New Glarus Home

Inspectors wroteNumber of residents sampled:Number of residents cited: effects the censusBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 95 residents who reside in the facility. Surveyor observed unsealed food in the freezer. Surveyor observed expired milk in circulation. Surveyor observed kitchen staff take the temperatures of food without properly cleaning the food thermometer probe. Surveyor observed kitchen staff serving food without taking the temperature. Surveyor observed food serving utensils not being used in a sanitary manner. Surveyor observed uncovered drinks being transported down the hallway during lunch tray delivery. Surveyor observed staff going into the main kitchen without beard nets on. Surveyor observed the dishwashing process. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible, or resident preferences indicate otherwise for 1 of 5 residents (R6) reviewed for nutritional status. R6 was assessed to be at risk for dehydration. The facility failed to update R6's care plan and did not implement monitoring or documenting fluid intake. Evidenced by:The facility's policy titled Hydration date implemented 1/5/26 states in part .Compliance Guidelines: 1. The facility will utilize a systemic approach to optimize the resident's hydration states: a. Identifying each resident's hydration status and risk factors b. Evaluating/analyzing the assessment information c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 2 Residents (R31) observed for administration of eye drops. RN C (Registered Nurse) had a breach in infection control when RN C did not wear gloves for administration of eye drops. Evidenced by: The facility's Infection Prevention and Control Program policy, dated 2/5/25, states, in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.4. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident. This affected 1 of 3 residents (R2) reviewed for abuse. R1 has a documented history of touching other male residents inappropriately. On 4/27/25, a resident woke to R1 in his room with R1 having his hands in the resident's brief, touching his penis. On 4/28/25, it was reported by a resident that R1's hand was in his crotch. This resident reported that R1 touched his genitals but did not hurt him. R1 was placed on 1:1 (one on one) supervision following these incidents. In the following months the facility decreased R1's supervision from 1:1 to 15-minute checks, to one-hour checks, to two-hour checks and finally discontinuing R1's supervision on 12/12/25. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to protect 1 of 3 sampled resident's (R1's) right to be free from sexual abuse by a resident. Staff witnessed R2 touch R1 on the breast. As a result of the incident, the facility placed interventions on R2's care plan to prevent further incidents from occurring. These interventions were observed not to be in place and staff were not aware of the care planned interventions. This is evidenced by:R1 admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) of 1, indicating severe cognitive impairment. R1's diagnoses include in part, dementia, severe, with other behavioral disturbance, hypertension, dorsalgia, and muscle weakness. R2 admitted to the facility on [DATE]. R2 has a BIMS of 3, indicating R2 has severe cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a performance review of every nurse aide at least once every 12 months for 2 of 5 Certified Nursing Assistants (CNAs) reviewed. CNA L did not have an annual performance evaluation completed. CNA M did not have an annual performance evaluation completed. This is evidence by: Example 1 CNA L's hire date was 5/3/23. CNA L did not have an annual performance evaluation completed for 2024. Example 2 CNA M's hire date was 2/10/23. CNA M did not have an annual performance evaluation completed for 2024. On 3/31/25 at 1:30 PM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B how often are CNA evaluations to be done. DON B indicates, yearly. Surveyor asked if DON B would expect all CNA's to have a yearly performance evaluation. DON B indicates, yes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 resident (R12) reviewed for handwashing. The facility staff did not complete proper hand hygiene while performing wound care. This is evidenced by: The facility's policy titled Clean Dressing Change, dated 5/4/25, states in part: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard in appropriate receptacle. 11. Wash hands and put on clean glvoes. 12. Cleanse the wound as ordered .14. [...]

