Bedrock Hcs At Riverdale Llc

F-F610.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 18 525321 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525321 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42038 potential for actual harm Based on interview and record review, the facility did not ensure a thorough investigation of Residents Affected - Few abuse/exploitation was completed for 1 of 3 Residents (Resident R1, Resident R3, and Resident R4) reviewed for abuse.

Resident R1 was observed being verbally abused by a staff member, the facility did not complete a full investigation.

Resident R3 reported an allegation of abuse that was not completely investigated.

Resident R4 reported an allegation of abuse that was not investigated.

Evidenced by:

Facility policy entitled Abuse, neglect, and Exploitation, dated 10/1/2022, states, in part: .It is the policy of this facility to provide protections for the health, welfare and rights of each resident . to prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Exploitation: means taking advantage of a resident . Mistreatment means inappropriate treatment or exploitation of a resident . Policy Explanation and Compliance Guidelines . IV. Identification of Abuse, Neglect and Exploitation. A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation of an individual of goods and services. This includes staff to resident abuse . B. Possible indicators of abuse include but are not limited to. 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status . 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 . B. Written procedures for investigations include: . 3. Investigating different types of alleged violations . 6. Providing complete and thorough documentation of the investigation .

Example 1

Resident R1 was admitted to the facility on [DATE REDACTED] with diagnoses that include traumatic brain injury, dementia, and diabetes mellitus. Resident R1's most recent MDS (Minimum Data Set) dated 11/27/24 states that Resident R1 has a BIMS (Brief Interview of Mental Status) of 9 out of 15, indicating that Resident R1 is moderately cognitively impaired.

Nurse's note written by RN L (Registered Nurse) dated 1/19/25 at 1:05 PM states Employee reported verbal disagreement between resident and one of the housekeeping employees [Employee initials]. Resident has verbally insulted employee with cuss words and derogatory statements. Employee was upset and returned comments including cuss words to the resident to stop being a fucking asshole. One of the staff reported the incident to RN (Registered Nurse) on duty (writer of statement). Writer reported incident to DON (Director of Nursing). Per her instruction sent employee home pending investigation of the incident. Left message for administrator, awaiting return call. Spent time with employee educating on possible ways to cope with situations where a resident is verbally assaulting you. Such as walking away or requesting help from another employee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 18 525321 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525321 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 It is important to noted that Surveyor called RN L for an interview, no return call was received.

Level of Harm - Minimal harm or Statement from MT K (Med Tech) states While passing noon meds, was at the end of the hall with [Resident R1 and potential for actual harm another resident name]. Hskp N (Housekeeper) walked up to Resident R1 and told him she didn't like the way he had talked to her earlier. She was swearing at him a lot. At first I thought she was joking with him because she Residents Affected - Few often does. But I was shocked that she was swearing. She got in his face and stated that if he apologised[sic] for swearing at her earlier she might apologise[sic] for swearing at him. I tried to get her away from him by calling her name. She said to me I know and walked away into a room. But came right back out, got in his face again and told him Fuck you! I'm a firecracker and I won't take shit from you. Do you understand me? Then she walked back down the hall. I was not aware of the incident she had earlier with him till[sic] I was informed by laundry dept (department).

It is important to note that there is no statement from LA O (Laundry Aide), Hskp N, or RN L (other than the nurse's note documented).

The facility submitted a self-report regarding this incident.

On 1/28/25, Surveyor reviewed the facility's self-report.

The facility provided education, with a subsequent quiz, titled Handling Challenging Behaviors. Out of 16 quizzes taken by staff, 4 had wrong answers; there is no evidence that staff was re-educated.

It is important to note that there was no education provided on abuse and the steps to take when witnessing abuse occur.

On 1/20/25, resident interviews were completed, 1 resident reported an allegation of abuse that was not investigated by the facility (refer to example 3).

