Pennsylvania Department of Health
WILLIAMSPORT SOUTH REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WILLIAMSPORT SOUTH REHABILITATION AND NURSING CENTER
Inspection Results For:

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WILLIAMSPORT SOUTH REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to three Complaint Investigations completed on May 22, 2024, it was determined that Williamsport South Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure each resident's medication regimen was free from unnecessary medications for one of five residents reviewed (Resident CR1).

Findings include:

Closed clinical record review for Resident CR1 revealed that she resided in the facility from April 2, 2024, to May 10, 2024. Diagnoses for Resident CR1 did not indicate a history of cancer or radiation treatments.

A verbal physician order dated April 10, 2024, instructed staff to administer Temozolomide (medication is used to treat certain types of brain cancer) 140 mg (milligrams) by mouth one time a day, "give med for duration of radiation NPO (nothing by mouth) for 90 min (minutes) prior to administration."

There was no appropriate diagnosis included with the Temozolomide medication order as the resident did not have cancer and was not prescribed radiation therapy.

Employee 5 (certified registered nurse practitioner, CRNP) electronically signed the order on April 15, 2024, for nursing staff to implement the medication.

Nursing staff discontinued the April 10, 2024, Temozolomide order on April 22, 2024, but entered a new verbal order on April 22, 2024, with the same administration parameter to administer the medication for the duration of radiation therapy. Employee 7 (Doctor of Medicine, MD) electronically signed the order on April 24, 2024.

The practitioner did not identify that Temozolomide was included in Resident CR1's medication profile without an appropriate diagnosis or indication for its use.

Interview with the Nursing Home Administrator, the Director of Nursing, and Employee 2 (medical records) on May 22, 2024, at 1:05 PM confirmed the above findings regarding Resident CR1's Temozolomide medication.

The facility implemented Temozolomide in Resident CR1's medication regimen without adequate indications for its use.

28 Pa. Code 211.9(k) Pharmacy services

28 Pa. Code 211.2(d)(3)(9) Medical director

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/02/2024

Cited: Resident CR1 does
not reside at the facility.

Like: A facility wide sweep
will be conducted to ensure
medications have appropriate
diagnosis.

Education: Practicing
physicians, Physician
Assistants, CRNP's, and
licensed staff will be
educated on appropriate
diagnosis related to the order
and educated regarding
confirming orders. The facility
will also complete chart checks,
order listing review 5 days a
week during clinical
review meeting.

Audit: HIM/designee will audit
all new orders daily 5 days a
week x 4 weeks then monthly
x 2 months to ensure order
is accompanied by appropriate
diagnosis.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on review of select facility policies and procedures, review of employee personnel records, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the required agencies an allegation of resident mental abuse for one of five residents reviewed (Resident CR1).

Findings include:

The CMS State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care, revised February 3, 2023, defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled by technology. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes abuse that is facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. Depending on what was photographed or recorded, physical and/or sexual abuse may also be identified.

The facility policy entitled, "Abuse Policy - PA," published December 4, 2023, defined mental abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. It is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. The investigation will include: who was involved, involved staff and witness statements of events, and environmental considerations. All staff must cooperate during the investigation to assure the resident is fully protected. The results of the investigation will be recorded and attached to the report. All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. The follow-up investigative notes will be submitted online within five working days of the initial report. Procedures must be in place to provide the resident with a safe, protected environment during the investigation which included notification of law enforcement and/or state agency as indicated. Complaints about a nursing assistant must be reported to the state specific agency for nursing assistants. If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State agency. The facility must submit reports that are accurate, to the best of its knowledge at the time of submission of the report.

The facility policy did not include that the inappropriate use of technology, taking resident pictures, or taking resident videos, are examples of mental abuse as stipulated in the State Operations Manual.

Review of Employee 1's (nurse aide) personnel file revealed an, "Employee Education/Counseling Form," dated May 7, 2024, that described an incident as, "It was brought to the facility's attention of (Employee 1) having used her electronic device (phone)." The facility noted a review of the electronic devices portion of the handbook. The only handbook reference highlighted noted, "The use of iPods, air pods, or any recording and/or video device inside the Facility is prohibited. Failure to adhere to this policy may result in discipline up to and including termination." The Nursing Home Administrator and Employee 1 signed the document on May 9, 2024.

There was no other information regarding for what purpose Employee 1 used her phone (e.g., record the inside of the facility, take pictures of residents, record other employees, etc.).

A witness statement from Employee 1 dated May 7, 2024, noted, "I have never taken a photo or video of a resident." There was no other information provided in the statement.