Inspectors wroteBased on observation, interview, and record review, the facility does not have an effective infection control program to control the spread of infectious disease, in this case COVID-19; this has the potential to affect all 87 residents residing at the facility. The facility is experiencing an extensive COVID outbreak that started on 12/30/24 when three (3) residents and one (1) staff member tested COVID positive. The outbreak has affected 6 of 6 units. As of 1/15/25, 38 residents and 18 staff members (total of 56) tested COVID positive during this ongoing outbreak. The facility failed to do the following: Staff were observed exiting COVID positive room with PPE on and doffing PPE in the hallway. While removing PPE in the hallway, staff contaminated clean PPE with dirty PPE. The facility is not documenting COVID positive residents' signs and symptoms on the line list or elsewhere. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the residents right to receive visitors of his or her choosing at the time of his or her choosing for 2 of 6 residents (R1 and R4). R1's medical record banner states R1's son, daughter, and daughter-in-law cannot visit. The facility posted a sign at the nurses' station indicating R1's son, daughter, and daughter-in-law are not allowed to visit. R4's medical record banner states R4 cannot receive visits from FM E (Family Member). The facility posted a sign at the nurses' station indicating R4 is not allowed visits from FM E. This is evidenced by: The facility Residents' Rights handout, undated, states, in part: .You retain the ability to exercise any rights that you do not delegate to a representative .You have the right to spend private time with visitors. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were free from sexual abuse perpetrated by a resident for 1 of 6 sampled residents (R2). R3 was found in R2's room sitting on the edge of the bed with R2's Depends unfastened and fondling R2 between the butt cheeks. Evidenced by: The facility policy titled, Abuse, Neglect, and Exploitation Policy & Procedures, dated 2/25/23, states, in part: . Policy Statement: It is the policy of New Glarus (referred to as the facility herein) to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 1 of 6 abuse investigations (R3) reviewed. Facility became aware of an abuse allegation on 11/26/24 at 4:30 AM and was not reported to State Agency until 11/26/24 at 10:39 AM. Evidenced by: The facility policy entitled, Abuse, Neglect, and Exploitation Policy & Procedures, dated 2/25/23, states, in part: . Policy Statement: [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an accusation of physical abuse for 1 of 6 residents (R3) reviewed for abuse. R3 was found in R2's room sitting on edge of bed with R2's depends unfastened, fondling R2 between the butt cheeks. Facility did not put anything in place to prevent this from happening again. Facility did not provide abuse education to all staff. Evidenced by: The facility policy entitled, Abuse, Neglect, and Exploitation Policy & Procedures, dated 2/25/23, states, in part: . Policy Statement: It is the policy of New Glarus (referred to as the facility herein) is to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 resident (R2) of 2 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R2 was at risk for pressure injury (PI) development. R2 developed a Stage 3 PI to the right ischium. Facility staff did not ensure PI interventions were in place and did not implement appropriate offloading interventions until after the PI was discovered. The facility policy, Pressure Injury Prevention and Management, updated 7/18/23, indicates, in part, as follows: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to health [sic] the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents maintain acceptable parameters of nutritional and hydration status for 1 of 1 Residents (R11) reviewed for nutritional status. R11 did not have appropriate interventions put into place to prevent continued weight loss. R11 had a weight loss of 20.6 pounds/12.86% over 2 months and 10 days, indicating a severe weight loss. This is evidenced by: Facility policy titled, Weight Policy, undated, states in part, Goal: To evaluate and meet the nutritional needs of our residents. Objective: Obtain weights as ordered or specified by this policy to monitor changes in weight, weight patterns, and implement appropriate interventions as needed. Procedure: . 3. Each resident will have weight measured at least monthly, unless on hospice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure snacks were offered at bedtime daily when there are more than 14 hours between the evening meal and breakfast. This has the potential to affect 90 of 90 residents and 6 of 6 units. R40, R19, R16, R70, and R2 voiced concerns that residents were not consistently being offered a snack at bedtime. These residents reside on the following hallways: 200 hall, 600 hall, and 300 hall Staff on the following hallways reported to the Survey team that bedtime snacks were not being offered to all residents: 500 hall, 300 hall, 600 hall, 400 hall, 200 hall, and 100 hall. There were more than 14 hours between the evening meal and breakfast and the facility staff were not offering snacks to all residents. Evidenced by: Facility policy, titled Resident Food Service: Snacks, revised 1/24, includes: [...]

