**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to assess residents for the ability to self-administer medications for one (Resident #60) of four residents reviewed during medication pass observation. Findings included: Review of a facility policy titled, Medication Administration Procedures Self-Administration of Medications, dated 04/2020, revealed, .Residents who desire to self-administer medications are permitted to do so if the facilities interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. An order to self-administer must be given by the physician. 1. Upon request of a resident to self-administer medications, the interdisciplinary team and physician will be consulted for evaluation. 2. Facility staff will administer the resident's medications until the interdisciplinary team completes an assessment and a physician order is obtained. 3. The interdisciplinary team will assess the resident's ability to self-administer medications safely at least quarterly and as needed. 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. 5. Medications stored at the bedside are reordered in the same manner as the other medications. The nursing staff is responsible for proper rotation of bedside stock and removal expired, discontinued, or recalled medications. 6. When the interdisciplinary team determines that bedside or in room storage of medications would be a safety risk to other residents, the medication of the residents permitted to self-administer are stored in the central medication cart or medication room. The resident requests each dose from the medication nurse who provides the medication to the resident in the unopened package for the resident to self-administer. The nurse then records such self-administration on the MAR [medication administration record] in the manner described above . A review of a FACE SHEET indicated the facility re-admitted Resident #60 on [DATE] with a diagnosis that included Orthopedic Aftercare Following Surgical Amputation of the Left Leg Below the Knee with an Infection Due to a Malignant Neoplasm of Connective and Soft Tissue of the Left Lower Limb Including the Hip. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident was independent with bed mobility and eating and required limited assistance from staff with all other activities of daily living (ADLs). Review of Resident #60's Care Plan, initiated [DATE], revealed self-administration of medications and keeping medications at the bedside were not included. A review of Resident #60's Physician Orders List indicated the resident's orders included Triamcinolone Acetonide (used to treat a variety of skin conditions) 0.1% topical ointment to be applied every day with wound changes, dated [DATE]. There were no orders indicating the resident could self-administer this medication. Medication pass observations were conducted on [DATE] at 7:54 AM with Licensed Practical Nurse (LPN) #19. LPN #19 was preparing Resident #60's medications and was unable to locate the resident's Triamcinolone ointment in the medication cart but found it in Resident #60's room. LPN #19 placed a small amount of the ointment in a plastic medication cup and left it in the room for the resident to apply. He left the tube of Triamcinolone in the resident's room at the resident's request. During an interview on [DATE] at 8:05 AM, Resident #60 stated that when they first arrived at the facility, they were not able to put the Triamcinolone on their foot. Now the resident was able apply the ointment themself. The resident wanted the medication left in their room since they would be discharged home that day. During an interview on [DATE] at 11:20 AM, LPN #19 stated he did not think about the medication not being able to be left in the room since the resident was alert and oriented and was able to apply it themself. He stated he did not know if the resident had been assessed, and he stated he had not done a self-medication administration assessment since working in the facility. During an interview on [DATE] at 4:55 PM, the Nurse Consultant (NC) stated if a resident wanted to self-administer their medications, the nurse should perform an assessment to determine if the resident was capable, and it should be care planned. She stated medications should only be left in the room if it was approved and they had a physician's order. During an interview on [DATE] at 5:15 PM, the Director of Nursing (DON) stated if a resident wanted to self-administer their medications, then an assessment should be done, the physician should be notified, and orders should be received for self-administration. She stated medication should not be left at the bedside unless the resident had been assessed and they had an order. During an interview on [DATE] at 5:56 PM, the Executive Director (ED) stated he did not know the process if a resident wanted to self-administer medications, but medications were not allowed to be left in the resident's room.

Based on observations, interviews, record review, and review of facility policy titled Resident Assessment Instrument (RAI) , the facility failed to ensure one (Resident #1) of one resident was assessed for appropriate adaptive equipment related to call lights. Findings included: A review of the facility's policy titled, Resident Assessment Instrument (RAI), dated 10/29/2015, revealed, .Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care . A review of FACE SHEET indicated the facility admitted Resident #1 on 10/17/2022 with diagnoses that included Multiple Sclerosis and Muscle Spasms. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2023, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS indicated Resident #1 required extensive assistance from staff with transfers, locomotion on and off the unit, dressing, eating, toileting, personal hygiene, and bathing. The resident had range of motion limitations to both upper and lower extremities. A review of Resident #1's Care Plan, dated 10/18/2022, revealed the facility would train the resident on how to use the call light to request assistance. During an interview with Resident #1 on 05/30/2023 at 10:08 AM, the resident stated they were unable to use the call light provided by the facility. An observation made on 05/30/2023 at 10:08 AM revealed the resident was not able to use the call light provided by the facility. The facility provided a flat pad call light. The resident was not able to push the call light for assistance. Resident #1 was observed using a personal speaking device to call the facility for assistance. During a phone interview with Resident #1's family member on 05/30/2023 at 3:37 PM, the family member stated that Resident #1 was unable to use the call light provided by the facility. An interview with Certified Nursing Assistant (CNA) #1 on 06/01/2023 at 10:18 AM revealed that the family purchased the personal speaking device that Resident #1 used to call for assistance. She stated that the resident would ask to be switched to the nurses' station and either a CNA or nurse would answer the phone at the nurses' station. CNA #1 stated no one was assigned to stay at the desk or to answer the phones. During an interview with the Occupational Therapist Assistant (OTA) on 06/02/2023 at 4:20 PM, he stated that staff could put in a referral so therapy could see the resident and evaluate the resident's needs for a call light. They would make accommodations to be sure the resident had a call light that they could use. An interview with the Nurse Consultant (NC) on 06/03/2023 at 4:36 PM revealed she expected the staff to have the resident evaluated by therapy to find out the best and easiest way for the resident to call for assistance. During an interview with the Director of Nursing (DON) on 06/03/2023 at 5:14 PM, she stated she expected that if staff observed that a resident was not able to use the call light provided, then she would expect them to notify the nurse. The nurse would put in a referral for therapy to assess the resident for a different type of call light. During an interview with the Executive Director on 06/03/2023 at 5:54 PM, he stated that he expected therapy to be notified to evaluate any resident who was not able to use the call light provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy titled Discharge Summary and Plan of Care, it was determined that the facility failed to have a completed discharge summary with a recapitulation (concise summary) of the residents' stay for two (Resident #98 and Resident #453) of two residents reviewed for discharge requirements. Findings included: Review of a facility policy titled, Discharge Summary and Plan of Care, dated 11/28/2016, revealed, .The Discharge Summary should include: - A recapitulation of the resident/guest's stay - A final summary of the resident/guest's status at the time of discharge - A post discharge plan of care developed with the resident/guest and his/her family, which will assist the resident/guest to adjust to his/her new living environment - A reconciliation of pre and post discharge medications should be conducted . 1. Review of a FACE SHEET indicated the facility admitted Resident #453 on 12/27/2022. Review of the discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed Resident #453 was discharged from the facility on 01/20/2023. Review of Resident #453's comprehensive care plans revealed a Care Plan Description of Discharge Anticipated, with a start date of 12/28/2022. This care plan included a Care Plan Goal of transitional discharge to be provided to me at my choosing. Review of Resident #453's Physician Orders List revealed an order for the nightshift charge nurse to prepare discharge summary, mediation [medication] list and assessment entry. Print 2 [two] copies for discharge, with an order date of 01/18/2023 and a start date of 01/20/2023. During an interview with the Social Worker (SW) on 06/02/2023 at 5:30 PM, the SW revealed there was no documentation related to the resident's discharge on [DATE]. During an interview with the Nurse Consultant (NC) on 06/03/2023 at 4:36 PM, the NC revealed that when a resident was discharged , the staff were to complete a discharge transfer summary and chart in the progress notes. She said if this was not completed, then they would not know the circumstances of the discharge or where the resident was discharged to. During an interview with the Director of Nursing (DON) on 06/03/2023 at 5:14 PM, she revealed she expected the staff to document a brief synopsis of the resident's condition at the time of discharge, including vitals, where the resident was going and how they were going and to notify the family and call report to the other facility if the resident was being discharged to another facility. 