Fondulac Rehabilitation and Health Care Center

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan with interventions to address the resident's care needs while on therapeutic leave for one resident (R1) of three residents reviewed for care plans.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders for blood glucose monitoring were followed for one resident (R1) out of three residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being for one resident (R1) in a sample of 14 reviewed for abuse and neglect. These failures resulted in R1 experiencing avoidable pain, fear, distress, discomfort, and humiliation when left waiting in a wheelchair while in pain, left in stool despite being able to make needs known, and left suspended in a mechanical lift sling instead of being promptly transferred and repositioned for comfort and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary grooming, hair care, personal hygiene, and personal appearance services were provided to maintain the highest practicable physical, mental, and psychosocial well-being for one (R12) resident reviewed for quality of care in a total sample of 14 residents. This deficient practice was evidenced by the facility's failure to provide and/or arrange timely hair care and grooming services for R12, whose hair was observed to be matted. The facility failed to follow its Resident Rights policy and Beautician/Barber policy to ensure R12's grooming and personal appearance needs were met in a manner consistent with R12's preferences, dignity, and quality of life. As a result, R12 experienced embarrassment, distress, and humiliation related to the condition of R12's hair.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary pain assessment, monitoring, and intervention to maintain the highest practicable physical and psychosocial well-being for one (R1) resident reviewed for pain management, in a total sample of 14 residents. This failure to assess and intervene when R1 was reported to be in pain during care and transfers, including when R1 was left suspended in a mechanical lift sling while beds were switched and when R1 waited an extended period in a wheelchair after activating the call light and requesting to return to bed due to pain. This failure resulted in R1 experiencing prolonged, unassessed, and/or unmanaged moderate-to-severe pain.

Inspectors wroteBased on interview and record review the Facility failed to guarantee Residents reasonable telephone access by not providing phone service access for family members to contact residents for four residents (R1, R3, R6, and R14) reviewed for telephone communication in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in a timely manner and failed to follow its Call Light Policy for one (R1) resident reviewed for call lights in the sample of 14 when R1's call light was not answered in a timely and efficient manner after R1 requested assistance due to pain and wanting to return to bed.

Inspectors wroteBased on interview and record the Facility failed to verify and document personal inventory items for one resident (R3) reviewed for discharge in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to develop and revise comprehensive, person-centered care plans to include resident-specific problems, goals, and interventions for three (R1, R6, and R12) residents reviewed for comprehensive care plans in the sample of 14.

Inspectors wroteBased on interview and record review the Facility failed to finalize a completed fall investigation, document and monitor a head injury and prevent a staff assisted fall and the facility failed to follow its SNF (Skilled Nursing Facility) Mechanical Lift Procedure and Safe Lifting and Movement of Residents policy when staff failed to promptly transfer R1 to the designated surface and reposition R1 for comfort and safety. R1 had multiple fractures, cervical spinal fusion, weight-bearing restrictions, limited upper-extremity use, immobility, and pain. Leaving R1 suspended in the mechanical lift sling while staff switched the beds failed to promote R1's safety, dignity, comfort, and medical condition, and resulted in avoidable pain, fear, discomfort, and distress for two (R1 and R3) residents reviewed for accidents/hazards in a sample of 14.

