their body), increase in disturbed self-image, increase in depression, and increase in need for assistance with ADLs. The care plan indicated Resident #1 had interventions in place including wound care/dressing changed to be performed to the stump/amputation area per physician orders. Record review of the physician orders which include active, completed, and discontinued order dated 9/23/25 indicated Resident #1 had an order for Cleocin ((Clindamycin) an antibiotic to treat infection) 150mg 2 capsules 3 times a day related to acquired absence of right leg below the knee. Record review of the MAR dated September 2025 indicated Resident #1 did not receive his Cleocin 300mg on 9/20/25 at 8:00 a.m. or 12:00 p.m. due to medication not being available. The MAR indicated Resident #1 received his Cleocin 300mg on 9/20/25 at 4:00 p.m. The MAR indicated Resident #1 did not received his Cleocin 300mg on 9/21/25 at 8:00 a.m. or 12:00 p.m. due to medication not being available. The MAR indicated Resident #1 received his Cleocin 300mg on 9/21/25 at 4:00 p.m. Record review of the Pyxis Inventory Sheet dated 5/5/25 indicated the Pyxis had Clindamycin 150mg capsules with 20 capsules available for dispensing. Record review of the Pharmacy Packing slip dated 9/19/25 and signed by unknown facility staff on 9/20/25 indicated Resident #1's Clindamycin 150mg capsules had been delivered to the facility. Record review of the Nursing Progress Note dated 9/19/25 at 4:08 p.m. written by LVN A indicated, [Resident #1] returned from the doctor's office with new orders. Cleocin 300mg by mouth three times a day for 10 days. Record review of the Administration Progress Note dated 9/20/25 at 7:07 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/20/25 at 11:38 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 7:25 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 11:48 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 2:15 p.m. written by LVN indicated Resident #1's Cleocin was initial dosed per orders. During an interview on 9/23/25 at 12:35 p.m. the DON said she could not say why Resident #1's Clindamycin was not started for 2 days when it was available in the Pyxis. The DON said the importance of ensuring antibiotics and other medications were started timely especially when available in the Pyxis was patient care. The DON said the negative effect of not performing the ordered wound care or starting the antibiotic on Resident #1 would be the infection to his wound growing. During an interview attempt in the hospital on 9/23/25 at 2:13 p.m. Resident #1 was sleeping. During an interview on 9/23/25 at 2:15 p.m. the Hospital Nurse said Resident #1 was admitted for a non-healing surgical wound following a BKA and infection to the surgical wound. The Hospital Nurse said he was unsure whether wound cultures had been collected but that blood cultures had been collected and were still pending. The Hospital Nurse said Resident #1 was given the option to have a surgical revision performed on his BKA to remove the infection to his wound or to have an AKA performed. The Hospital Nurse said Resident #1 had chosen to move forward with and AKA and it was scheduled for 9/24/25. The Hospital Nurse said Resident #1 was receiving Zosyn (an antibiotic to treat infections) via IV for the infection to his surgical wound. The Hospital Nurse said to his understanding Resident #1's surgeon had order antibiotics for the wound infection and the facility had not administered the antibiotics. During an interview on 9/24/25 at 8:25 a.m. the Regional Nurse said they had checked the Pyxis reports, and it indicated Clindamycin had not been removed from the Pyxis for Resident #1 on 9/19/25, 9/20/25, or 9/21/25. During an interview on 9/24/25 at 10:08 a.m. MA D said she had worked 6:00 a.m.-10:00 p.m. on 9/20/25 and 9/21/25. MA D said Resident #1's Clindamycin did not arrive at the facility until 9/21/25. MA D said there had been some kind of issue with medication being placed in the correct resident cubbies. MA D said neither of the nurses working the weekend had access to the Pyxis. MA D said Resident #1 did not receive his antibiotic on 9/20/25 and only received the evening dose on 9/21/25 when she found the medication in his cubby. MA D said Resident #1's Clindamycin was not previously in his cubby when she looked for it. MA D said the facility's EMR system will not allow them to go correct an error in marking a medication as given that was not given. MA D said she had accidentally marked that Resident #1's evening dose of Clindamycin was given on 9/20/25, but it had not been. During an interview attempt on 9/24/25 at 10:28 a.m. the surveyor left a message with office staff for the Vascular Surgery NP with no return phone call received. During an interview on 9/24/25 at 11:00 a.m. LVN A said Resident #1's Clindamycin was started on 9/21/25 for his evening dose. LVN A said on 9/21/25 during her shift 6:00 a.m-6:00 p.m. the medication had not come in from the pharmacy and she did not have access to the Pyxis. LVN A said she was new to the facility and management was aware she did not have access to the Pyxis. LVN A said Resident #1's Clindamycin had actually been delivered on 9/20/25 but was not put on