Inspectors wroteBased on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 90 residents who reside in the facility. Surveyor observed multiple staff in food preparation areas, while food was being prepared, without donning hair restraints. Surveyor observed staff not allowing dishes to air dry completely before stacking them. Surveyor observed dented cans in circulation. Surveyor observed opened and undated food. Surveyor observed unclean stored equipment in facility's main kitchen. Evidenced by: Example 1 Facility policy, titled Uniform Dress Code, revised 1/24, includes: . Wear approved hair restraint when on duty regardless of length or presence of hair . [...]

Inspectors wroteBased on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director, or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member, or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 90 residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for the months of February and June, 2024. This is evidenced by: The facility QAPI plan, titled (Facility Name) QAPI Plan, undated, states in part: .(Facility Name) will establish a quality management committee that consists of the following members: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an Infection Control Program designed to provide a safe environment to help prevent the development and transmission of disease and infection (such as Legionella). This has the potential to affect all 90 residents who reside in the facility. The facility did not maintain a water management program to prevent the spread of Legionella. The facility did not ensure laundry services were being conducted according to current standards of practice to prevent the transmission of communicable diseases between residents. One resident was not added to the line list after showing signs and symptoms of an infection according to facility policy and procedure. This is evidenced by: Example 1: The facility policy titled, Infection Prevention and Control Program Policy, dated 2/13/23, states in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly, according to facility policy, and that residents were allowed to meet without staff present. This has the potential to affect more than a limited number of residents residing in the home. During Resident Council Task, 10 of 12 members voiced concerns that they do not receive follow up from voiced concerns, complaints, or suggestions for a whole month, until the next meeting. These residents indicated the facility policy states the management team will get back to them in 10 business days. During Resident Council Task, 10 of 12 members indicated the management team comes when they are not invited and at times the council wants to meet without staff present. Evidenced by: [...]

Inspectors wroteBased on observation and interview, the facility did not ensure a sufficient number of trained staff worked in the facility's food service department in order to safely and effectively carry out the meal preparation and other food and nutrition services for 3 of 21 sampled residents (R42, R40, R2) and 3 of 6 supplemental residents (R19, R16, R70). R42 voiced concerns about meals being late. Surveyor observed meals to be 45 minutes or more late. R40, R19, R16, R70, and R2 voiced concerns that their meals were often served late. Evidenced by: Facility meal time schedule reads as follows: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for 1 of 21 total sampled residents (R42) and 1 of 6 supplemental residents (R391) reviewed. R42 and R391 voiced concern the water is cold when they take a shower. Evidenced by: The facility policy titled, Safe Water Temperatures Policy and Procedure, dated 12/4/24, states, in part; .6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be maintained for 3 years and kept in the maintenance office . Example 1 R391 was admitted to the facility on [DATE] with diagnoses including: [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to resolve resident grievances for 1 sampled resident (R40) and 1 supplemental resident (R34) reviewed for grievances. R40 voiced a grievance to NHA E (Nursing Home Administrator) and DON B (Director of Nursing) in August that she would like her morning catheter flush to be scheduled at 8:00 AM (note, the facility has an acceptable range to complete this between 7:00 AM - 9:00 AM) so that she is able to attend activities and church on time. Currently, R40 stated the facility is flushing the catheter after 9:00 AM resulting in her missing activities and being late for church. R40 stated, That should not be. R34 voiced a grievance of receiving her bedtime medications late. The facility did not notify her of a resolution to her grievance until 4 weeks after she voiced the concern. Evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the State Survey Agency for 1 of 3 residents reviewed for abuse (R16). R16 and R19 reported an allegation of abuse when staff told R16 to keep his mouth shut. The facility staff failed to report the allegation of abuse to NHA A (Nursing Home Administrator) and to the state agency.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the State Survey Agency for 1 of 3 residents reviewed for abuse (R16). R16 and R19 reported an allegation of abuse when staff told R16 to keep his mouth shut. The facility staff failed to report the allegation of abuse to NHA A (Nursing Home Administrator) and to the state agency.