Inspectors wroteBased on observation, interview and record review the Facility failed to maintain environmental equipment safety, comfortability and appearance for a torn/ripped bed mattress that created unsafe gaps for one resident (R10) reviewed for environment in a sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment by failing to ensure resident bathrooms were free of fecal matter, resident rooms were cleaned daily with trash removed daily, floors throughout the facility were swept and mopped, and soiled linens and adult briefs were properly disposed of. These failures have the potential to affect all 74 residents residing in the facility reviewed for physical environment. Findings Include:On 5/30/2026 at 9:30 AM, during the initial tour of the facility, the floors in the front entrance, dining room, and main nurses' station were observed to have dirt, debris, and a sticky substance that adhered to shoes while walking. On Hall A, dirt, debris, and a sticky substance were present on the hallway floors and in all resident rooms. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their own discharge policy for discharging a resident for one resident (R5). This failure led to R5 being discharged to a home with no running water, with all of R5's medical supplies being left in the weather elements and being ruined, no food in the home and no home health assistance as ordered by the doctor. The failure of leaving R5's medical supplies on the porch has the potential for R5 to get infections in wounds that could lead to hospitalizations, serious illness or even death. The failure to have no home health set up for home could lead to multiple health concerns worsening and causing illness, hospitalizations and death. The Immediate Jeopardy began on 3/31/26 at unknown time when R5 was transported home with all of his belongings left on the front porch with no home health set up for assistance with anything. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure fall assessments were done and accurate for 4 residents (R1, R4, R11, R12, failed to document any follow up assessments after a fall for one resident (R11), provide adequate supervision while showering for one resident (R4), and failed to assess the safety of residents who request to shower independently for five residents (R8, R9, R10, R11, R12). These failures led to R1 falling and breaking her hip, requiring surgery and an increase in need for assistance with Activities of Daily Living. These failures led to R4 being left alone in the shower with no assistance then falling and breaking her arm. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure accuracy of the plan of care for one resident (R5) of three resident's reviewed for care plan accuracy. R5's Medical Record documents that he was admitted on [DATE] with diagnoses to include but not limited to Chronic Respiratory Failure with Hypoxia, Type II Diabetes Mellitus and Chronic Peripheral Insufficiency. R5's Medical Record documents he was cognitively intact and made all of his own decisions. R5's care plan dated 3/9/26 documents focus areas as (R5) has a behavior problem relating to false accusations. (R5) refuses showers and will tell other staff no shower was offered. The resident has mood problem, he has delusional thoughts, he will state everyone is against him, if you don't agree with him, he thinks you are calling him a liar. These care plans were entered by V2 (Registered Nurse/Director of Nursing). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident (R2) from resident-to-resident sexual abuse for one of four residents (R2) reviewed for abuse in the sample of ten. This failure resulted in R1 a cognitively intact resident sexually assaulting R2 a cognitively impaired resident on more than one occasion. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/3/25 when the facility failed to protect a resident (R2) from resident-to-resident sexual abuse. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 5/24/25 at 9:00 AM. On 5/24/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate a resident head count once an exit door was alarming without known cause, failed to ensure a gait to the outside smoking patio was kept secure, failed to develop a care plan and implement interventions for residents at risk for elopement, and failed to provide adequate supervision for two of three residents (R6 and R7) reviewed for elopement risk in the sample of 10. These failures resulted in cognitively impaired resident (R6) who required assistance with ADL's (Activities of Daily Living) exiting the facility without staff knowledge or supervision on 4-22-25, and being found 2.2 miles away from the facility, on a concrete median, by a stop light, in the dark, with complaints of being cold. The road R6 traveled along was a busy main road that had numerous steep hills and curves. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement their abuse policy and procedures to identify and report resident to resident suspected crime and sexual abuse immediately to local law enforcement, resident representatives, and the state agency for two (R1, R2) of three residents reviewed for reporting abuse in the sample of ten. These failures resulted in R1 having unsupervised access to all 79 residents within the facility after R1 sexually assaulted R2.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their abuse policy and procedure to thoroughly investigate an allegation of resident-to-resident sexual abuse, implement measures to provide safety and supervision to prevent further abuse, and failed to submit a final report of the final investigation to the state agency within five working days for two of three residents (R1 and R2) reviewed for protection from abuse in the sample of ten. These failures resulted in R1 having unsupervised access to all 79 residents within the facility after R1 sexually assaulted R2.

Inspectors wroteBased on record review and interview the facility failed to employ a licensed Administrator to ensure all residents were protected from abuse and all abuse allegations were investigated and reported to the police, State Agency, and residents' representatives, to ensure all staff received mandatory annual in-servicing, and to maintain positive staff feedback. These failures have the potential to affect all 79 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 79 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure all staff received annual Infection Control and Prevention in-service training. This failure has the potential to affect all 79 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure all staff received annual Compliance and Ethics in-service training. This failure has the potential to affect all 79 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure all staff received annual Behavioral Health in-service training. This failure has the potential to affect all 79 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety prior to repositioning for one of three residents (R1) reviewed for incidents and accidents in the sample of three. This failure resulted in R1 sustaining a deep leg laceration requiring a hospital visit, receiving 13 stitches, and antibiotic treatment.