Interview with the Nursing Home Administrator (NHA) on May 22, 2024, at 12:05 PM indicated that Employee 1's education was necessary because the NHA received an email dated May 3, 2024, at 8:35 AM of a picture of a toilet.

The email did not include Employee 1's name or reference to any facility resident.

When the surveyor requested information from the facility regarding how a picture of a toilet indicated Employee 1 required education pertaining to phone use, the NHA provided a statement from Employee 2 (medical records) dated May 3, 2024, that noted, "I was told by a CNA (nurse aide) that (Employee 1) was taking pictures and videos of her residents and sent them to people including her boyfriend...(the boyfriend) called several times to the facility but was hung up on because (Employee 1) told (Employee 3, licensed practical nurse/unit manager) to take the calls and that her boyfriend was "just trying to get her fired." (The boyfriend) called a lot, myself and (Employee 4, social services) and I'm not sure who else heard (Employee 3) say, "that (the boyfriend) is crazy and won't stop calling etc." (This was before the CNA came to me on Fri 5/3 (Friday May 3, 2024) and said (Employee 3) never took the calls for (the boyfriend) to report what (Employee 1) was doing) because (Employee 1) tried to intercept the situation by telling (Employee 3) this was just "boyfriend drama." This CNA did not want involved out of fear of (Employee 1) retaliating on her."

Interview with the NHA on May 22, 2024, at 12:05 PM confirmed that the facility did not attempt to obtain a statement from Employee 1's boyfriend, Employee 3, or Employee 4, regarding the reported concern. The facility did not notify the Department or other agencies (Area Agency on Aging or law enforcement) regarding the allegation of staff taking photos or videos of a resident inappropriately.

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(a)(c) Resident rights

Plan of Correction - To be completed: 07/02/2024

Cited: Allegation of mental abuse
was reported to DOH, OOA, and
State Police on 5/23/24.

Like: A review of incidents from
the last 30 days will be completed
to determine if other residents
were affected. Identified potential
allegations will be reported.

Education: NHA will be educated
by regional support staff on
reporting all allegations of
abuse timely.

Audits: DON/designee will
complete and audit once a week
x 4 weeks, then monthly x 2 months
to ensure any allegations are
reported timely. Results will be
taken through QAPI.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide bathing assistance for a dependent resident for one of five residents reviewed (Resident CR1).

Findings include:

Closed clinical record review for Resident CR1 revealed that she resided in the facility from April 2, 2024, to May 10, 2024.

Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated April 3, 2024, revealed that staff assessed that Resident CR1 was dependent upon staff to shower or bathe.

Review of the Documentation Survey Report (electronic documentation by nurse aides for the completion of tasks related to activities of daily living) dated April 2024, for Resident CR1 revealed that nurse aides were to complete bathing via a bed bath on Tuesdays and Saturdays. Staff documented that Resident CR1 required the physical help of staff or was completely dependent upon the physical performance of the task by staff for bathing. The report revealed that staff failed to document the completion of a bed bath for Resident CR1 on the following dates:

Saturday, April 13, 2024
Tuesday, April 16, 2024
Saturday, April 27, 2024

The surveyor reviewed the above findings for Resident CR1 during an interview with the Nursing Home Administrator on May 23, 2024, at 10:45 AM.

483.24(a)(2) ADL Care Provided for Dependent Residents
Previously cited deficiency 2/16/24

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 07/02/2024

Cited: Resident CR1 no
longer resides at the facility.

Like: A facility wide sweep
will be conducted to ensure
bathing preferences are
honored.

Education: NHA/designee
will educate licensed staff
and CNA's on honoring
residents bathing preferences.

Audits: HIM/designee will
audit 5 residents daily on
weekdays x 4 weeks,
then monthly x2 months to
ensure bathing preferences
are being honored. Results
will be taken through QAPI.

483.30(a)(1)(2) REQUIREMENT Resident's Care Supervised by a Physician:

§483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

§483.30(a) Physician Supervision.
The facility must ensure that-

§483.30(a)(1) The medical care of each resident is supervised by a physician;

§483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician supervised the care of one of five residents reviewed (Resident CR1).

Findings include:

Closed clinical record review for Resident CR1 revealed that she resided in the facility from April 2, 2024, to May 10, 2024. Diagnoses for Resident CR1 did not indicate a history of cancer or radiation treatments.

A verbal physician order dated April 10, 2024, instructed staff to administer Temozolomide (medication used to treat certain types of brain cancer) 140 mg (milligrams) by mouth one time a day for, "give med for duration of radiation NPO (nothing by mouth) for 90 min (minutes) prior to administration."

There was no appropriate diagnosis included with the Temozolomide medication order as the resident did not have cancer and was not prescribed radiation therapy.