On 1/29/25 at 11:25 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what

the process is when a staff member witnesses abuse, DON B stated that they staff member should protect

the resident. Surveyor asked DON B if she would have expected MT K to get between Resident R1 and Hskp N, DON B stated yes. Surveyor asked DON B if staff should have been educated on abuse, DON B stated yes. Surveyor asked DON B if she would expect a statement to be obtained from LA O, Hskp N, and RN L, DON B stated yes. Surveyor asked DON B who reviews the results from the quizzes for correctness, DON B stated that she will upon her return and will re-educate as needed.

41788

Example 2

Resident R3 admitted to the facility on [DATE REDACTED] and has diagnoses that include schizoaffective disorder (a mental health condition including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and mood symptom, such as depression or bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).

Resident R3's Admission Minimum Data Set (MDS) Assessment, dated 11/21/24, shows that Resident R3 has a Brief Interview of Mental Status (BIMS) score of 11 indicating Resident R3 has moderate cognitive impairment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 18 525321 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525321 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The facility's Grievance/Concern Form, dated Thursday January 23, 2025, states, in part: .

Level of Harm - Minimal harm or Date of Occurrence: January 23, 2025, 11:36PM. potential for actual harm Location of Occurrence: Nurse Station. Residents Affected - Few Staff or Residents Involved: CNA M (certified nursing assistant) and Resident R3

Summary of Concern:

Resident came up to nurses' station. Writer along with staff seated at station charting. Resident came up to station. CNA M asked what do you need, Resident R3, the radio? Resident R3 then replied I don't talk to you, you don't talk to me and put his hand up to his mouth. Then proceeded to call staff a [derogatory name.] Staff went and got him ice and asked him to go back to his room or go down to puzzle room. Resident R3 was so disrespectful he said over and over what do they say about blacks? Resident R3 called [derogatory] over and over and made jesters with his fingers opening up his nostrils asking, have you seen your nostrils? We asked him to go to his room. He demanded said he'd sit here, and you want me to stay. He also just kept death staring and kept running his mouth.

Facility Initial Self Report states in part: . dated 1/24/25, at 3:00 PM, states, in part: .

Summary of Incident: .

Is date and time when occurred known? Yes.

Date occurred . 1/24/25.

Time Occurred: 3:00PM.

Is occurred date and time estimated? No.

Date discovered . 1/24/25.

Briefly Describe the incident . Resident made an allegation that CNA (Certified Nursing Assistant) threatened him.

Resident made an allegation that CNA threatened him .

Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct . The alleged staff member has been suspended investigation initiated .

Report Submitted Date: 1/24/25 4:53:02PM.

Facility conducted interviews on 1/24/25 with 20 residents asking:

1) Has CNA M ever been unprofessional while providing cares?

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 18 525321 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525321 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 2) Has any staff member made threatening comments?

Level of Harm - Minimal harm or 3) Are staff professional while providing cares? potential for actual harm 4) Do you feel safe at our facility? Residents Affected - Few 5) Do you know who to report abuse to?

No concerns were noted.

Facility interviewed 4 staff from the night shift that worked the night of 1/23/25.

Facility did not interview Resident R3.

On 1/29/25, at 11:26 AM, Surveyor interviewed DON B (Director of Nursing) and asked what the allegation of abuse was made by Resident R3 and if it was reported timely. DON B indicated she received a call from Resident R3's social worker from Inclusa who had reported to her Resident R3 informed the social worker that a CNA threatened Resident R3 with a gun. Surveyor asked if DON B had this documented with a date and time and DON B indicated not knowing if DON B had put in a progress note or not. DON B indicated investigation was initiated after call received. DON B indicated 4 staff was interviewed that had witnessed the incident and residents. The staff stated Resident R3 was racial slurring at CNA M. CNA M was kind and did not make any derogatory remarks to Resident R3 per staff interviews. DON B indicated CNA M was suspended 1/24/25. DON B found the investigation to be unsubstantiated based on those interviews with staff and residents and CNA M returned to work that night on 1/24/25. Surveyor asked DON B if Resident R3 was interviewed, and DON B indicated she did not interview Resident R3 as she did not want to bring it to his attention again and get Resident R3 going again. Surveyor asked if Resident R3 should have been interviewed for a thorough investigation. DON B indicated yes.