2. Review of a FACE SHEET indicated the facility admitted Resident #98 on 05/03/2023. Review of Resident #98's comprehensive care plans revealed a Care Plan Description of Discharge Anticipated, with a start date of 05/04/2023. This care plan included a Care Plan Goal of transitional discharge to be provided to me at my choosing. During an interview on 05/30/2023 at 12:29 PM, Resident #98 stated they were discharging home that day. A review of Resident #98's Discharge to Home Instructions, dated 05/30/2023, revealed it was incomplete. The resident's diet was documented, and it indicated the resident was to follow up with their primary care physician. The medications/treatments, home equipment to be used, exercise/mobility care instructions/restrictions, symptoms to report to the physician after discharge, contact name and number for non-emergency questions, discharge summary, and other instructions were blank. The form was signed as being completed by Licensed Practical Nurse (LPN) #11. During an interview on 06/02/2023 at 3:30 PM, LPN #11 stated it was her third day working on the floor and she was still learning the system and the paperwork, but Unit Manager (UM) #8 was showing her. She stated she was the person that completed the discharge paperwork for Resident #98, and it was her first time doing it at the facility. She stated UM #8 showed her how to do it. She reviewed the Discharge to Home Instructions provided to Resident #98 and agreed that the form was incomplete, and LPN #11 said it should contain more information about the resident's stay. She stated she was unsure why it was incomplete. During an interview on 06/02/2023 at 3:36 PM, UM #8 stated the case manager sent a blue folder with the resident when they discharged that had a list of their medications, durable medical equipment (DME) supplies, and home health information. She was not able to say why the Discharge to Home Instructions was not filled out. During an interview on 06/03/2023 at 5:15 PM, the Director of Nursing (DON) stated the discharge summary should be a brief synopsis of the resident's condition at the time of discharge, including their vital signs and where the resident was going. During an interview on 06/03/2023 at 5:56 PM, the Executive Director (ED) stated he was unsure who was responsible for completing discharge summaries or what they should include.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to provide dependent residents assistance with activities of daily living (ADLs) to ensure good grooming for one (Residents #449) of seven residents reviewed for ADL care. Specifically, the facility failed to shave Resident #449 when needed. Findings included: The facility's policy, titled, Hygiene and Grooming, dated 10/01/2010, indicated, Good hygiene and grooming help prevent the spread of infection and promote the resident's feeling of self-worth and dignity. Guidelines for the provision of hygiene and grooming services are: -Shower, tub or complete bed bath as needed -Twice daily oral hygiene (A.M. and P.M.) -Hair and scalp shampoo, as needed -Shaving daily or as needed. A review of a FACE SHEET indicated the facility admitted Resident #449 on 05/12/2023 with diagnoses that included Fusion of the Cervicothoracic Spine (bones in the neck and upper back), Osteomyelitis (infection of the bone) of the Lumbar Vertebra (bones in the lower back), Kyphosis (curvature of the spine), and Chronic Pain. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/19/2023, revealed Resident #449 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The resident required extensive assistance from staff with bed mobility, transfers, dressing, and toilet use and required supervision with set-up help from staff only for personal hygiene. Review of Resident #449's Care Plan, initiated 05/15/2023, revealed the resident required assistance to complete daily activities of care safely. Interventions directed staff to assist with shaving. On 05/30/2023 at 11:27 AM, Resident #449 was observed sitting up in their wheelchair with their lunch tray on the over-the-bed table in front of the resident. The resident had a couple of days' hair growth on their face. The resident was wearing a hospital gown with a gait belt around them. On 06/01/2023 at 10:39 AM, Resident #449 was observed lying on the bed and continued to have several days of hair growth on their face. The resident was interviewed during this time and stated they preferred to be clean shaved and really needed to be shaved. Resident #449 stated they could do it themself if staff would give them the supplies to do it. On 06/03/2023 at 9:37 AM, Resident #449 was observed lying on the bed and had not been shaved. During an interview at this time, the resident again stated if the staff would give them the supplies, the resident would do it themself. Resident #449 stated they had asked the staff for supplies, but they did not help. A review of Resident #449's May 2023 ADL Assistance and Support form revealed the personal hygiene section was incomplete. It had not been filled in for the entire month. There was no documentation of the resident receiving assistance with personal hygiene. During an interview on 06/03/2023 at 9:55 AM, Unit Manager (UM) #8 stated residents should be shaved when they preferred to be shaved or be assisted or set up to do it themselves. During an interview on 06/03/2023 at 10:23 AM, Certified Nursing Assistant (CNA) #9 stated she shaved residents when they requested to be shaved. She did not think Resident #449 would be able to shave themself and stated she was not aware the resident wanted to be shaved. During an interview on 06/03/2023 at 5:15 PM, the Director of Nursing (DON) stated residents should be shaved every time they got a shower, if not every day. During an interview on 06/03/2023 at 5:56 PM, the Executive Director (ED) stated residents should be shaved as needed.

Based on interviews, record review, and facility policy review, it was determined that the facility failed to ensure medications were available from the pharmacy for two (Resident #452 and Resident #142) of six residents reviewed for unnecessary medications. Specifically, the facility failed to ensure Resident #452's Prednisone and Resident #142's inhaler was available from the pharmacy for administration. Findings included: Review of a facility policy titled, Medication Policies Ordering and Receiving Medications from Provider Pharmacy, dated 04/2020, specified, .Medications and related products are received from the provider pharmacy on a timely basis. Procedures 1. A. New medication orders are transmitted to the pharmacy. C. The first dose of non-emergency medication is scheduled to be given after the regularly scheduled pharmacy delivery to the facility . 1. A review of a FACE SHEET indicated the facility admitted Resident #452 on 05/26/2023 with diagnoses that included Asthma and Acute Respiratory Failure with Hypoxia (below normal level of oxygen in the blood). The resident was not at the facility long enough for a Minimum Data Set (MDS) to be completed. Review of Resident #452's Care Plan, initiated 05/29/2023, revealed the resident had altered respiratory function related to shortness of breath and asthma. Interventions directed staff to observe for effectiveness of medication, observe for changes in respiratory rate and depth, and observe for shortness of breath, congestion, or cyanosis (bluish skin color due to decreased amounts of oxygen). A review of Resident #452's May 2023 Physician Orders revealed the resident had an order to administer one tablet of Prednisone 10 milligram (mg) orally once daily for six days, ordered 05/26/2023. A review of Resident #452's May 2023 Med [medication] Tech [technician] (Administration Record) revealed the resident did not receive their Prednisone for the first three days after they were admitted to the facility, on 05/27/2023, 05/28/2023, or 05/29/2023. A review of a Consolidated Delivery Sheets from the pharmacy, dated 05/30/2023, indicated 21 tablets of Resident #452's Prednisone 10 mg were delivered. During an interview on 06/02/2023 at 11:28 AM, Medication Aide Certified (MAC) #23 stated if a medication was not available during the medication pass, she would notify the nurse and they would do the follow-up. She stated she could not remember what nurse she talked to about Resident #452's prednisone. During an interview on 06/02/2023 at 3:30 PM, Licensed Practical Nurse (LPN) #11 stated if a medication was not available during the medication pass, they should notify the pharmacy and the physician and document it. She stated medications should be available for administration by the next medication pass. LPN #11 was not working on the floor yet when the omission of Resident #452's prednisone occurred. During an interview on 06/03/2023 at 9:55 AM, Unit Manager (UM) #8 stated if a medication was not available during the medication pass, staff should check to see if it was available in the emergency medication kit and then call the pharmacy to find out when it was going to be delivered. She stated the pharmacy delivered between 11:00 AM to 12:00 PM, then between 6:00 PM and 7:00 PM, and then again overnight. She stated if a medication was not available on the first pharmacy run then it should be on the next one. If it was not, then she would call the pharmacy. She stated most of the time the MAC would tell her when they did not have a medication to administer. She stated she was not aware that Resident #452 did not receive their prednisone. During an interview on 06/03/2023 at 5:15 PM, the Director of Nursing (DON) stated if a MAC did not have a medication available to administer, then they should notify the nurse, and the nurse should contact the pharmacy to find out where the medication was and contact the physician to notify that the medication was not available. During an interview on 06/03/2023 at 5:56 PM, the Executive Director (ED) stated if a medication was not available during the medication pass, then they needed to find out where the medication was and notify the physician that the medication was not available. 