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Based on record review and interview, the facility failed to ensure medications were administered in a safe manner in 1 (Patient#16) of 4 sampled patient charts reviewed. Nursing staff were administering psychotropic/Sedative medication with incomplete parameters in the physician order. The physician orders were written as a PRN (Pro re nata which translates to as needed) order, and did not give detailed parameters on specific indications for medication administration and the order did not give the maximum dosage/frequency allowed for administration

This deficient practice had the likelihood to cause harm in all patients receiving medications at the facility.



Findings include:


PATIENT #16

Patient #16 was a 50-year-old female who was admitted on 4-14-2019 for suicidal ideation.

Review of the Physicians Medication Orders for 4-14-2019 showed an order for Lorazepam (Ativan). The order stated, "Lorazepam (Ativan) 2 mg = 1 ml, Intramuscular (IM) Q 4H PRN Anxiety, Indication: Anxiety." The first dose was administered on 4/14/2019 8:25 PM. The end date on the physician's order was listed as 4/24/2019, 10 days later. Anxiety was listed as an indication, however, there were no specific parameters listed for that indication. The decision to medicate the patient with psychotropic/sedative medication was left to a nursing judgement. There was no maximum dosage listed on the order.

Review of the Progress Notes for 4-16-2019 revealed the following:

"Patient has been calm and cooperative this shift. C/O anxiety this afternoon and was given Ativan PO (meaning by mouth). Medication was effective..

The Ativan was administered without documentation of what behavior Patient #16 was exhibiting.

Based on observation and interview, the facility failed to ensure 1 of 2 Kitchens (Main campus) were organized in a manner to prevent contamination. The facility failed to:

A. ensure pots, pans, and serving utensils were stored in a manner to prevent contamination.

B. ensure food items were stored in a manner to prevent contamination.

C. ensure floors and shelves in the kitchen were kept clean.


This deficient practice had the likelihood to cause harm to all patients.

Findings include:





During an observation on 04/15/2019 after 2:00 p.m. the following was found in the Main campus kitchen;

Clean pots and muffin pans were stacked on an open shelf. The pans that were stored on the back side of the shelf were making direct contact with the wall. The muffin pans were making direct contact with a trash can.

Thirty-five (35) plus cookie sheets were stored on shelves and on a cart. The pans had a buildup of carbon and were dented. Some were stacked together and were still wet.

The condition of the pans created a medium for bacteria growth


Steam table pans were stored on an open shelf. The pans stored on the back side of the shelf were making direct contact with the wall.

Shipping boxes of food were stored on shelves in the freezer and milk refrigerator. Some of the boxes were on shelves with food items that had been removed from the boxes.


Packages of bread were stored on pallets that were soiled with spills and debris.


The Room Service Freezer had a rubber door sealant that was soiled with a build-up of debris.


The back of the large commercial skillet had a buildup of grease and debris. The metal panel behind the appliance was covered with white debris. The floor behind the appliances were soiled and had spills.

Two open shelves had steam table pans, tops for pans, and scoops stored on them. The shelves were soiled with dried spills, dust and debris. One of the shelves had a dead bug on it. The bottom of one shelf was tied with strings.

Food Service director #11 stated the strings were to prevent the pans from falling off onto the floor.

Twenty-five (25) plus stainless steel tongs used for picking up food were hanging off the side of the soiled shelf and were not covered. Both shelves were not covered and were in high traffic areas


Canned food was stored on metal shelves in the dry food storage area. The shelves were soiled with dried spills.

Food Service director #11 confirmed the observations.