Inspectors wroteBased on interview and record review the facility failed to administer physician ordered insulin to a resident (R12) with a diagnosis of Type Two Diabetes Mellitus with Diabetic Chronic Kidney disease for one of one resident reviewed for insulin use in a sample of 47. This failure resulted in R12's emotional distress feeling like the facility was going to kill him because he wasn't getting his insulin as ordered and resulted in multiple abnormal laboratory values that reflected hyperglycemia.

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse for eight consecutive hours in a 24 hour period on four of 31 days per the Facility's July Nursing Schedule. This has the potential to affect all 63 residents living in the facility. Findings. The Facility Assessment, dated 8/12/24, states, The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time. The Facility's 2024 July Nurses Schedule shows there are no Registered Nurses working on four weekend days: 7/06/24, 7/07/24, 7/20/24, 7/21/24. On 8/21/24 at 12:05 PM, V3, Assistant Director of Nursing, stated, Yes, we did have gaps in the July schedule that we did not have Registered Nurse Coverage. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve foods as written on the menu. This has the potential to affect all 63 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure use of a safe sanitation solution; place food on the steam table at the appropriate time; maintain clean appliances/fixtures in the kitchen; label, date and appropriately package all opened food; use only institutional approved storage containers; date, label and discard as required, all food items in the resident's floor refrigerator. This has the potential to affect all 63 residents living in the facility.

Inspectors wroteThis failure resulted in two deficient practice statements. A. Based on observation, interview, and record review the facility failed to perform hand hygiene during medication administration for two residents (R22 and R35) of three reviewed for medication administration, in a sample of 47. B. Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi-drug resistant organisms (MDROs). This failure has the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to notify the facility Ombudsman monthly of a resident transfer to the hospital and failed to provide the resident and resident representative with a written notice of transfer. This failure has the potential to affect all 47 facility residents. Findings Include: 1. R25's facility Census List, provided by V9/Business Office Manager on 8/19/24 documents that R25 was transferred to a local hospital on 2/9/24 and on 6/8/24. No evidence of a facility notification to R26 of a transfer/discharge was present on R25's chart. 2. R35's facility Census List, provided by V9/Business Office Manager on 8/19/24 documents that R35 was transferred to a local hospital on 4/24/24, 7/6/24 and 8/6/24. No evidence of a facility notification to R26 of a transfer/discharge was present on R35's chart. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for four of four residents (R25, R35, R45 and R70), reviewed for bed holds, in the sample of 47. Findings Include: The facility Bed Hold Guarantee Policy, dated (revised) 8/1/17 directs staff, The resident, resident family or legal representative will be given the appropriate 'Notice of Bed Hold Policy'' at the time of discharge or therapeutic leave, if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave. 1. R25's medical record documents that R25 was hospitalized on [DATE] and 6/8/24. R25's medical record does not contain documentation of written notice to R25 or R25's resident representative, of the facility bed hold policy. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan addressing target behaviors exhibited, anticoagulant use, and psychotropic medication use for four of 19 residents (R4, R7, R12, and R49) reviewed for care plan accuracy in the sample of 47.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform the required nurse shift to shift controlled substance reconciliation for 19 of 19 residents, (R2, R3, R8-R10, R13, R17, R19, R22, R25, R34, R37, R43, R44, R47, R50, R52, R59 and R65) reviewed for controlled substances in a sample of 47.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident mental abuse to the state agency for one of three residents (R23) reviewed for abuse in the sample of 47.

