Marshfield Care Center for Rehab and Healthcare

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were treated with dignity and respect, when staff did not allow one resident (Resident #26) to eat in the dining room with other residents, talk with other residents, and smoke with other residents after the resident displayed behaviors. The facility census was 51. Review of the facility's policy titled, Resident Rights, dated 06/10/25, showed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to promote and facilitate each resident's right of self-determination when staff failed to provide timely bathing for four residents (Resident #1, #2, #3, and #4) out of a sample of seven residents. The facility census was 48. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide pharmaceutical services in a manner to ensure the proper storage, destruction, and accountability of medications when the facility did not have a process in place for timely destruction of the unused medications to ensure a clean and orderly medication room when a sample of medications for 22 residents' (Resident #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26) medications were located in the medication room waiting to be destroyed. The facility census was 48. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents from misappropriation of property when the facility did not provide sufficient pharmaceutical services to prevent diversion of medication resulting in one staff member obtaining narcotic medications for 14 residents (Resident #21, #10, #17, #22, #14, #1, #3, #2, #6, #11, #18, #8, #12, and #20) and keeping the medication instead of stocking them in the medication cart. The census was 51. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a procedure to document a resident's choices regarding advanced directives (a written instruction, such as a living will, or power of attorney, recognized under state law, relating to the provision of heath care when the individual is incapacitated), when the facility failed to clearly document code status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) in one resident's (Resident #1) chart out of 7 sampled residents resulting in staff being unable to locate the resident's code status in an emergency. The facility census was 42. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice when the facility staff failed to notify family and physician of fall with possible injury in a timely fashion, when staff failed to complete and document initial assessment and ongoing fall monitoring, including neurological checks (evaluates the nervous system), for one resident (Resident #2), who suffered a fall resulting in a fracture, out of 7 sampled residents. The facility census was 42. Review showed the facility did not provide a policy and procedure related to falls, fall documentation, and/or fall notifications. 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to have ordered medications available for staff administration and failed to notify the physician of the unavailable medications resulting in three residents (Resident #1, #2, and #3) not receiving medications as ordered. The facility census was 49. Review of the facility's policy titled Medication Administration, revised 05/07/25, showed medications are administered as ordered by the physician and in accordance with professional standards of practice.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per professional standards related to pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for all residents when staff failed to provide wound care per physician orders, failed to update wound care orders, failed to complete full and timely assessments and monitoring of all wounds, and failed to care plan related to wounds for one resident (Resident #1) resulting in deterioration of two wounds and infection of one wound. The facility census was 46. Review of the facility policy titled, Wound Care Policy for Long-Term Care, undated, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection control program when staff failed to perform hand hygiene and failed to follow Enhanced Barrier Precautions (EBP - infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) while providing wound care for three residents (Residents #1, #2, and #3). The facility also failed to ensure staff were trained on EBP and EBP supplies and signage were available. The facility census was 46. Review of the facility policy titled Hand Hygiene, dated 04/28/22, showed the following: -The facility will provide guidelines to employees on proper handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to maintain $4,000.00 cash for one resident (Resident #1) when staff had possession of the cash and could not locate the cash and provide it to the resident upon request. The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards that protected food from possible contamination at all times when staff failed to ensure condiments kept in the serve-out refrigerator were not expired and when staff failed to ensure non-food contact surfaces were clean and maintained in good repair. The facility census was 48. Review showed the facility did not have a policy regarding cleaning the kitchen and/or serving station. Review of the facility's Daily Deep Cleaning Scheduled showed the following: -Tuesday: The PM [NAME] was to clean the steam table top to bottom, behind and front glass, and de-lime the steam table; -Saturday: The PM [NAME] was to clean and de-lime steam table, clean floor underneath steam table, and behind steam table from top to bottom. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to immediately report an allegation of employee to resident verbal abuse of involving one resident (Resident #1). The facility census was 48. Review of the facility's Abuse and Neglect Policy, revised September 2024, showed the following: -It is the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; [...]

Inspectors wroteBased on interview and record review, the facility failed to document a timely and thorough investigation of verbal abuse when staff did not begin an immediate investigation into an allegation of staff cursing at one resident (Resident #1) and failed to document interviews with multiple staff as part of the investigation. A sample of ten residents was reviewed. The facility had a census of 48. Review of the facility's Abuse and Neglect Policy, revised September 2024, showed the following: -It is the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to keep food safe from potential contamination when staff stacked clean dishware inside one another instead of air drying, which could potentially contaminate food served from those items, when staff failed to keep dented cans separate from other canned goods, and when staff did not wear appropriate hair net correctly. The facility census was 51. 1. Review of the 2022 Food Code, issued by the Food and Drug Administration (FDA), showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for three residents (Resident #3, Resident #4 and Resident #30) who were selected out of a total sample of 18 residents with a facility census of 51. Review of the facility's policy titled Transfer or Discharge Documentation, revised December 2016, showed the following: -When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider; [...]