2. A review of Resident #142's FACE SHEET revealed the facility admitted the resident on 02/27/2023 with diagnoses that included Pneumonia, Dementia, Heart Failure, Acute Respiratory Failure, and Chronic Obstructive Pulmonary Disease. A review of Resident #142's five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2023, revealed the resident did not experience shortness of breath or trouble breathing during this assessment period. A review of Resident #142's care plan initiated on 02/28/2023, indicated the resident had altered respiratory function related to respiratory failure. The interventions included to observe for the effectiveness of medication, observe for changes in respiratory f rate and depth, observe for shortness of breath, congestion, cyanosis (a bluish discoloration of the skin that can result from poor circulation or inadequate oxygenation of the blood), and pharmacy consult as needed. A review of Resident #142's Physician Orders, dated March 2023, revealed on 02/27/2023, the resident received an order for Anoro Ellipta with instructions to inhale into the lungs daily for shortness of breath and wheezing. A review of Resident #142's Med [medication] Tech [technician] (Administration Record), for March 2023, revealed staff did not administer the Anora Ellipta inhaler on 03/07/2023 and 03/08/2023. The Administration Record note dated 03/07/2023 indicated the medication was not administered as the medication was not available. The note dated 03/08/2023 written by Medication Aide, Certified (MAC) #23, indicated the medication was not administered as the medication was not available and was ordered from pharmacy. During an interview on 06/03/2023 at 10:02 AM, Unit Manager (UM) #8 stated if there was a missing medication, staff should go to Hall 2 to check the backup medications, and if not there, call the pharmacy. UM #8 stated the pharmacy delivered medications three times per day. During an interview on 06/03/2023 at 11:05 AM, the Nurse Consultant (NC) stated the expectation was for the staff to look around for the medications on the other medication carts, notify the nurse, and notify the pharmacy. The NC stated it was not acceptable for a resident to miss any doses of their medication. Per the NC, a medication aide should notify the nurse that a resident missed a dose of their medication, so the nurse could notify the physician and/or nurse practitioner. During an interview on 06/03/2023 at 11:35 AM, MAC #23 stated she wrote not given on the administration record on 03/08/2023 because she did not know exactly what to do. Per MAC #23, was reeducated since then to inform the nurse and the physician because it may have been a medication the resident should not have missed. During an interview on 06/03/2023 at 5:59 PM, the Executive Director stated his expectation was for staff to follow the physician's orders. This deficiency was cited as a result of complaint/report #AL00043835.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, and facility policies titled Medication Administration-General Guidelines and Blood Glucose Testing the facility failed to ensure adequate monitoring of blood glucose (sugar) levels as ordered by the physician for the use of insulin for Resident #143 and #294, two of five residents reviewed for unnecessary medications. Findings included: Review of a facility policy titled, Medication Administration-General Guidelines, dated 2011, specified, . Medications are administered in accordance with written order of the attending physician . A review of a facility policy titled, Blood Glucose Testing, revised on 10/01/2019, revealed, .The physician's order should specify the type of specimen to be obtained. Blood glucose levels for residents with diabetes vary, depending on food intake, medication, and exercise . A review of Resident #143's FACE SHEET revealed the facility admitted the resident on 03/16/2023 with diagnoses that included Type Two Diabetes. A review of a discharge Minimum Data Set (MDS), dated [DATE], revealed Resident #143 lacked a Brief Interview for Mental Status (BIMS) score, indicating the resident had severe cognitive impairment. Per the MDS, the resident required supervision to limited assistance with all activities of daily living (ADLs). Review of Resident #143's Physician Orders for the month of 03/2023 revealed an order dated 03/16/2023 directing staff to conduct capillary blood glucose (CBG) monitoring every morning, to administer three units of Insulin Aspart three times a day with meals, and to administer nine units of Semglee (Insulin Glargine) at bedtime. Review of Resident #143's Medication Administration Record (MAR), dated March 2023, revealed staff failed to obtain ordered CBG checks on 03/19/2023. Review of a nursing Progress Note, dated 03/20/2023 at 10:57 PM, indicated Licensed Practical Nurse (LPN) #16 entered Resident #143's room to check the resident's blood glucose level and found Resident #143 standing and wobbling. When LPN #16 assisted Resident #143 to a chair, the resident began shaking and was unable to keep their eyes open. LPN #16 checked the resident's blood glucose level, which was severely elevated at 537 milligrams/deciliter (mg/dL). When checked again, the blood glucose measured 517 mg/dL. Resident #143's vital signs were noted to be unstable. Hospice services was contacted and gave orders to send the resident to an emergency department (ED). Review of an ED note, dated 03/21/2023 at 2:24 AM, revealed Resident #143 presented to an ED from the facility via emergency medical services (EMS) on 03/20/2023 due to increased altered mental status and hyperglycemia. While with EMS, the resident's blood glucose remained severely elevated (over 500 mg/dL). A review of Resident #294's FACE SHEET revealed the facility admitted the resident on 05/19/2023 with diagnoses that included Diabetes. A review of Resident #294's Physician Orders revealed orders, with date ranges of 05/23/2023-06/03/2023 and 06/03/2023-06/08/2023, for blood glucose checks three times daily. Resident #294 had a physician's order dated 05/19/2023 for . Humalog U-100 Insulin 100 unit/mL subcutaneous solution. GIVE SUB-Q [Subcutaneous] PER SLIDING SCALE ORDER 3 [three] TIMES DAILY BEFORE MEALS & BEDTIME FOR DM [Diabetes Mellitus]: 0-60=0 U [units] & [and] CALL MD [medical doctor]; 61-150=0 U; 151-200=2 u; 201-250=4 U 251-300=6 U; 301-350=8 U 351-400=10 U; >400 CALL MD/CRNP [Medical Doctor or Certified Registered Nurse Practitioner] Generic: INSULIN LISPRO . A review of Resident #294's MAR, dated May 2023 and June 2023, revealed the blood glucose checks were not completed as ordered on ten occasions on the following dates and times: -05/24/2023 at 9:00 PM -05/25/2023 at 4:30 PM -05/28/2023 at 4:30 PM -05/31/2023 at 4:30 PM -06/02/2023 at 6:30 AM -06/06/2023 at 11:00 AM and 4:00 PM -06/07/2023 at 11:00 AM and 4:00 PM -06/08/2023 at 11:00 AM During an interview on 06/02/2023 at 5:01 PM, LPN #19 indicated he checked resident MARs to determine and record which residents required blood glucose monitoring. He noted he obtained blood glucose values prior to administering insulin to residents. LPN #19 stated a MAR blank indicated the associated directive was not completed by staff. During an interview with the Director of Nursing (DON) on 06/03/2023 at 5:14 PM, she stated she expected staff to follow physician orders. During an interview with the Administrator on 06/03/2023 at 5:54 PM, he stated he expected staff to follow physician orders. He stated it was not acceptable to have blanks on medication sheets. During an interview on 06/03/2023 at 4:46 PM, the Nurse Consultant (NC) indicated she recently conducted an in-service for medication aides regarding obtaining CBGs but was not sure if there was an in-service for nursing staff. The NC indicated it was important to obtain a diabetic resident's CBG because the resident could be hypoglycemic or hyperglycemic. During an interview on 06/03/2023 at 5:20 PM, the DON indicated her expectation was for physician orders to be followed, noting if staff did not have time to pass medications or conduct monitoring tasks, the expectation was to ask for help. The DON stated that, for diabetic residents, the expectation was for the CBG to be measured and sliding scale insulin administered, if warranted. The DON identified that the importance of obtaining a CBG included recognizing severe hyperglycemia, which she noted could affect many body systems, and recognizing severe hypoglycemia, which could result from a resident receiving too much insulin. The DON reported she was not aware that medication aides were obtaining CBG values from which nurses operated. During an interview on 06/03/2023 at 6:01 PM, the Executive Director (ED) indicated his expectation was for orders to be followed as written unless changed. The ED indicated it was not acceptable to have a blank on a MAR without a valid reason, which should be documented.