Inspectors wroteBased on interview and record the facility failed to immediately remove an employee accused of mental abuse from resident care and complete an abuse investigation for alleged staff to resident abuse for one of three residents (R23) reviewed for Abuse in the sample of 47.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed for three of four residents (R1, R44 and R58) reviewed for PASARR screenings in the sample of 47.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician ordered daily skin checks and scheduled pressure ulcer treatments were completed and a pressure ulcer care plan was developed for three of three residents (R34, R35, R44) reviewed for pressure ulcers in the sample of 47.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene during suprapubic catheter care for one of two residents (R7) reviewed for urinary catheters in a sample of 47.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist reviewed a resident's medication regimen monthly for six consecutive months for one of five residents (R57) reviewed for unnecessary medications in a sample of 47.

Inspectors wrote2. R49's current Diagnosis Report documents R49's diagnoses to include: Schizophrenia; Schizoaffective Disorder; Mood Disturbance and Anxiety; and Depression. R49's current Physician's Orders document the following medication order: Clozaril (antipsychotic, date of order 06/12/22) 1500 milligrams twice daily. R49's Monthly Behavior Tracking Records (dated February 2024 - August 2024) do not document any target behaviors or a consistent pattern of adverse behaviors displayed by R49. These same forms had multiple days throughout each month that were left blank, and R49's Behavior Tracking Record (dated May 2024) is completely blank for the entire month. R49's current care plan has no mention of any target behaviors displayed by R49 and has no documentation of any behavioral interventions in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain physician ordered laboratory tests for one of one resident (R67) reviewed for lab monitoring in a sample of 47. Findings Include: The facility policy, Laboratory Tests, dated (reviewed) 9/27/2017 directs staff, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medications(s), wishes of the resident and family and current standards of practice. Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. Obtain laboratory orders upon admission, readmission and PRN (as needed) for medication and condition monitoring per the physician's order. R67's admission Physician Order Sheet/POS, dated 7/16/24 includes the following diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to inform residents of their rights during their stay in the facility. This has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to deliver mail six days a week. This has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to inform residents of their rights and where/whom to file a grievance. This has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse/RN was staffed eight hours per day, every day in July 2023. This failure has the potential to affect all residents residing in the facility on those days.

Inspectors wroteBased on interview and record review, the facility failed to offer residents snacks outside of the scheduled meal service times. This has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the Facility failed to accurately complete, document, systematically organize and have readily accessible medical records for all 62 Residents residing in the Facility. This failure has the potential to affect all 62 Residents residing in the Facility.

Inspectors wrote2. The facility's Medication Administration policy and procedure, Revised 11/18/17, documents 11. Avoid touching medication. If contact with medication is likely, prepare medication using gloves. 12. Appropriate hand washing is to be completed and/or alcohol based get rub or (cleansing agent) must be used, throughout the medication pass. This should occur: Before and after medication pass. After touching an oral medication during administration. It is acceptable to use an antiseptic gel type solution between residents. On 8/2/23 at 8:18 am V4 LPN (Licensed Practical Nurse) stepped up to the medication cart and did not perform hand hygiene prior to preparing medications for R15. V4 LPN noted to have a soiled protective adhesive bandage to her right thumb. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's designated Infection Control Preventionist (ICP) was scheduled to work at the facility in a manner that allowed the Infection Control Preventionist role to be fulfilled and failed to ensure the DON (Director of Nursing) who assists in the ICP role completed an approved ICP Certification. This failure has the potential to affect all 62 residents who currently reside in the facility. Findings Include: The facility's Infection Control Surveillance and Monitoring Policy, revised 4/11/22, states, It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. The facility shall employ, at a minimum, a part time Infection Control Preventionist (ICP). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a person-centered plan of care for four of 16 residents (R23, R29, R37, R56) reviewed for care plans in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise a care plan for six (R29, R38, R68, R419, R43, and R56) of 26 residents reviewed for care plan revision in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain consents for residents on psychotropic medications, failed to provide clinical justification for the use of dual therapy, failed to identify and track behaviors that warranted the use of psychotropic medications, failed to ensure behavior tracking logs and resident care plans identified specific target behaviors, failed to document non-pharmacological interventions prior to the use of psychotropic medications, and failed to complete psychotropic medication assessments for five of six residents (R23, R37, R38, R43, R65) reviewed for unnecessary medications in the sample of 26.