Inspectors wroteBased on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed-hold policy for three residents (Resident #3, Resident #4 and Resident #30) who were transferred out to the hospital. A sample of three residents out of total sample of 18 were selected for review in a facility with a census of 51. Review of the facility's policy titled Bed Holds and Returns, undated, showed the following: -Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy; -Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail the rights and limitations of the resident regarding bed-holds; [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when light fixtures in the kitchen and dining area had dead bugs present. The facility census was 51. Review showed the facility did not provide a policy regarding light fixtures. 1. Observations on 07/29/24, beginning at 9:48 A.M., and on 07/31/24, beginning at 8:49 A.M., of the kitchen and dining areas showed the following: -The light just before entering the kitchen had several dead bugs present; -The light above the refrigerator and freezer, towards the back of the kitchen, had several dead bugs present; -The two lights when entering the kitchen had several dead bugs present. During an interview on 08/01/24, at 9:00 A.M., Dietary Aide (DA) C said the following: -Ceiling lights are maintained by maintenance; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all resident's drug regimens were free from unnecessary drugs when staff failed to provide adequate monitoring related to the administration of one resident's (Resident #148) diltiazem (used to treat high blood pressure and to control angina (chest pain) for (bradycardia-type of abnormal heart rhythm that occurs when the heart beats more slowly than normal) medication. A sample of 18 residents were reviewed in a facility with a census of 51. Review of the facility's policy titled Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner, and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame. [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure all residents were free from significant medication errors when staff failed to prime (removing the air from the needle and cartridge that may collect during giving the resident too much or too little insulin) an insulin pen for one resident (Resident #30) prior to the administration of insulin. The facility had a census of 51. Review of the facility's policy titled Insulin Administration, revised September 2014, showed the policy did not address priming insulin pens before injection. Review of the facility's policy titled Administering Medications, revised December 2012 showed the policy did not address priming insulin pens before injection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the gnat population, when multiple gnats were present in one room, with two residents (Residents #2 and Resident #37) out of a total sample of 18. The facility census was 51. Review of the facility policy titled Pest Control, revised May 2008, showed the following: -The facility shall maintain an effective pest control program; -This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 1. Review of Resident #2's face sheet (admission data) showed the resident admitted to the facility on [DATE]. Review of the resident's annual assessment sheet (MDS - a federally-mandated assessment form completed by facility staff), dated 06/03/24, showed the following: -No cognitive impairment; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control program for all residents when the facility failed to have a program in place for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility water supply or where moist conditions existed. The facility had a census of 53. Record review of the CDC (Centers for Disease Control and Prevention) Toolkit for Legionella (also titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings), dated 03/25/2021, showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services-DHSS) when staff received allegation of possible abuse involving three residents (Resident #29, Resident #45, and Resident #103) The facility census was 53. Record review of the facility's policy titled Abuse-Reportable Events, revised 4/21/20, showed the following: -It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physicians' orders for bed rails and failed to complete ongoing assessments that included inspections and measurements to check for entrapment risk for three residents (Resident #26, #28, and #45); failed to obtain consent for use of bed rails for two residents (Resident #26 and #28); and failed to care plan the use of bed rails for one resident (Resident #28). The facility census was 53. Record review of the facility's policy titled Bed Safety, revised December 2007, showed the following: -The facility shall strive to provide a safe sleeping environment for the resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective system of records of receipt and disposition of controlled medications when the facility did not maintain pharmacy receipts for accurate reconciliation and failed to reconcile discontinued controlled medications which staff kept in a locked cabinet in the medication room accessible to nurses. The facility census was 53. Record review of the facility policy titled, Discarding and Destroying Medications revised October 2014, showed: -Medication will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances; -All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all allegations of possible abuse were thoroughly and timely investigated when staff failed to document investigations of alleged abuse involving two residents (Resident #29 and #103). The facility census was 53. Record review of the facility's policy titled Abuse-Reportable Events, revised 4/21/20, showed the following: -When an employee becomes aware of an allegation or suspicion of abuse the employee should immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately; -The charge nurse will assess the resident or residents; -Notify the Administrator or the person on-call, if after hours. The person on-call will notify the Administrator; [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated 11/10/2022. Based on record review and interview, the facility failed to provide care and services in accordance with standards of practice and the resident's care plan, when staff failed to obtain a urine sample timely for one resident (Resident #2) resulting in a delay in antibiotic treatment. The facility census was 49. Record review of the facility's policy titled Lab and Diagnostic Test Results-Clinical Protocol, revised September 2012, showed the following: -The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs; -The staff will process test requisitions and arrange for tests; -The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility; -A nurse will review all results; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff consistently documented urine output as ordered and care planned for two residents (Resident #28 and Resident #45) who had catheters (a sterile tube inserted into the bladder to drain urine). The facility census was 53. Record review of the facility's policy titled Urinary Catheter Care, revised September 2014, showed the following: -The purpose of the procedure is to prevent catheter-associated urinary tract infections (UTI); -Input/Output: Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor; -Maintain an accurate record of the resident's daily output, per facility policy and procedure. 1. Record review of the Resident #28's face sheet (admission data) showed the following: [...]