Based on record review, the facility policy titled, Incidents and Accidents, and interviews, the facility failed to maintain medical records for residents that were complete and accurately documented for two (Resident #141 and Resident #106) of 27 sampled residents. Specifically, 1) the facility failed to document the administration of medications for Resident #141. 2) the facility failed to complete an incident report when Resident #106 was found on the floor on 04/18/2023. Findings included: 1) A review of Resident #141's FACE SHEET revealed the facility admitted the resident on 03/15/2023 with diagnoses that included Aftercare Following Joint Replacement Surgery, Anxiety Disorder, Hypertension, Gastro-esophageal Reflux Disease (GERD), and Hypokalemia (low potassium). A review of the five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2023, revealed Resident #141 was independent with daily decision making according to the Staff Assessment for Mental Status. The resident was independent with eating and personal hygiene; required supervision from staff with set-up help only for transfers, walking in the room or corridor, and toilet use; limited assistance of one person for bed mobility, locomotion on and off the unit; extensive assistance from staff for dressing, and the resident required physical help for part of the bathing activity. The MDS indicated the resident had a surgical wound. A review of Resident #141's Care Plan, dated 03/16/2023, indicated the resident had a surgical incision/wound related to a right total knee arthroplasty (TKA). The Care Plan instructed the staff to assess wound healing weekly, do full skin evaluations with a bath or shower, assess the skin daily with routine care, assess and treat pain if present, reduce incisional pressure with position changes, encourage good nutritional intake, and assess changes in skin status that indicate worsening of the surgical wound and notify the physician. A review of Resident #141's March 2023 Physician Orders indicated the following medications were ordered to be administered to the resident beginning 03/15/2023: - Ascorbic Acid (vitamin c) 1,000 milligram (mg) tablet, give one tablet by mouth daily for a supplement. - Cholecalciferol (vitamin D3) 25 microgram (mcg) (1,000 unit) tablet, give one tablet by mouth daily for a supplement. - Thera-M (multivitamin) 27 mg-0.4 mg tablet, give one tablet by mouth daily for a supplement. - Omega-3 Fish Oil 300 mg-1,000 mg capsule, give two capsules by mouth daily for a supplement. - Potassium Chloride ER (extended release) 8 milliequivalent (meq) tablet, give one tablet by mouth daily for a supplement. - Methocarbamol 500 mg tablet every six hours for muscle spasms. - Benefiber Sugar Free (a natural fiber) 3 grams/4 grams oral powder. Administer 10 milliliters by mouth twice daily. - Triamterene - Hydrochlorothiazide (HCTZ) 37.5- 25 mg tablet, give one tablet by mouth daily for hypertension. A review of Resident #141's March 2023 MAR [Medication Administration Record] revealed N was documented for the doses of ascorbic acid, cholecalciferol, Thera-M, Omega-3 fish oil, and potassium chloride on 03/22/2023 and 03/23/2023. In addition, an N was documented for the 8:00 AM dose of HCTZ on 03/22/2023 and there was no documentation (blank) for the 8:00 AM dose of HCTZ on 03/23/2023. Further, N was also documented for the 8:00 AM dose of Benefiber on 03/23/2023. Per the MAR, a N indicated the medication was not administered. A further review of Resident #141's March 2023 MAR [Medication Administration Record] revealed the 12:00 AM doses for methocarbamol 500 mg on 03/23/2023 and 03/24/2023 were blank, and there was no documentation the medication was administered. A review of the Administration Record and Departmental Notes notes for the month of March 2023 revealed no documented explanation about the medications not being administered. During an interview on 06/01/2023 at 3:03 PM, Registered Nurse (RN) #12 stated if there was a blank on residents' MARs, it meant either the staff person did not document it, or it was not given. During an interview on 06/02/2023 at 3:30 PM, Licensed Practical Nurse (LPN) #11 stated if there was a blank on a MAR, the medication was not given, or the staff person gave the medication but did not document that it was given. During an interview on 06/03/2023 at 9:55 AM, Unit Manager (UM) #8 stated a blank on the MAR record indicated the medication was either not given or staff did not document the medication was administered. During an interview on 06/03/2023 at 5:15 PM, the Director of Nursing (DON) stated if there were blanks on the MAR then the medication was not given. During an interview on 06/03/2023 at 5:56 PM, the Executive Director (ED) stated there should be no blanks on the MAR without a documented reason. An interview with the Nurse Consultant on 06/03/2023 at 4:36 PM revealed if there was a blank on a MAR, staff had cleared the medication so they could see what other medications needed to be administered. She stated the risk of clearing a medication was if the medication had not been given, staff would not know it still needed to be administered. She stated staff had been educated not to clear the system. 2) The facility policy titled, Incidents and Accidents, effective 11/10/2014, revealed, .An incident is an occurrence that may not be consistent with the routine operation of the facility or the routine care of a particular resident/guest. Per the policy, b) An Incident/Accident report should be completed . A review of Resident #106's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2023, revealed the facility admitted Resident #106 on 04/13/2023 with diagnoses that included Alzheimer's disease and atrial fibrillation. The Staff Assessment for Mental Status revealed Resident #106 had moderately impaired cognitive skills for daily decision making, The MDS also revealed the resident required supervision (set-up help only) with bed mobility, transfers, walking in the room and corridor, dressing, toilet use, and personal hygiene and limited assistance with bathing. The MDS further revealed the resident utilized a walker for mobility and was not steady while walking, moving on and off the toilet, and transferring from surface to surface. The MDS indicated, the resident had one fall with injury, not major since admission. A review of Resident #106's Care Plan(s), dated 04/14/2023 revealed the resident had a potential for falls related to impaired mobility, weakness, and the use of multiple medications. Interventions directed staff to assist with ambulation, toileting and mobility as needed; observe for the need for additional assistive devices; review the toileting program as needed; and encourage a clutter free environment and path to the bathroom. A review of Resident #106's Departmental Notes dated 04/18/2023 at 7:50 AM, revealed a certified nursing assistant responded to Resident #106's yell for help and found the resident on the floor in their room with a skin tear on their left elbow. Review of the resident's medical record did not reveal an incident report related to the fall the resident had on 04/18/2023. During an interview on 06/03/2023 at 8:06 AM, the Director of Nursing (DON) stated when a resident fell, the nurse should complete an incident report after assessment of the resident. During an interview on 06/03/2023 at 4:44 PM, the Nurse Consultant (NC) stated an investigation should have been completed after each fall to determine the cause or causes of the fall. During an interview on 06/0320/23 at 5:59 PM, the Executive Director (ED) stated after a fall, he expected staff to investigate and assess the resident for injury and notify the family and the physician. He stated he also expected staff to follow up and determine a root cause of the fall so that interventions could be put in place to prevent further falls. This deficiency was cited as a result of complaint/report #AL00043725.