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician's order was obtained for code status (Do Not Resuscitate/DNR) for one resident (R419) of 26 residents, in a total sample of 26 residents reviewed for DNR Physician orders.

Inspectors wroteBased on interview and record review, the facility failed to submit correct MDS (Minimum Data Set) assessments for two residents (R5 and R56) reviewed for MDS correctness in a sample of 26.

Inspectors wroteBased on observation, interview and record review the Facility failed to document a completed admission Smoking Assessment in R219's Medical Chart for one Resident (R219) of 12 reviewed for Smoking in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the Facility failed to follow Physician Orders for Resident weights for one (R219) of 26 Residents reviewed for Weights in a sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the professional standards of quality care to ensure required care and services were provided for residents receiving enteral nutritional feedings for two (R29 and R56) of two residents and failed to implement a physician referral for a resident who is refusing gastrostomy tube cares, feedings, and flushes for one (R56) of two residents reviewed for gastrostomy tubes in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have oxygen orders on one (R29) of one resident reviewed for oxygen in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have Dialysis orders, failed to obtain a daily weight, and failed to coordinate communication between the Dialysis facility and the nursing home on one (R29) of one resident reviewed for Dialysis in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to post and have reports from the most recent survey of the facility available. This has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a cooked pork roast was cooled to a safe temperature before storing in the refrigerator, open containers of food were covered to prevent contamination and labeled with the date opened, foods with expired dates were discarded, staff food was not stored in the refrigerator with residents' food, refrigerators were clean and without debris, and clean bowls in the kitchen were stored to prevent debris from falling into the eating surface. These failures have the potential to affect all 67 residents in the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure staff wore masks covering their noses and mouths while in the resident areas of the facility. This failure has the potential to affect all 57 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to have documented efforts to obtain COVID-19 laboratory test results within 48 hours or that it attempted to contact its local and state health departments for assistance with timely COVID-19 laboratory testing. These failures have the potential to affect all 57 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Range of Motion exercises for limited range of motion, for seven of seven residents (R6, R9, R35, R40, R49, R55 and R57) reviewed for range of motion, in a sample of 27. Findings Include: The facility policy, Restorative ADL (Activities of Daily Living) Programs, dated (revised) 01/02 directs staff, Restorative programs shall be planned for any resident with a reasonable likelihood for improvement in their functioning levels or to prevent a loss of function. Documentation or program implementation, follow through and individual resident progress towards goals will be done as follows: The Nursing Assistant performing the program as part of the daily care will document and initial the daily flow sheet as indicated for each restorative program. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to reconcile controlled medications for 29 of 29 residents (R1, R5, R6, R9, R12, R14, R18, R19, R21, R22, R24, R26, R28, R29, R31, R32, R33, R35, R36, R37, R38, R47, R48, R49, R52, R54, R209, R308 and R309) reviewed for medications, in the sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform daily skin checks and failed to follow dietary recommendations for the use of a high protein supplement for a resident with multiple pressure wounds for one of two residents (R57) reviewed for pressure wounds in a sample of 27.

Inspectors wroteBased on observation, interview and record review, facility staff failed to perform a resident bed to wheelchair transfer to minimize the risk of injury for one resident (R57) of three residents, reviewed for transfers, in a sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to minimize the risk of infection by keeping a urinary collection bag off of the floor and failed to place a urinary collection bag in a privacy bag for two of two residents (R13 and R57), reviewed for urinary catheters, in a sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to provide behavioral health care services and develop individualized interventions/programs recommended in the PASRR (pre-admission screening and resident review) for one of one resident (R51) reviewed for behavioral health services in a sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow manufacturer's warnings for administration of medications, for two residents (R36, R42) in the sample of twelve residents, reviewed for medication pass. This failure resulted in two medication errors out of thirty opportunities for error, for a 6.67% medication error rate.

Inspectors wroteBased on record review and interview the facility failed to do accuchecks (test for blood sugar levels) or give insulin to one resident (R36) of three residents reviewed for insulin in a sample of 27.