50698

Example 3

Resident R4 was initially admitted to the facility on [DATE REDACTED] with a readmitted [DATE REDACTED]. Resident R4 has diagnoses that include muscle wasting and atrophy, encephalopathy (brain disease that alters brain function or structure), chronic kidney disease stage 3, and depression.

Resident R4's most recent Minimum Data Set (MDS) assessment dated [DATE REDACTED] shows Resident R4 has a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident R4 is cognitively intact.

On 1/28/25 at 1:00 PM, Surveyor interviewed Resident R4. Resident R4 stated to Surveyor about a week ago, a nurse threw an empty water cup at him. Resident R4 stated after taking his medication and drinking water, he put the empty water cup

on the medication cart. Resident R4 indicated the nurse threw the empty water cup at him, hitting him on the back with

the empty cup. Resident R4 was not able to recall the nurse's name and stated the nurse was a black one. Resident R4 stated

he told the NHA (Nursing Home Administrator) and DON B (Director of Nursing) about this incident. The NHA Resident R4 mentioned is no longer at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 18 525321 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525321 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 On 1/29/25 at 9:15 AM, Surveyor reviewed resident interviews completed regarding abuse from a Facility Reported Incident (FRI) involving a different resident and incident dated 1/19/25. Resident R4 was one of the Level of Harm - Minimal harm or completed interviews. When asked if Resident R4 was ever abused by anyone in the facility, Resident R4 answered Yes. potential for actual harm Underneath this response, it reads Nurse throwing cup at him.

Residents Affected - Few It is important to note the interview does not say which staff person completed the interview.

On 1/29/25 at 11:25 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she was not aware of Resident R4's allegation of abuse. DON B stated no one reported this to her and she did not read the completed interviews regarding abuse from the FRI which involved a different resident, was not aware of Resident R4's response about answering he was abused by someone in the facility and mentioning a nurse throwing a cup at him. DON B indicated she did not investigate this allegation and stated she should have.

The facility did not follow their policy and did not investigate the allegation of abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 525321 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525321 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41788 potential for actual harm Based on interview and record review the facility did not ensure residents are free of any significant Residents Affected - Few medication errors for 1 of 4 residents (Resident R2) reviewed for medications.

Resident R2 had 9 medications not administered for 2 days in month of January, and 1 medication not administered

on 1 day in the month of January including a cancer medication and pain medication.

This is evidenced by:

The facility's policy entitled, Administration Procedures for all Medications, dated 10/25/14, states, in part: .

Oral Medication Administration

Purpose: To administer oral medications in a safe, accurate, and effective manner .

Procedures: .

I. Chart medication administration on Medication Administration Record Immediately following each resident's medication administration .

Resident R2 was admitted to the facility on [DATE REDACTED] and has diagnoses that include secondary malignant neoplasm of bone (a condition where cancer cells from another part of the body (primary tumor) spread to the bones), neoplasm related pain (acute) (chronic) and type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Resident R2's Quarterly Minimum Data Set (MDS) Assessment, dated 12/11/24 shows Resident R2's Brief Interview of Mental Status (BIMS) score of 15 indicating Resident R2 is cognitively intact.

Resident R2's Care Plan states, in part: .

Focus: Needs pain management and monitoring related to: Cancer . Date Initiated: 7/5/24.

Goal: .Patient will achieve acceptable pain level goal. Date Initiated: 7/5/24 .

Interventions/Tasks: Administer pain medication as ordered. Date Initiated: 7/5/24 .

Focus: Alteration in Blood Glucose due to: Insulin Dependent Diabetes Mellitus. Date Initiated: 7/5/24 .

Interventions/Tasks: Administer medications as ordered. Date Initiated: 7/5/24 .

Focus: Chemotherapy Treatment Cancer. Date Initiated: 7/5/24 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 525321 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525321 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Interventions/Tasks: Administer medications prior to treatment to minimize side effects, per provider order. Date Initiated: 7/5/24 . Level of Harm - Minimal harm or potential for actual harm Resident R2's January Medication Administration Record (MAR) shows on 1/20/25 & 1/22/25 the following medications were not administered by blanks on MAR: Residents Affected - Few -Anastrozole (breast cancer medication) oral tablet 1 milligram (mg). Give 1 tablet by mouth in the morning for cancer. Order Date: 12/9/24.