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident #300's FACE SHEET revealed the facility admitted the resident on 04/15/2022 with diagnoses that included cerebrovascular disease, vascular dementia, insomnia, and hypertensive heart failure. A review of Resident #300's Care Plan, initiated on 04/16/2022, indicated the resident was at risk for complications related to Hypertension, Diabetes, Anti-anxiety Medication Use, Anti-depressant Medication Use, and Anti-Psychotic Medication Use. The Care Plan directed staff to administer medications as ordered for diabetes, administer antianxiety medication as ordered, and administer behavior medications as ordered. A review of Resident #300's Physician Orders List revealed orders dated 04/15/2022 for the following: - Admit to Aspire [NAME] for respite care; - Trazodone 100 milligram (mg) tablet, take one tablet by mouth at bedtime for Depression - Klonopin 0.5 mg tablet, take one tablet by mouth at bedtime for Anxiety - Lorazepam 1 mg tablet, take one tablet by mouth at bedtime for Anxiety - Novolog Flexpen U-100 insulin aspart 100 units per milliliter (units/mL), give per sliding scale order three times daily before meals and at bedtime for Diabetes - Loperamide 2 mg tablet, give two tablets to equal 4 mg by mouth and one tablet by mouth after each loose stool a needed for Diarrhea - Promethazine 25 mg rectal suppository, give one suppository rectally every four to six hours as needed for nausea and vomiting - Senna-S 8.6 mg-50 mg tablet, take one tablet by mouth twice per day for constipation -Aspirin 81 mg delayed release, take one tablet by mouth daily for heart health - Donepezil 10 mg tablet, take one tablet by mouth daily for Dementia - Lactulose 10 grams per 15 milliliter (mL) oral solution, 15 mL by mouth daily for constipation - Tresiba FlexTouch U-100 insulin subcutaneous pen, inject 14 units subcutaneously daily for Diabetes - Hydrochlorothiazide 12.5 mg tablet, one tablet by mouth daily for edema - Losartan 25 mg tablet, take one tablet by mouth daily for Hypertension - Docusate Sodium 100 mg tablet, one tablet by mouth at bedtime for constipation - Diclofenac 1 percent (%) topical gel, apply 2 grams topically four times a day to affected areas as needed for pain - Hydrocodone 5 mg- acetaminophen 325 mg tablets, take one tablet every eight hours for pain - Tramadol 100 mg tablet, take one tablet every eight hours for pain - Meloxicam 7.5 mg tablet, take one tablet by mouth daily for pain - Risperidone 1 mg disintegrating tablet, take one tablet twice a day for behaviors Each medication order included a note to the pharmacy that indicated, do not send [,] FAMILY TO PROVIDE**. A review of Resident #300's April 2022 MAR [Medication Administration Record] revealed ordered medications were not administered on the following dates: - Trazodone was not administered on 04/15/2022, 04/18/2022, or 04/19/2022 - Lorazepam was not administered from 04/15/2022 to 04/19/2022 - Donepezil, Hydrochlorothiazide, Losartan, Loperamide, Promethazine, Meloxicam, Diclofenac, and Risperidone were not administered from 04/16/2022 to 04/20/2022 - Lactulose oral solution was not administered from 04/18/2022 to 04/20/2022 - Tresiba FlexTouch U-100 insulin was not administered on 04/16/2022 or 04/18/2022-04/20/2022, - Docusate Sodium was not administered on 04/18/2022 or 04/19/2022, - Senna-S 8.6mg-50 mg tablet was not administered on 04/18/2022-04/20/2022, and - Hydrocodone-Acetaminophen and tramadol were not administered on 04/16/2022 or 04/18/2022-04/20/2022. A review of a Confirmation of Receipt of Online Incident Report from the Alabama Department of Public Health Online Incident Reporting System, dated 04/21/2022, revealed the facility reported to the state agency that Resident #300's family alleged medications were not given as ordered during the resident's respite stay. A review of a Verification of Investigation, signed by the facility Executive Director (ED) on 04/27/2022, revealed Resident #300 was admitted to the facility for a five-day respite stay on 04/15/2022. The facility determined there was a misunderstanding between hospice and the facility as to who would provide the resident's medications. According to the Verification of Investigation, the family provided only the resident's Klonopin, Hydrocodone-Acetaminophen, and Insulin and, while nursing staff pulled some of the resident's ordered medications from house stock, the remaining medications were not received, as it was the facility's understanding they were not to order them from the pharmacy because the family would be providing the medications. A review of a Quality Assurance Committee Action form, dated 04/21/2022, indicated one-on-one education was completed with the nurses involved, an audit was conducted of all respite residents in the facility at the time of 04/21/2022, in-service education was provided for all licensed nursing staff regarding medication administration, sponsors were called for respite residents to attempt to obtain medications, the pharmacy and physician were contacted if a medication was not available to be given, and eight weeks of monitoring was initiated to ensure all medications were given as ordered. During an interview on 06/20/2023 at 10:57 AM, the ED of Resident #300's hospice company indicated if there was a situation where the family could not bring in medications or they did not have enough, hospice would call in the orders. The hospice Executive Director also indicated there was an occurrence with Resident #300 where hospice was not notified until day four of the resident's stay that the resident did not have all their medications. The investigation revealed there was miscommunication from the facility because the hospice policy was that family would always bring in medications for respite care. The family brought in the some of the resident's medications, but Resident #300 did not get any of the other routine medications while at the facility. During an interview on 06/23/2023 at 9:17 AM, LPN #3 indicated she remembered talking to the previous leadership team about the situation with Resident #300. She remembered that it was a big issue and said since then, a hospice nurse was required to come in with the respite resident, and the hospice nurse or the family would bring in the medications. During an interview on 06/25/2023 at 12:04 PM, the DON indicated that for respite care, the admissions office received the medications and got with the hospice nurse. Some families brought in the medications. The DON indicated her expectation was that hospice would provide a list of medications and if the family did not bring in the medications, the facility nurse needed to find out what was going on. If the family did not bring the medications in, the DON expected the pharmacy to fill the orders so the resident could have their medications. During an interview on 06/25/2023 at 12:28 PM, the facility ED indicated his expectation was for the facility to have the medications for residents on respite care and they be administered as ordered and indicated if for some reason the family did not provide the medications, they would be ordered from the pharmacy. This deficiency was cited as a result of complaint/report #AL00041888, #AL00042116, and #AL00043725 3. A review of the facility's policy titled Dressings-Clean dated 12/20/2016 revealed the purpose of the policy was To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. Each wound site should be treated individually. The policy indicated the standard was Physician's orders should specify type of wound, frequency of change, type of dressing or products to be used. A review of a FACE SHEET revealed the facility readmitted Resident #112 on 03/10/2023 with diagnoses that included Major Laceration of the Spleen, Major Laceration of the Liver, Hemoperitoneum, and Contusion of of the Colon. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/17/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS indicated the resident had a surgical wound. Review of Resident #112's care plan, dated 03/15/2023, indicated the resident had a surgical incision/wound with a goal for the resident to be free of complications related to their surgical wound. Interventions directed staff to assess changes in skin status that indicated worsening of the surgical wound and reassess the treatment plan if the wound was not healing within two to four weeks. Review of Resident #112's Departmental Notes, dated 05/15/2023 and written by a licensed practical nurse, revealed the resident visited a burn center and orthopedic doctor and new orders were received to change the dressing to the abdominal wound twice daily. Review of Resident #112's wound care orders, dated 05/15/2023, indicated the abdominal surgical wound dressing was to be changed twice daily. The order directed staff to cleanse the resident's abdominal wound bed with Vashe wound cleanser, apply Xeroform gauze to the wound bed, cover with sterile gauze, apply abdominal (ABD) pads to cover the area, and secure with Ominifix retention tape. Prior to 05/15/2023, the treatment was to be completed daily. Review of Resident #112's May 2023 TAR [Treatment Administration Record] revealed the abdominal wound dressing was to be changed daily at 8:00 AM and 8:00 PM. The TAR documentation