the medication cart. LVN A said she found the medication after he had missed his morning and noon doses in his cubby. LVN A said the importance of ensuring antibiotics were started in a timely manner was to prevent the worsening of an infection. Record review of the facility's Administering Medication policy revised April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame. The Administrator was notified on 9/24/25 at 2:37 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/24/25 at 2:46 p.m. The facility's Plan of Removal was accepted on 9/24/25 at 8:01 p.m. and included: Action: The Director of Nursing immediately set up access for all licensed nurses to access the Pyxis systemPerson(s) Responsible: Director of NursingDate/Time: 09/24/25 Action: Director of Nursing and Assistant Director of Nursing have been educated by the Regional Nurse Consultant on: 1. New employee (licensed nurses) set up and access to the Pyxis on hire prior to start of first shift. 2. Transcribing new medication orders to PCC when received3. Licensed nurse nurses will check Pyxis system upon receipt of orders and determine if medication is available for initial dose. 4. Administration of initial dose of antibiotic medications timely by the licensed nurse5. Obtaining medications from Pyxis when medication is not available in the medication cart6. If medications are not stocked in the Pyxis the nurse will notify the pharmacy via telephone and request a STAT delivery and get an ETA for delivery. The nurse will notify the Director of Nursing and the physician if antibiotic medications are not available within 2 hours for follow up orders.Person(s) Responsible: Regional Nurse ConsultantDate/Time: 09/24/25Action: Licensed Nurses have been educated by the Director of Nursing on: 1. Transcribing new medication orders to PCC when received2. Licensed nurse nurses will check Pyxis system upon receipt of orders and determine if medication is available for initial dose. 3. Administration of initial dose of antibiotic medications timely by the licensed nurse4. Obtaining medications from Pyxis when medication is not available in the medication cart5. If medications are not stocked in the Pyxis the nurse will notify the pharmacy via telephone and request a STAT delivery and get an ETA for delivery. The nurse will notify the Director of Nursing and the physician if antibiotic medications are not available within 2 hours for follow-up ordersLicensed nurses/MAs and newly hired licensed nurses/MAs will be educated prior to working their next scheduled shiftPerson(s) Responsible: Regional Nurse Consultant, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate/Time: 09/24/25 Action: The Director of Nursing, Assistant Director of Nursing will review all new orders and MARS daily during morning clinical meeting to ensure all new medication orders have been transcribed, ordered and initial doses administered in a timely manner. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 09/24/25 On 9/25/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the audit for 5 of 9 residents with a new antibiotic order in the past 90 days indicated all residents received their initial dose of medication within 24 hours of receiving the order. Record review of an in-service dated 9/23/25 indicated 5 staff members had been in-serviced regarding accessing the Pyxis to obtain medications newly ordered, ensuring all antibiotic orders were entered into the electronic medical records, ensuring all new medications including antibiotics were initial dosed by a licensed nurse, and ensuring medications are ordered STAT if they do not come in from the pharmacy. Staff interviewed (LVN A, LVN B, LVN C, and MA D) on 9/25/25 between 9:10 a.m. and 10:03 a.m. said they had in-serviced regarding new medication orders. They said for a new medication order the nurse was to obtain the medication from the Pyxis if available, order the medication from the pharmacy and if it did not come in to call the pharmacy and make the medication a stat order, and initial dose all new medications. All nurses interviewed said they had access to the Pyxis. During an interview on 9/25/25 at 10:09 a.m. the DON said all nurses now had access to the Pyxis. The DON said any newly hired nurses would immediately receive access to the Pyxis. The DON said she and the ADON would be checking for new medication orders daily and ensure the orders if available in the Pyxis had been initial dosed and if not available in the Pyxis had been ordered stat from the pharmacy. On 9/25/25 at 10:18 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as isolated with a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple rooms and at least 100 square feet in single resident rooms for 2 of 10 resident rooms (Resident room [ROOM NUMBER] and 311) reviewed for square footage.<BR/>The facility failed to provide 80 square feet per resident for a room certified for 4 residents and provide 100 square feet for a room certified as a private room. <BR/>These failures could place residents at risk of not having adequate space to meet their needs.<BR/>Findings include:<BR/>During an observation on initial tour on 03/13/2023 at 9:20 A.M. revealed 2 residents resided in room [ROOM NUMBER] and no residents were residing in room [ROOM NUMBER].