Employee 5 (certified registered nurse practitioner, CRNP) electronically signed the order on April 15, 2024, for nursing staff to implement the medication. There was no indication that Employee 5 identified that there was no appropriate diagnosis for its use.

Employee 6 (CRNP) documented progress notes that stipulated that Resident CR1's medication list was reviewed and/or reconciled during visits on the following dates and times:

April 16, 2024, at 11:24 PM
April 19, 2024, at 2:58 PM
April 21, 2024, at 6:44 PM
April 23, 2024, at 1:32 PM
April 26, 2024, at 4:37 PM
May 1, 2024, at 10:35 PM
May 6, 2024, at 6:27 PM

The practitioner did not identify that Temozolomide was included in Resident CR1's medication profile without an appropriate diagnosis or indication for its use during any of those visits.

Nursing staff discontinued the April 10, 2024, Temozolomide order on April 22, 2024, but entered a new verbal order on April 22, 2024, with the same administration parameter to administer the medication for the duration of radiation therapy. Employee 7 (Doctor of Medicine, MD) electronically signed the order on April 24, 2024.

The practitioner did not identify that Temozolomide was included in Resident CR1's medication profile without an appropriate diagnosis or indication for its use.

Interview with the Nursing Home Administrator, the Director of Nursing, and Employee 2 (medical records) on May 22, 2024, at 1:05 PM confirmed the above findings regarding Resident CR1's Temozolomide medication.

The facility was unable to provide evidence that physician practitioners conducted a medical evaluation of a resident before ordering a new medication.

28 Pa. Code 211.2(d)(3)(8)(9)(10) Medical director

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist identified a potential medication irregularity for physician review for one of five residents reviewed (Resident CR1).

Findings include:

Closed clinical record review for Resident CR1 revealed that she resided in the facility from April 2, 2024, to May 10, 2024. Diagnoses for Resident CR1 did not indicate a history of cancer or radiation treatments.

A verbal physician order dated April 10, 2024, instructed staff to administer Temozolomide (medication used to treat certain types of brain cancer) 140 mg (milligrams) by mouth one time a day for, "give med for duration of radiation NPO (nothing by mouth) for 90 min (minutes) prior to administration."

There was no appropriate diagnosis included with the Temozolomide medication order as the resident did not have cancer and was not prescribed radiation therapy.

A Pharmacy Monthly Medication Review dated April 16, 2024, at 10:03 AM indicated that Resident CR1 was reviewed by the consultant pharmacist and to, "See report for recommendation."

Interview with the Nursing Home Administrator, the Director of Nursing, and Employee 2 (medical records) on May 22, 2024, at 1:05 PM confirmed that the consultant pharmacist did not provide a written report to the attending physician and the Director of Nursing identifying the potential medication irregularity that Resident CR1 was prescribed a medication used for cancer with no appropriate cancer diagnosis and with parameters pertinent to radiation therapy when Resident CR1 did not receive radiation treatments.

483.45(c)(4) Drug Regimen Review
Previously cited deficiency 2/16/24

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/02/2024

Cited: Resident CR1 no longer
resides at the facility and has
had no ill side effects from the
medication error to date.

Like: HIM/designee will audit
Pharmacists monthly reviews
x3 months.

Education: The Pharmacist will
be educated on importance of
accurate medication reviews.

Audit: DON/designee will audit
the Pharmacists monthly
medication reviews x 3 months.
Results will be taken through
QAPI.

§ 211.3(c) LICENSURE Verbal and telephone orders.:

(c) Verbal and telephone orders for medications shall be dated and countersigned by the prescribing physician, or physician ' s delegee authorized under 42 CFR 483.80(e), within 48 hours.

Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure that a physician signed a verbal medication order within 48 hours for one of five residents reviewed (Resident CR1).

Findings include:

Closed clinical record review for Resident CR1 revealed a verbal physician order dated April 10, 2024, that instructed staff to administer Temozolomide (medication is used to treat certain types of brain cancer) 140 mg (milligrams) by mouth one time a day, "give med for duration of radiation NPO (nothing by mouth) for 90 min (minutes) prior to administration."

Employee 5 (certified registered nurse practitioner, CRNP) electronically signed the order on April 15, 2024, for nursing staff to implement the medication.

Interview with the Nursing Home Administrator, the Director of Nursing, and Employee 2 (medical records) on May 22, 2024, at 1:05 PM confirmed a physician did not sign the verbal order for Resident CR1's Temozolomide medication within 48 hours.

Plan of Correction - To be completed: 07/02/2024

Cited: Resident CR1 no longer
resides at the facility and has
had no ill side effects from the
medication error to date.