did not indicate the wound treatment was provided at 8:00 AM on 05/28/2023, 05/30/2023 and 05/31/2023 or at 8:00 PM on 05/19/2023, 05/20/2023, 05/21/2023, 05/22/2023, 05/23/2023, 05/25/2023, 05/26/2023, 05/27/2023, 05/29/2023, 05/30/2023, and 05/31/2023. During an interview with Resident #112 on 05/30/2023 at 10:45 AM, the resident stated that their evening wound care was not always being provided. During an interview on 06/02/2023 at 5:03 PM with Registered Nurse (RN) #20, the Treatment Nurse, she stated RN #22 and Resident #112 had complained to her that evening wound care was not being provided by other nurses as ordered. During an interview with RN #22 on 06/02/2023 at 5:32 PM, she stated some staff would conduct wound care and some would not. During an interview with Unit Manager #8 on 06/03/2023 at 10:08 AM, she stated the nurses assigned to provide the resident's care were supposed to complete the wound treatment if the wound treatment nurses were not working. She noted that wound treatment nurses worked during the day shift Monday through Friday. During an interview with the Nurse Consultant on 06/03/2023 at 4:36 PM, she stated she knew Resident #112's wounds treatments were not being performed. She said risks associated with wound care not being completed included infection. She stated she expected the staff to provide the wound care as ordered. During an interview with the Director of Nursing on 06/03/2023 at 5:14 PM, she stated she expected staff to follow physician's orders and provide wound care as ordered. She stated she was not aware Resident #112's wound care was not being completed until that week. She stated not conducting wound care as ordered put the resident at risk for infection. During an interview with the Executive Director (ED) on 06/03/2023 at 5:10 PM, he indicated that there was no policy related to following physician orders and stated it was a standard of practice. During a follow up interview with the ED on 06/03/2023 at 5:54 PM, he stated he expected staff to provide wound care as ordered. He stated he was not aware the wound care was not being conducted for Resident #112. He stated the risks associated with wound care not being conducted included worsening of the wound. Based on interviews, record review, and facility document and policy review, it was determined the facility failed to provide care and treatment in accordance with professional standards of practice to meet the needs of five (Residents #98, #141, #454, #112, and #300) of 50 sampled residents. Specifically, the facility failed to: 1. Obtain orders for the care and monitoring of a peripherally inserted central catheter (PICC) line for Resident #98; 2. Transcribe orders for care of a surgical wound for Resident #141; 3. Ensure care of a surgical wound was completed as ordered for Resident #112; and 4. Ensure coordination between the facility and Resident #300's hospice provider regarding who would provide the resident's medications while in the facility for respite care (generally a short-term temporary admission, usually for residents receiving hospice benefits). As a result, Resident #300 did not receive their medications as ordered by a physician. Findings included: 1. A review of a FACE SHEET indicated the facility admitted Resident #98 on 05/03/2023 with diagnoses that included Orthopedic Aftercare Following the Surgical Amputation of the Right Leg Above the Knee. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/10/2023, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required supervision from staff with all activities of daily living (ADLs). Review of Resident #98's care plan, initiated 05/04/2023, indicated a potential for complications related to a central line (right double lumen PICC line). Interventions instructed staff to clean the central line site as ordered, observe for signs of infection, flush the central line as ordered, and notify the physician if staff were unable to flush the port. During an interview on 05/30/2023 at 12:29 PM, Resident #98 confirmed they had a PICC line and wanted it removed before they were discharged that day. A review of a Departmental Note, dated 05/03/2023, indicated Resident #98 arrived at the facility via ambulance and had a right double lumen PICC line. The note indicated the dressing was last changed on 04/29/2023. Further review of the Departmental Notes revealed no further documentation of the PICC line. A review of Resident #98's May 2023 Physician Orders revealed no orders to monitor or flush the PICC line nor to change the dressing. A review of Resident #98's May 2023 MAR [Medication Administration Record] revealed no directions for staff to monitor the PICC line and no documentation of the PICC line being flushed or the dressing being changed. During an interview on 06/03/2023 at 9:55 AM, Unit Manager #8 stated Resident #98 did have a PICC line, but it was not being used for anything while at the facility. She stated she had completed dressing changes and flushed the PICC line. During an interview on 06/03/2023 at 10:25 AM, the Director of Nursing (DON) stated the PICC line was not used for the resident while they were at the facility, but the DON was having trouble locating documentation regarding the PICC line. During an interview on 06/03/2023 at 5:56 PM, the Executive Director stated he expected the staff to provide whatever care was necessary for a PICC line. 2. A review of Resident #141's FACE SHEET revealed the facility admitted the resident on 03/15/2023 with diagnoses that Included Aftercare Following Joint Replacement Surgery, Presence of a Right Artificial Knee Joint, Obesity, Anxiety Disorder, Hypertension, Gastro-esophageal Reflux Disease (GERD), and Hypokalemia (low potassium). Resident #141 was discharged on 03/24/2023. A review of a five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2023, revealed Resident #141 was independent with daily decision making according to a Staff Assessment for Mental Status (SAMS). Per the MDS, the resident was independent with eating and personal hygiene; required supervision from staff with set-up help only for transfers, walking in the room or corridor, and toilet use; limited assistance of one person for bed mobility, locomotion on and off the unit; extensive assistance from staff for dressing, and physical help for part of the bathing activity. The MDS indicated the resident had a surgical wound. A review of Resident #141's Care Plan, dated 03/16/2023, indicated the resident had a surgical incision/wound related to a right total knee arthroplasty (TKA). The Care Plan instructed the staff to assess wound healing weekly, do full skin evaluations with a bath or shower, assess the skin daily with routine care, assess and treat pain if present, reduce incisional pressure with position changes, encourage good nutritional intake, and assess changes in skin status that indicated worsening of the surgical wound and notify the physician. A review of a Patient Transfer Form from the discharging hospital, dated 03/15/2023, indicated Resident #141 had a right total knee arthroplasty (TKA or knee replacement) on 03/13/2023 with recommendations to change the silver dressing to the right knee every seven days. A review of an admission Checklist, dated 03/15/2023, indicated wound care was a need for Resident #141. A review Resident #141's Nursing admission Review, dated 03/15/2023, revealed it was incomplete. The Skin Integrity section of the assessment was not completed. A review of Resident #141's Physician Orders for the month of March 2023 revealed no wound care or treatment orders for the surgical wound to the resident's right knee. A review of Resident #141's MAR [Medication Administration Record] revealed no directions or orders for the treatment of the surgical wound to the resident's right knee. A review of Departmental Notes for the timeframe from 03/15/2023 through 03/23/2023 revealed no documentation regarding the resident's skin integrity, appearance of the incision to the right knee, or treatment to the surgical wound being provided. During an interview on 06/03/2023 at 9:55 AM, Unit Manager #8 stated medical records staff entered admission orders into the computer. She stated once a resident arrived, a nurse reviewed paperwork sent with the resident from the hospital and compared it with what was in the computer. She stated usually when a resident came with a dressing to a surgical wound, there were orders to leave the dressing in place for at least seven days. She stated if the resident had a surgical wound and had no physician orders to treat the wound, she would notify the wound nurse and