-Cetirizine HCL (hydrochloride) (medication for allergies) Oral Tablet 10 mg. Give 1 tablet by mouth one time

a day for seasonal allergies. Order Date: 12/9/24.

-Farxiga Oral Tablet 10 mg (Dapagliflozin Propanediol). Give 1 tablet by mouth in the morning related to Type 2 Diabetes Mellitus (DM). Order Date: 12/9/24.

-Metformin HCI (hydrochloride) ER (extended release) oral tablet Extended Release 24-hour 500 mg. Give 1 tablet by mouth in the morning for DM 2 . Order Date: 12/9/24.

-Omeprazole Oral Capsule Delayed Release 20 mg. Give 1 capsule by mouth in the morning for indigestion. Order Date: 12/9/24.

-Buspirone HCI Oral Tablet 7.5 mg. Give 1 tablet by mouth two times a day related to anxiety disorder . Order Date: 12/9/24.

-Furosemide Oral Tablet 20 mg. Give 1 tablet by mouth two times a day for edema. Order Date: 12/9/24.

-Gabapentin Oral Capsule 300 mg. Give 1 capsule by mouth every morning and at bedtime for pain related to Neoplasm related pain . Order Date:12/9/24.

-Senna-Docusate Sodium Oral Tablet 8.6-50mg. Give 2 tablets by mouth two times a day for constipation. Order Date: 12/9/24.

Resident R2's January MAR shows on 1/25/25 Resident R2's Methadone HCI Oral Tablet 10 mg. Give 1 tablet by mouth three times a day for pain. Order Date: 1/16/25 was not administered.

Resident R2's Physicians Orders for January 2025, states, in part: .

Anastrozole oral tablet 1 milligram (mg). Give 1 tablet by mouth in the morning for cancer .

Buspirone HCI Oral Tablet 7.5 mg. Give 1 tablet by mouth two times a day related to anxiety disorder

Cetirizine HCL Oral Tablet 10 mg. Give 1 tablet by mouth one time a day for seasonal allergies.

Furosemide Oral Tablet 20 mg. Give 1 tablet by mouth two times a day for edema .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 525321 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525321 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Gabapentin Oral Capsule 300 mg. Give 1 capsule by mouth every morning and at bedtime for pain related to Neoplasm related pain . Level of Harm - Minimal harm or potential for actual harm Methadone HCI Give 1 tablet by mouth three times a day for pain .

Residents Affected - Few Omeprazole Oral Capsule Delayed Release 20 mg. Give 1 capsule by mouth in the morning for indigestion .

Senna-Docusate Sodium Oral Tablet 8.6-50mg. Give 2 tablets by mouth two times a day for constipation .

On 1/28/25, at 9:20 AM, Surveyor interviewed Resident R2 who indicated there has been times she had to wait a day or two to get medications due to pharmacy.

On 1/28/25, at 12:40PM, Surveyor interviewed LPN J (Licensed Practical Nurse) and asked what a blank on

the MAR indicates and LPN J indicated the medication was not administered. Surveyor asked if a medication is not given should it be documented, and LPN J indicated yes. Documentation in progress notes should show if the medication was not available, pending, or resident refusal and the nurse would notify physician. Surveyor asked if it is acceptable for a resident to not receive ordered medications. LPN J indicated no.

Of note: No documentation was put into the Progress Notes for 1/20/25, 1/22/25 and 1/25/25 regarding the medications why these medications were not administered and reason.

On 1/28/25, at 2:01 PM, Surveyor interviewed CND C (Chief Nursing Officer) and asked what would blanks

on the MAR indicate. CND C indicated the medication was not given. Surveyor asked if CND C would expect to see documentation in progress notes that a medication was not administered and reason. CND C indicated yes. Surveyor asked CND C if it is acceptable for a resident to not receive medications and CND C indicated no. CND C indicated if a medication is not available the pharmacy should be called to inquire about

the medication, check the contingency for the medication, and if not available the nurse should call physician for direction and document.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 525321