Inspectors wroteBased on interview and record review, the facility did not complete the Preadmission Screening and Resident Review (PASRR) Level II when it was realized that a resident would reside in the facility for more than 30 days. This affected 1 of 19 residents reviewed (R65). R65's PASRR level 1 screen indicated he would only be residing in the facility for 30 days or less and was exempt from needing a PASRR level 2 screen. R65 resided in the facility for longer than 30 days and a PASRR level 2 screen was not performed. Evidenced by: The PASARR Level 1 Screen directions include, in part, the following: 42 CFR 483.128(a) requires that the resident or his/her legal representative receive a written notice (copy of this front page) if the resident is suspected of having a serious mental illness or a developmental delay, and therefore, will require a Level II Screen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the residents environment remained as free of accident and hazards as possible for 1 of 1 sampled resident (R56) and 2 of 2 supplemental Residents (R54 & R141). Surveyor observed R54's motorized wheelchair (Motorized Assistive Devices) being charged in the 600 hall dining room and not behind a fire safe door. DON B stated, R141's motorized wheelchair battery is charged in the recreational/activity area on the 300 hall. Surveyor observed staff transfer R56 without a gait belt when he was feeling ill and dizzy. Evidenced by: Example 1 The facility does not have a policy and procedure for charging motorized wheelchairs. On 12/4/24 at 10:05 AM, Surveyor observed R54's motorized wheelchair battery being charged in the 600 hall dining room and not behind a fire safe door. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 2 of 2 residents (R) (R41 and R65) reviewed out of 21 sampled residents. R41's diagnosis list indicates she has a diagnosis of Post Traumatic Stress Disorder (PTSD). R41's Comprehensive Care Plan does not include known triggers, personalized interventions, and/or goals related to her past history of trauma. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that its medication error rate was 5% or less for 35 medication pass opportunities. The facility's medication error rate was 5.71% with two (2) errors observed for R31 and R2. This is evidenced by: The facility policy, Medication Administration, dated 7/1/24, states in part, as follows: Policy: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards Procedure: Ensure the six right of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation Januvia reference - https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021995s023mg.pdf documents: Take Januvia whole. Do not split, crush or chew. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents have an environment free of hazards and did not provide adequate supervision and assistive devices for 2 of 5 total sampled residents (R2 & R1). R2's care plan was not followed, resulting in a fall with left distal femur fracture on 7/10/24. R1 was an elopement risk and wears a WanderGuard. R1 was known to make attempts to follow others out of the building. On 7/18/24, R1 eloped from the facility and was found by Witness T approximately 0.3 miles down the road across the street from the church. R1's WanderGuard did not alarm when she exited the Memory Care Unit (MCU) and staff were not aware R1 exited the building. Evidenced by: The facility policy entitled Safe Resident Handling/Transfers, dated 7/15/23, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure facility staff treated 1 (R5) of 16 residents reviewed with dignity and respect. Facility staff held R5's arms down and gave R5 medication in a syringe when R5 displayed agitation. R5 has dementia with severe agitation. Facility staff held R5's arms down and gave R5 medication in a syringe when R5 displayed agitation. This is evidenced by: The facility policy Medication Administration Policy date created 9/1/23, states in part: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .18. Report and document any adverse side effects or refusals . The facility policy Dementia Care date created 8/1/24, states in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are thoroughly investigated for 1 of 3 residents (R5) reviewed for self-reports. On 7/9/24, the facility reported an allegation of abuse to the state agency. The facility did not complete a thorough investigation for this allegation. This is evidenced by: The facility policy Abuse, Neglect, and Exploitation Policy & Procedure last updated 2/25/23, states in part: .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .6. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (R2) reviewed for wandering and elopement potential. R2 was noted to have increased exit seeking behaviors and the facility failed to increase supervision to prevent R2 from eloping.