the wound nurse would assess the resident and obtain orders. During an interview on 06/03/2023 at 5:15 PM, the Director of Nursing (DON) stated the admissions staff person received orders from the hospital and then sent them out to the different departments. She stated the medical records staff was also a nurse and entered orders in the computer. She stated the next day, staff reviewed all hospital orders to ensure they captured everything. The DON stated an admission body audit should be completed and the wound nurse should be notified of skin issues so the wound nurse could also assess and obtain physician orders. The DON noted she did not work at the facility during the time Resident #141 was at the facility and could not comment on why treatment orders were not entered for the surgical wound to the resident's right knee. During an interview on 06/03/2023 at 5:56 PM, the Executive Director stated when a resident was admitted to the facility, medical records staff entered the orders the facility received from the referral source. He stated he did not know whether the orders were verified by the physician or by another nurse. He stated he expected orders to be transcribed correctly, timely, and followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of a policy titled Perineal Care, the facility failed to ensure a Certified Nursing Assistant (CNA), changed her gloves during incontinent care before placing the clean brief for Resident Identifier (RI) #9. This affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy Perineal Care with an effective date of 10/1/2010, revealed: PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdowns. RI #9 was admitted to the facility on [DATE] with a diagnosis of Personal History of Urinary Tract Infections. On 3/18/21 at 3:08 PM, Employee Identifier (EI) #4, CNA, entered RI #9's room for the provision of incontinent care. EI #4 lowered the head of the bed, explained the procedure, washed her hands and donned gloves. EI #4 removed the soiled brief and provided the perineal care. EI #4 placed and secured the clean brief with the same gloves she used to clean RI #9. On 3/18/21 at 3:41 PM, an interview was conducted with EI #4. EI #4 was asked, when should the staff providing incontinent care change gloves. EI #4 replied, if the gloves get soiled. EI #4 was asked, when should staff providing incontinent care wash or sanitize their hands. EI #4 replied, before and after providing the care. EI #4 was asked, when did she change gloves and wash her hands while providing incontinent care to RI #9. EI #4 replied, she washed her hands before providing the care and washed them after providing the care; she replied she did not change gloves. On 3/18/21 at 7:02 PM, an interview was conducted with EI #1, Director of Nursing (DON). EI #1 was asked, how were CNAs trained to perform incontinent care. EI #1 replied, they were trained in class, in-serviced, and check offs. EI #1 was asked, when should staff change gloves while providing incontinent care. EI #1 replied, they should put on the gloves before providing the incontinent care, after discarding the soiled brief their gloves should be changed, and after applying the clean brief they should remove their gloves. EI #1 was asked, when should staff providing incontinent care not change gloves after removing a wet brief and before applying the clean brief. EI #1 replied, never.

Based on observations, interviews and review of facility policies, titled Leftover Food Storage and Use, Food Storage Temperature Logs, FOOD STORAGE TEMPERATURE LOG,' and Food from Families and Friends, the facility failed to ensure: 1. food in the kitchen freezer was labeled with an open and use by date, 2. PM temperatures were logged on 3/17/21 for the resident's supplement refrigerator on the 400 hall, and, 3. food item in the resident's supplement freezer was labeled. This had the potential to affect 73 of 73 residents who received meals from the kitchen and 30 residents who had the potential to utilize the supplement refrigerator on the 400 hall. Findings Include: 1. A review of a facility policy titled, Leftover Food Storage and Use with an Effective date of Sept. 12, 2019 revealed . Purpose: To Assure that food borne illnesses are avoided.PROCESS: . b. Leftover foods should be covered, labeled and dated. On 3/16/21 at 12:47 PM a tour of the facility kitchen was conducted with Employee Identifier (EI) #2, Dietary Manager (DM). The walk in freezer was observed to have three medium packages of meat with no date on them or label identifying what the package of meat was. EI #2 said it was meat loaf; it did not look like meatloaf. On 3/18/21 at 2:54 PM an interview was conducted with EI #2. EI #2 was asked what was in the walk in freezer with no label on it and with no use by date. EI #2 replied, meat loaf. EI #2 was asked who was responsible for labeling food items in the walk in freezer. EI #2 replied, who ever was putting the product in the unit. EI #2 was asked when should food be labeled when placing them in the freezer. EI #2 replied, immediately, before you put them in. EI #2 was asked how should food items be labeled when placing them in the freezer. EI #2 replied, with a date and the name of the food. EI #2 was asked what did the facility policy say regarding labeling food items in the kitchen freezer. EI #2 replied, to make sure it was labeled with a date. EI #2 was asked why was it important to label food items in the kitchen freezer. EI #2 replied, so they will know when it went in and how old it was. EI #2 was asked was all four package of food/meat loaf labeled. EI #2 replied, only one was. On 3/18/2021 at 3:09 PM, an interview was conducted with EI #3 Clinical Dietary Manager (CDM). EI #3 was asked what was the facility policy on labeling items in the kitchen freezer. EI #3 replied, label and date all items. EI #3 was asked should all items in the walk in freezer be labeled. EI #3 replied, all opened items. EI #3 was asked who was responsible for labeling items in the walk in freezer. EI #3 replied, whomever put them in there. EI #3 was asked why should food items be labeled in the walk in freezer. EI #3 replied, so they know what it was and how long it had been there. EI #3 was asked when should left over food items be labeled. EI #3 replied, when they put them in there. EI #3 was asked if there were four items of meatloaf in the freezer should they all be labeled. EI #3 replied, yes. 2. A review of a policy titled, Food Storage Temperature Logs with an effective Date: August 10, 2018 reveal . PURPOSE: In order to prevent food borne illnesses, foods should be stored at proper temperature. STANDARD: The FDA Food Code Guidelines should be used for the storage of food items. Temperature should be monitored and recorded on a food temperature log. PROCESS: a. The FNS (Food Nutrition Service) Manager, or designee, should check food storage temperatures twice daily; at the open and close of the kitchen . A review of a document titled, FOOD STORAGE TEMPERATURE LOG with a date of March 2021 revealed on the March 17 date section the PM temperature for the Refrigerator and Freezer section was blank. On 3/18/21 10:18 AM, the surveyor observed the unit 4, 400 hall resident's refrigerator. The temperature log for 3/17/21, PM temperatures for the refrigerator and freezer was missing. On 3/18/21 at 3:04 PM an interview was conducted with EI #2, DM. EI #2 was asked who was responsible for taking temperatures or the resident's supplement refrigerator and freezer. EI #2 replied, they were, the kitchen staff. EI #2 was asked who was responsible for documenting the PM temperatures of the resident's supplement refrigerator and freezer on 3/17. EI #2 replied, he was because he was there that night. EI #2 was asked why were the temperatures for the PM shift on 3/17 not documented for the refrigerator and freezer. EI #2 replied, because there was no sheet on the refrigerator. EI #2 continued to say he made a note and put it in his pocket and it was his intention to put it on a new sheet the next day. EI #2 was asked what did the facility policy say about documenting the temperatures of the resident's supplement refrigerator and freezer. EI #2 replied, document through out the day, their policy document AM and PM. EI #2 was asked why was it important to document the temperatures of the resident's supplement refrigerator. EI #2 replied, so they would know if the refrigerator was down and things had a chance to spoil. EI #2 was asked why did he not get a new log sheet and write the temperatures on it. EI #2 replied, it was his intention to come in that morning and do