**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to assess if it was safe for one nonsampled resident (Resident 56) to self-administer the medications. * The facility failed to assess and develope a plan of care to address the self-administration of the medications when Resident 56 had a bottle of Flax Seed Oil (supplement) and Omegas + Tumeric (supplement) at the bedside. This failure had the potential for Resident 56 to administer the medications inaccurately and negatively affect the Resident 56's well-being. Findings: Review of the facility's P&P titled Medication Self-Administration dated 1/2017 showed the following: - Residents have the right to self-administer medications if the interdisciplinary team (IDT), determines that this practice is clinically appropriate; - On admission or shortly thereafter, each resident will be assessed to determine if they want to self-administer their medications; - It is the responsibility of the IDT to determine if its is safe for the resident to self-administer drugs before the resident may exercise that right. The IDT must determine whether the resident or the nursing staff will be responsible for storage and documentation of the administration of the medications, as well as the location where the medications will be administered. These determinations should appear on the resident's comprehensive plan of care; and - The determination of whether it is safe for the resident to self-administer medications should be completed within seven days of the completion of the resident's comprehensive assessment. On 1/21/25 at 1007 hours, a concurrent observation and interview was conducted with Resident 56. A bottle of Flax Seed Oil and Omegas + Tumeric were observed at Resident 56's bedside. Resident 56 stated she had taken one capsule of Flax Seed and one capsule of Omegas with Tumeric medications twice a day as her supplements. Resident 56 stated she had been self-administering the supplements since she was admitted to the facility. Medical record review for Resident 56 was initiated on 1/22/25. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's H&P examination dated 8/9/24, showed Resident 56 had the capacity to understand and make decisions. Review of Resident 56's MDS dated [DATE], showed Resident 56's BIMS score was 15 (cognitively intact). Review of Resident 56's Order Summary Report dated 12/31/24, failed to show a physician's order for the Flax Seed Oil one capsule and Omegas + Tumeric one capsule twice a day and to allow Resident 56 to self-administer the medications. Review of Resident 56's Plan of Care failed to show a care plan problem was developed to address Resident 56's self-administration of the Flax Seed Oil and Omega + Tumeric medications. On 1/21/23 at 1517 hours, a concurrent observation and interview for Resident 56 was conducted with LVN 4. LVN 4 verified Resident 56 had a bottle of Flax Seed Oil and Omegas + Tumeric at the bedside. LVN 4 verified there was no physician's order for the use of the medications, and Resident 56 should not have the medications at the bedside. On 1/23/25 at 1457 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated any resident who requested to self-administer medications should be assessed by the MDS nurse then approved by the physician. The DON verified Resident 56 had no physician's order, assessment, and care plan problem addressing Resident 56's self-administration of the medications. On 1/27/25 1400 at hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 24 final sampled residents (Resident 106) received a Level II mental health evaluation, after a Level 1 Screening was positive for serious mental illness, for one of three final sampled residents, reviewed for PASRR. This failure posed the risk for Resident 106 not receiving specialized services beneficial to the resident's wellbeing. Findings: Medical record review for Resident 106 was initiated on 1/21/25. Resident 106 was discharged from Acute Care Hospital 1 on 11/19/24, and then admitted to the facility on [DATE]. Review of Resident 106's Level 1 PASRR screening (completed at Acute Care Hospital 1) dated 11/18/24, showed Resident 106 was positive for serious mental illness and a Level II mental health evaluation referral was required. Review of Resident 106's Unable to Complete Level II Evaluation for Serious Mental Illness dated 11/18/24, showed a Level II Mental Health Evaluation was not scheduled for the following reason: Resident 106 was discharged from the facility (Acute Care Hospital 1). The case is now closed. To reopen, the facility must submit another screening. On 1/23/25 at 1037 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked if the California Department of Health Care Services Level II evaluators were aware Resident 106 currently resided in the facility. RN 1 reviewed Resident 106's medical record and verified there was no documentation showing the California Department of Health Care Service Level II evaluators were aware of Resident 106's admission to the facility. RN 1 stated status post admission to the facility, the facility should have completed another PASRR Level 1 screening to ensure (if needed) Resident 106 received a