Inspectors wroteBased on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from medication carts. This occurred for 3 of 4 medication carts/storage rooms observed. Staff administered an expired Aspirin tablet to resident (R) R6 during medication administration. During the complaint survey, 3 of 4 observations were made of stock bottles with expired dates on medication carts.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the Comprehensive Person-Centered Care Plan, the residents' goals, and preferences for 2 of 17 residents (R63 and R56) and 4 of 4 (R325, R61, R327, and R9) supplemental residents reviewed for respiratory care. The facility did not ensure R63, R327m and R9's oxygen tubing and concentrators were cleaned on a regular basis. The facility did not ensure R325 and R61's continuous positive airway pressure (CPAP, a device that is a non-invasive form of therapy for people with sleep apnea) had been cleaned on a regular basis. R56 had two instances in the past 3 months where her oxygen equipment was not changed per Physician Order. This is evidenced by: [...]

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect 7 residents on the 400, 500, and 600 wings of the facility. Nutritional supplements were not stored in accordance with manufacturer recommendations.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 17 residents (R16). R16 was observed to have a clear medication cup with 1 tablet of Colestid medication in her room on her bedside table. R16 was observed to have a clear medication cup with antifungal medication powder in her room on her bedside table. This is evidenced by: The facility's policy, Self-Administration of Medication Policy, undated, documents, in part: Policy Statement: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medication after the facility's interdisciplinary team has determined which medications may be self-administered safely . 4. [...]

Inspectors wroteBased on observation and interview, the facility did not maintain personal privacy for 1 one 1 (R120) supplemental resident out of a total sample of 17 residents reviewed of confidential personal medical records. Surveyor observed R120's Medication Administration Record (MAR) on an open computer located on the medication cart in the hallway. Surveyor observed a clipboard with resident names and personal health information on the medication cart with no staff present. Surveyor observed SW (Social Worker) staff have an open laptop facing the main hallway. Evidenced by: The facility's policy, Confidentiality of Personal and Medical Records, undated, states in part: . 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents with limited range of motion (ROM) and mobility maintained or improved function unless reduced range of motion/mobility was unavoidable based on the resident's clinical condition for 1 of 4 residents reviewed for ROM/mobility out of 17 total sampled residents (R11). R11 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, dementia, anxiety, and osteoporosis. R11's quarterly Minimum Data Set (MDS) assessment on 6/1/23 notes R11 is severely cognitively impaired. R11 has an Activated Power of Attorney for Health Care (APOAHC). R11's comprehensive care plans indicates R11's washcloths in bilateral hands was discontinued 3/18/23. R11's Guidelines for Daily Care, dated 9/12/23, indicates the following: Special Instructions: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 out of 17 sampled residents (R39 and R16). R39 and R16 had multiple medication errors related to not receiving medication timely as ordered by the physician. This is evidenced by: The facility policy entitled, Medication Administration Policy, undated, states, in part: . 11. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . Example 1: R39 was admitted on [DATE] with diagnoses that include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all medication were safely and securely stored for 1 of 17 (R328) sampled residents observed. R328's medications were observed poured into a medication cup, sitting on top of a medication cart on the 600 hallway, unsecured, without staff present. This is evidenced by: The facility's policy, Medication Storage Policy, undated, states, in part: . 1.c. During a medication pass, mediations must be under the direct observation of the person administering medications or locked in the medication storage area/cart . R328 was admitted to the facility on [DATE], with a diagnosis of age-related osteoporosis with current pathological right femur fracture. R328's Minimum Data Set (MDS) was not completed at the time of the survey. R328's Physician Orders include the following: [...]