it. On 3/18/21 at 3:09 PM , an interview was conducted with EI #3, CDM. EI #3 was asked, what was the PM temperatures for the resident's refrigerator and freezer log on 3/17. EI #3 replied, it was not logged. EI #3 was asked who initialed the PM temperatures for the refrigerator and freezer on 3/17. EI #3 replied, no one, it was not logged. EI #3 was asked who was responsible for taking PM temperatures in the resident refrigerator and freezer. EI #3 replied, whoever worked the unit that night that shift. EI #3 was asked, what was the facility policy on taking temperatures in the resident's refrigerator and freezer. EI #3 replied, take temperatures twice a day AM and PM. EI #3 was asked, who was responsible for documenting the temperatures for the resident's supplement freezer and refrigerator. EI #3 replied, whoever was working the unit for that shift. EI #3 was asked why was it important to document the temperatures of the resident's supplement refrigerator and freezer. EI #3 replied, to be sure it was working properly and the food was stored at the right temperature. EI #3 was asked what hall was the refrigerator located on. EI #3 replied, the 400 hall. EI #3 was asked what was the writing on the 18, 20 and 21. EI #3 replied, it looked like temperatures that were scratched out. EI #3 replied, she was not sure why they were down there. 3. A review of a Policy titled, Foods from Families and Friends with an effective date of November 28, 2016 revealed . PURPOSE: To preserve the resident /guest (s) right to receive gifts of food from family and friends, while reducing the potential for food borne illnesses. STANDARD: Foods brought into the facility from outside sources, for resident/ guest (s), should not be stored in the Food & Nutrition /Service Department. PROCESS: b. If food is to be stored, it should be labeled with resident/guest (s) name, dated . On 3/18/21 at 10:11 AM on top of the 300 hall refrigerator freezer, there was peppermint crunch frozen Greek Yogurt 3.5 FL (fluid) oz (ounce) bars four per box noted. There was no name on the box indicating who the bars belonged to. There were two bars left in the box. On 3/18/21 3:09 PM an interview was conducted with EI #3. EI #3 was asked what was in the resident's refrigerator freezer with no label on it. EI #3 replied, frozen yogurt popsicles. EI #3 was asked, who did it belong to. EI #3 replied, she did not have any idea. EI #3 was asked, what was the facility policy for labeling items in the resident's supplement freezer. EI #3 replied, all items should be labeled with date and the resident name. EI #3 was asked, who was responsible for labeling items in the resident's supplement refrigerator/freezer. EI #3 replied, whoever puts it in there. EI #3 was asked, why was it important to label items in the resident's supplement refrigerator/freezer. EI #3 replied, so they would know who it belonged to and how long it had been there.

Based on record review, interview, and review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, the facility failed to ensure the required signatures were on nine of nine Non-Controlled Record of Medication Destruction Sheets for the month of February, 2020. This affected one of five months of Non-Controlled Medication Destruction Records reviewed. Findings Include: Review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, dated 3/2011, revealed: . 3. The registered nurse and/or pharmacist witnessing the destruction ., ensures that the following information is entered on the Record of Medication Destruction form . J. Signature of witnesses, two witnesses required for non-controlled substances . in the designated areas on the destruction form. On 02/13/20 at 9:41 a.m., the surveyor reviewed the facility's Non-Controlled Drug Destruction Book. A review of the February 2020, Non-Controlled Medication Destruction Sheets, revealed nine of nine sheets dated 02/06/2020, did not contain required two signatures. On 02/13/20 at 5:09 p.m., an interview was conducted with Employee Identifier (EI) #1, Registered Nurse (RN), Director of Nursing (DON). EI #1 was asked, how many signatures were required for non-controlled medication destruction. EI #1 said, two. EI #1 was asked, how many signatures were on the nine pages dated 02/06/20. EI #1 replied one. EI #1 was asked why there was only one signature. EI #1 stated it just was not done. EI #1 was asked what was the concern with not having the required number of signatures for medication destruction. EI #1 answered that was how they verified what they were destroying to make sure they were destroyed.

Based on observation, interview, and review of the facility policy titled Food Receipt and Storage and the 2017 FDA Food Code, the facility failed to ensure: 1. staff placed a large pan of frozen crab cake meat on the shelf, off of the floor in the walk in freezer; 2. food items in the walk-in freezer and reach-in freezer were sealed; and 3. a dented can of baked beans was removed from active service storage. This had the potential to affect 106 out of 106 residents receiving meals from the kitchen. Findings include: A review of the facility policy titled, Food Receipt and Storage, with an effective date of August 23, 2017 revealed: .Purpose: Foods should be received and stored properly . Standard: Foods should be . stored in accordance with FDA Food Code recommendations. Process: . II. Storage of Foods: . c. Items . should be kept at least 6 inches from the floor. f. Place dented, . cans, . in a separate area . k. Open food items should be covered, . A review of the 2017 FDA Food Code page 80 revealed, . 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, Food shall be protected from contamination by storing the food: . (2) Where it is not exposed to splash, dust, or other contamination; . page 402 . it is also critical to monitor food products to ensure that . they do not fall victim to conditions that endanger their safety, . dented cans may also present a serious potential hazard. page 430 Preventing Contamination from the Premises 3-305.11 Food Storage . Pathogens can contaminate and/or grow in food that is not stored properly. On 02/11/2020 at 02:00 p.m., the initial tour of the kitchen was conducted with Employee Identifier (EI) #2, the Chef. On 2/11/2020 at 02:18 pm, during observation of the walk-in freezer, a large pan of food was noted under the bottom shelf, on the floor of the freezer. EI #2 was asked what was in the pan. EI #2 replied it was a pan of crab cake meat. EI #2 was asked why he placed the pan of crab cake meat on the floor. EI #2 stated he placed it there in a hurry due to the truck coming in and forgot to move it to the shelf. EI #2 was then asked, what he should have done with the pan. EI #2 replied he should have put it on the shelf. On 02/11/2020 at 2:00 p.m., during the initial tour of the kitchen, the surveyor observed a rolling rack with large can items. EI #2 was asked if the can items on the rack were the can food items that would be served to the residents. EI #2 stated yes. The surveyor observed a large can of baked beans to have a dent at the top of the can near the seam. EI #2 was asked what was the concern with the large can of baked beans. EI #2 replied it had a dent in it. EI #2 was asked what they did with dented cans. EI #2 stated that they would remove them. EI #2 was asked if they should serve food items from a dented can and EI #2 stated no. Also during the initial tour of the kitchen. an observation of the reach-in freezer was made. Noted was a box of frozen pureed bacon, in an opened/unsealed plastic bag, inside an unsealed box. A box containing 6 premade pizzas, single serve size, in an unsealed bag inside the unsealed box was also observed. EI #2 was asked, what would be the concern with unsealed food items in the freezer. EI #2 replied, freezer burn. EI #2 was asked what that would affect. EI #2 stated it would affect the palatability of the food. EI #2 was asked who was responsible for ensuring the food stayed sealed. EI #2 stated it would be the responsibility of everyone in the kitchen that had access to the freezers. EI #2 was asked if the food items noted in the freezers were sealed and EI #2 replied no. EI #2 was then asked why the food items in the freezers were left unsealed. EI #2 stated that in the reach in freezer, during the day they are in a hurry and at the end of the evening shift the items get sealed in the reach in, but there was no excuse for the walk-in freezer. EI #2 was then asked how the food items should have been sealed. EI #2 replied the food items should have been wrapped, the plastic should have been closed.