Like: Facility wide sweep to
ensure any outstanding orders
not signed within 48 hours are
countersigned at that time.

Education: Physicians, PA's,
and CRNP's will be educated
on ensuring all verbal and
telephone orders for
medications are dated and
countersigned within 48 hours.
The facility will also complete
chart checks, order listing
review 5 days a week during
clinical review meeting.

Audits: DON/designee will
complete an audit daily on
weekdays x 2 weeks, then
monthly x2 months to ensure
verbal orders are dated and
countersigned by the
prescribing physician within
48 hours. Results will be
taken through QAPI.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure that staff responsible for the administration of medications were knowledgeable of the procedure for the disposition of unused medication on four of four resident hallways (North, South, East, and West hallways; Employees 8, 9, 10, 11, 12, and 13).

Findings include:

The facility policy entitled, "Disposition of Discontinued Medication," last reviewed without changes on August 24, 2023, indicated that the facility will destroy or return medication in accordance with the facility policy. The policy included the disposition of medications for a discharged resident and discontinued medications returned to the pharmacy.

The facility policy entitled, "Administering Medications," last reviewed without changes on August 24, 2023, indicated that the Director of Nursing will supervise and direct all nursing personnel who administer medications and/or have related functions. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medications shall document in the electronic health record per protocol.

The facility policies regarding medication administration and the disposition of medications upon discharge did not include instructions regarding how staff are to dispose of medications.

Interview with the Director of Nursing on May 22, 2024, at 10:40 AM indicated that nursing staff are to use drug disposal units (Drug Buster, bottled solution that dissolves medications and pills into a non-toxic slurry; safe and effective to use to discard tablets, capsules, creams, etc. into the trash) to discard unused medications during medication administration.

Interview with Employee 8 (licensed practical nurse, LPN) on May 22, 2024, at 2:58 PM on the South hallway revealed that it was her training that medications may be discarded in a Drug Buster drug disposal bottle.

Interview with Employee 9, LPN, on May 22, 2024, at 2:59 PM at the South/West nursing station confirmed that it was also her training that medications are discarded in Drug Buster drug disposal bottles. Observation of a medication cart on the South hallway with Employee 9 revealed the sharps container (plastic storage container with a secured lid that is used to safely store hazardous needles and sharp objects until they can be properly disposed of by a contracted medical waste disposal company) secured on the side of the cart contained at least three tabs of medication.

Interview with Employee 10, LPN, on the West hallway on May 22, 2024, at 3:26 PM revealed that medications are not to be discarded in the sharps containers but in drug disposal bottles. Observation of the medication cart on the West hallway with Employee 10 revealed one medication tablet identified in the sharps container secured on the medication cart.

Observation of the East hallway on May 22, 2024, at 3:30 PM revealed a medication cart outside a resident's room. Interview with Employee 11, LPN, revealed that if a medication is a narcotic, staff must dispose of it in the Drug Buster, but any other medication could be discarded in the sharps container. Employee 11 stated, "They do not specify (no facility policy what to do)." Observation of the sharps container attached to Employee 11's medication cart revealed at least 12 tablets of medication. Employee 11 then assisted the surveyor to observe the sharps container attached to the second medication cart used on the East hallway, which revealed at least six medication tablets in the sharps container.

Interview with Employee 12, LPN, on May 22, 2024, at 3:38 PM revealed that she originally believed that staff used sharps containers for medication disposal until the house nursing supervisor told her, "No," one time. Employee 12 stated that the supervisor told her that medications must be disposed of in the Drug Buster and now she uses the Drug Buster bottle.

Observation of the North hallway on May 22, 2024, at 3:42 revealed Employee 13, LPN, passing medications. Employee 13 stated that staff are to dispose of medications in the Drug Buster when necessary. Employee 13 verified that the sharps container secured to her medication cart contained at least six medication tablets.

The surveyor observed medications discarded in the sharps containers secured to five of eight medication carts observed.

The surveyor reviewed the above findings regarding medication disposition during an interview with the Nursing Home Administrator and the Director of Nursing on May 22, 2024, at 3:55 PM.

Plan of Correction - To be completed: 07/02/2024

Cited: The sharps containers
were appropriately disposed of.

Like: Facility wide sweep
completed to ensure
medications are not wasted in
sharps containers.

Education: DON/designee will
educate licensed staff on
appropriate wasting of
medications. Licensed staff
will complete nurse orientation
of appropriate discarding of
medications.

Audits: UM/designee will audit
weekly x4 weeks, then monthly
x2 months of appropriate
wasting of medications when
medications need to be wasted.
Results will be taken through
QAPI.

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