Inspectors wroteBased on record review, and interview, the facility failed to have a physician's order indicating where and when the resident was to go to dialysis (a process of cleaning the blood by a special machine, necessary when the kidneys are not able to filter the blood) treatment and failed to monitor the resident before and after dialysis , including bruit and thrill (a bruit is a rumbling sound that you can hear and a thrill is a rumbling sensation that you can feel for good blood flow rate), for one resident (Resident #31). The facility had a census of 53. Record review of the facility policy titled, Dialysis-General Guidelines and Management, dated 5/2017, showed the following: -Dialysis residents will receive dialysis services as per physician orders and will be monitored accordingly; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide laboratory services as ordered by the physician, when staff failed to obtain a STAT (immediate) lab timely for one resident (Resident #1). The facility census was 49. Record review of the facility's policy titled Lab and Diagnostic Test Results-Clinical Protocol, revised September 2012, showed the following: -The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs; -The staff will process test requisitions and arrange for tests; -The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility; -A nurse will review all results. Record review of Laboratory A's agreement, undated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain radiology services timely to meet the needs of two residents (Resident #3 and #4) when the physician ordered STAT (without delay - immediate) x-rays. The facility census was 49. Record review of the facility's policy titled Lab and Diagnostic Results - Clinical Protocol, revised 12/2012, showed the following: -The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs; -The staff will process test requisitions and arrange for tests. Record review of the Laboratory A's service schedule, undated, showed the following: -Facility will give provider reasonable notice of required laboratory work; -On-call emergency laboratory services (STAT)-provider shall be available until 8:00 P.M. Monday through Friday and on weekends and holidays from 8:00 A.M. to 8:00 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain completed and accurate records when staff failed to document an assessment of change in condition and contact of the responsible party regarding the change of condition for one resident (Resident #48) when staff sent the resident out to the hospital emergency room for evaluation. The facility census was 53. 1. Record review of Resident #48's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool completed by facility staff), dated 7/10/22, showed the following: -Cognitively intact; [...]

Inspectors wroteBased on record review and interview, the facility failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) by not accurately coding indwelling catheters, Bilevel Positive Airway Pressure (BiPAP, non-invasive form of therapy for patients suffering from sleep apnea), and restraints for three of 13 sampled residents (Residents #14, #41 and #50). The facility census was 52. The facility did not provide a policy on completing the MDS. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5 percent (%). Facility staff made three medication errors out of 25 opportunities, resulting in a medication error rate of 12%. This effected three of 13 sampled residents (Residents #33, #38, and #153). The facility census was 52. Review of the facility's policy on Medication and Treatment Orders revised on July 2016, showed: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; - The policy did not reference the five checks of medication administration which include the right resident, right time and frequency of administration, right dose, right route, and right drug; - The policy did not reference the administration of medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff destroyed and did not store an expired bottle of liquid Ativan (often used at end of life and to treat anxiety), a Schedule IV medication (has a low potential for abuse relative to the schedule III medications) that had been discontinued for one resident (Resident #21), failed to ensure staff destroyed and did not store eye medication for an expired resident, failed to ensure staff did not store their personal belongings and medications in the nurses' medication cart when staff's insulin pen lay next to a resident's narcotic pain medication that was not secured in the locked compartment of the cart for one resident (Resident #44), failed to obtain Tramadol (a narcotic-like pain reliever) from the emergency kit one dose at a time when staff pulled three doses and failed to label the individual [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when they failed to assure all staff used personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards examples include gloves, gowns, and masks) correctly for one sampled resident who was on contact isolation precautions for Methicillin-resistant Staphylococcus aureus (MRSA, a bacterium that causes infections in different parts of the body), did not use proper hand washing techniques including washing their hands upon entering and exiting resident rooms, failed to wash their hands and change gloves during incontinent care. This affected three of 13 sampled residents (Residents #20, #34, #41) and one additional sampled resident (Resident #203). The facility census was 52. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement, follow, and monitor a facility-wide antibiotic stewardship program. The facility census was 52. 1. Review of the facility's Antibiotic Stewardship Program policy, dated December 2016, showed: - The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents; - Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. - As a part of the facility's Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform two additional residents (Residents #27 and #49) when changes were made to his/her Medicare coverage prior to the end of service date. The facility census was 52. The facility did not provide a policy for the procedure for completing and presenting residents and/or their responsible parties with the Notice of Medicare Non-Coverage (NOMNC) form when changes when made to their Medicare coverage. 1. Review of Resident #27's NOMNC service notice showed: - Skilled nursing services ended 7/16/19; - The notice was not signed by the resident or the resident's representative and was dated 11/5/19. 2. Review of Resident #49's NOMNC service notice showed: - Last covered day for skilled services was 10/16/19; - The notice was signed by the resident and dated 11/5/19. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their restraint policy for one of 15 sampled residents (Resident #14), when staff did not obtain specific physician's orders for restraint use and did not follow a restraint re-evaluation system. The facility census was 52. 1. Review of the facility's Use of Restraints policy revised April 2017, showed: - Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom or movement or restricts normal access to one's body. - Restraints shall only be used upon the written order of a physician to include: the specific reason for the restraint and how the restraint will be used to benefit the resident's medical symptom; [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to assure they provided care and treatment in accordance with professional standards of practice when staff failed to follow physicians' orders and provide wound care for two residents (Resident #27 and #22) of 13 sampled residents. The facility census was 52. Review of the facility's policy titled Pressure Ulcers revised July 2017, showed: - Definitions: Pressure Ulcer (UP), refers to localized damage to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device - Stage I UP: Non-blanchable erythema (reddening of the skin), of intact skin; - Stage II UP: Partial -thickness skin loss with exposed dermis; - Stage III UP: Full-thickness skin loss; - Stage IV UP: Full-thickness skin and tissue loss; - Unstageable UP: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement measures to treat and prevent pressure ulcers (UP, injuries to skin and underlying tissue resulting from prolonged pressure on the skin) when staff did not document a new UP and implement measures to ensure treatment was provided and did not inform direct care staff for one of 13 sampled residents (Resident #20). The facility census was 52. Review of the facility's undated policy titled Wound Documentation Must Include, showed: - Location: Where is the wound located; - Size: Estimate size of lesion in centimeters (cm); - Exudate: Estimate drainage amount, type, color, and odor; - Tissue type in wound bed: Estimate the percentage; - Periwound: Intact skin tissue that surrounds the open wound. Review of the facility's policy titled Pressure Ulcers revised July 2017, showed: - Definitions: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide care to prevent urinary tract infections (UTIs) for a resident with an indwelling catheter when staff failed to follow their policy and inform the resident's physician when blood was noted in the urinary drainage bag and blood was visible on disposable wipes when staff provided catheter care and the resident complained of burning at the catheter insertion site when the resident has a history of UTIs, failed to ensure the catheter bag and tubing did not touch the floor and staff failed to provide catheter care in a way to prevent infections for one of 13 sampled residents (Residents #41). The facility census was 52. Review of the facility's policy titled Catheter Care Urinary, revised September 2014, showed: - Purpose: To prevent UTI in those residents with an indwelling catheter; [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure they documented the administration of their controlled substances to ensure the narcotic count and the Controlled Substance Record were accurate which affected two of 13 sampled residents (Resident #44 and #27). The facility census was 52. 1. Review of the facility's policy titled Controlled Substances, revised December 2012, showed: - The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances; - Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and effective medication administration system that was free of significant medication errors for one out of 13 sampled residents when staff did not follow the manufacturer's guidelines and administered an insulin pen without priming the pen prior to insulin administration and failed to hold the insulin pen against the skin for 6 seconds for one resident (Resident #33). The facility census was 52. 1. Review of the facility's policy on Medication and Treatment Orders revised on July 2016, showed: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; [...]