<BR/>During an interview on 03/15/2023 at 8:30 A. M., the Administrator said resident rooms [ROOM NUMBERS] still required room waivers. She said room [ROOM NUMBER] was certified for 4 residents and measured 74 square feet per resident and room [ROOM NUMBER] was certified as a private room and measured 81 feet instead of 100 square feet.<BR/>Record review of a resident roster, dated 03/13/2023, indicated room [ROOM NUMBER] was certified for 4 residents and room [ROOM NUMBER] was certified for 1 resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple rooms and at least 100 square feet in single resident rooms for 2 of 10 resident rooms (Resident room [ROOM NUMBER] and 311) reviewed for square footage.<BR/>The facility failed to provide 80 square feet per resident for a room certified for 4 residents and provide 100 square feet for a room certified as a private room. <BR/>These failures could place residents at risk of not having adequate space to meet their needs.<BR/>Findings include:<BR/>During an observation on initial tour on 03/13/2023 at 9:20 A.M. revealed 2 residents resided in room [ROOM NUMBER] and no residents were residing in room [ROOM NUMBER].<BR/>During an interview on 03/15/2023 at 8:30 A. M., the Administrator said resident rooms [ROOM NUMBERS] still required room waivers. She said room [ROOM NUMBER] was certified for 4 residents and measured 74 square feet per resident and room [ROOM NUMBER] was certified as a private room and measured 81 feet instead of 100 square feet.<BR/>Record review of a resident roster, dated 03/13/2023, indicated room [ROOM NUMBER] was certified for 4 residents and room [ROOM NUMBER] was certified for 1 resident.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation.<BR/>The facility failed to ensure:<BR/>- items in the reach in cooler had a label and an open date.<BR/>-items on the prep table had been opened and not labeled with the open date.<BR/>These failures could place residents who ate food from the kitchen at risk of foodborne illness.<BR/>Findings included:<BR/>During observations, interviews and record reviews on 05/027/25 of the kitchen the following was noted:<BR/>On 05/27/25 at 10:16 AM in the 3-door cooler <BR/>1-46 oz honey thick Orange Juice was not dated when opened. It had a truck delivery date on the container of 05/07/2025.<BR/>1-46 oz. nectar thick Orange Juice was not dated when opened. It had a truck delivery date on the container of 05/14/2025.<BR/>The packaging on the container reads: After opening may be kept up to 7 days under refrigeration.<BR/>1 small white bowl of white substance plastic covering dated 05/20/25.<BR/>1 small square plastic covered container with no label or date contained a small brown square of some substance.<BR/>During an observation on 05/27/2025 at 10:40 AM on the prep table opposite the dish machine the following was noted:<BR/>1-46 oz honey thick sweet tea was not dated when opened. It had a truck delivery date on the container of 5/14/25.<BR/>1-46 oz. nectar thick sweet tea was not dated when opened. It had a truck delivery date on the container of 5/21/25.<BR/>The packaging on the container reads: After opening may be kept up to 7 days under refrigeration.<BR/>During an interview and observation on 05/27/2025 at 10:27 AM the DM removed all four thickened liquid cartons that were open and discarded them. She said the date marked on the box was the date the truck delivered the item and was to help with product rotation. She said items were to be marked when opened. She said leftovers in the refrigerator should be used within 3 days or discarded. She said the white substance was a bowl of icing and should have been discarded. She said the item in the small square container was a piece of fudge that belonged to a resident. She discarded the icing and fudge.<BR/>Record review the facility's Food Receiving and Storage policy, revised November 2022, indicated the following: .Refrigerated /Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) .7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple rooms and at least 100 square feet in single resident rooms for 2 of 10 resident rooms (Resident room [ROOM NUMBER] and 311) reviewed for square footage.<BR/>The facility failed to provide 80 square feet per resident for a room certified for 4 residents and provide 100 square feet for a room certified as a private room. <BR/>These failures could place residents at risk of not having adequate space to meet their needs.<BR/>Findings include:<BR/>During an observation on initial tour on 03/13/2023 at 9:20 A.M. revealed 2 residents resided in room [ROOM NUMBER] and no residents were residing in room [ROOM NUMBER].<BR/>During an interview on 03/15/2023 at 8:30 A. M., the Administrator said resident rooms [ROOM NUMBERS] still required room waivers. She said room [ROOM NUMBER] was certified for 4 residents and measured 74 square feet per resident and room [ROOM NUMBER] was certified as a private room and measured 81 feet instead of 100 square feet.<BR/>Record review of a resident roster, dated 03/13/2023, indicated room [ROOM NUMBER] was certified for 4 residents and room [ROOM NUMBER] was certified for 1 resident.