Level II Mental Health Evaluation, to determine if Resident 106 could benefit from specialized services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical records, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 28 and 53) reviewed for PASRR were accurately screened. * The facility failed to ensure Residents 28 and 53 PASRR screenings were completed by the appropriate facility staff member. In addition, the facility failed to verify with DHCS when Resident 53's PASRR Level 1 screening was closed due to the facility staff not responding to two or more separate attempts of communication by DHCS. These failures posed the risk for Residents 28 and 53 not properly screened, and the risk to not receive adequate level of services, comprehensive assessment, intervention and evaluation for conditions related to Residents 28 and 53's mental disorder. Findings: 1. According to https://www.dhcs.ca.gov/services/MH/Pages/PASRR_faq_level1.aspx: -It is the facility's responsibility to designate a qualified staff that can complete Level 1 screenings. The facility staff must have knowledge of medical terminology, knowledge related to the medical/ behavioral history and current status of the individual, and met the individual or individual's family/ conservator and be directly involved in the individual's care; and - Under the Resolutions on Level 1 Case list section, showed the different types of resolutions included L1 - Categorical Review, which meant the case is with DHCS for further review. If the individual cannot benefit from specialized mental health services, a Categorical Letter will be available after the review has been completed. Review of the facility's P&P titled PASRR (Preadmission Screening Resident Review) revised 3/2019 showed the following: -A tentative result of either negative or positive will appear on the Level 1 screening after it has been submitted online. A tentative resolution of Level 1 - Categorical Review may also appear. The facility should periodically review the status until it reaches the closed status; and -If the results of the Level 1 Screening indicate Categorical Review, the Level 1 Screening will be submitted to DHCS for further review. The Level 1 Case List should be reviewed periodically online until the case is resolved. Medical record review for Resident 53 was initiated on 1/26/25. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's PASRR Level 1 Screening dated 8/6/24, showed the Business Office Manager completed the screening. Further review of the PASSR showed an L1 - Categorical Review resolution. Review of the Notice of Attempted Evaluation letter from DHCS dated 8/6/24, showed unable to complete Level II evaluation for serious mental illness, and SMI Level II Mental Health Evaluation was not scheduled for the following reason: facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level 1 Screening. The case is now closed. To reopen, the facility must resubmit a new Level I Screening. Further review of Resident 53's medical record failed to show a documented evidence a follow-up call or inquiry was sent to DHCS, nor a new Level 1 Screening was submitted. 2. Medical record review for Resident 28 was initiated on 1/26/25. Resident 28 was readmitted to the facility on [DATE]. Review of Resident 28's PASRR Level 1 Screening dated 12/5/23, showed the Business Office Manager completed the screening. On 1/24/25 at 1043 hours, an interview and concurrent medical record review for Residents 28 and 53 was conducted with RN 1. RN 1 verified the PASSR screenings forms for Resident 28 and 53 showed the Business Office Manager completed the form. RN 1 stated only the Business Office Manager's computer had the access to the PASSR website, so the nurses used the Business Office Manager's computer access to complete the PASSR screening. When asked regarding completion of Resident 53's Level 1 screening as stated in the DHCS letter, RN 1 verified Resident 53's Level 1 screening was for categorical review, and a letter was sent by the DHCS showing the screening was not completed because the facility staff was unresponsive after two or more attempts of communication 48 hours after the Level 1 screening. RN 1 could not find documented evidence the DHCS letter was followed up or a new PASSR Level 1 screening was submitted for Resident 53.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary services as ordered by the physician for one of one sampled resident reviewed for physician's consult (final sampled resident, Resident 82). * The facility failed to ensure the dermatology consult was provided to Resident 82 as ordered. This failure had the potential for the resident not to receive the necessary care and services. Findings: During the initial tour of the facility on 1/21/25 at 0905 hours, Resident 82 was observed awake and lying in bed. Resident 82's left forearm was observed with an intact foam dressing. Resident 82 stated he had a wound in his left forearm, and he was getting treatment for it. Medical record review for Resident 82 was initiated on 1/23/25. Resident 82 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 82's H&P examination dated 7/3/24, showed Resident 82 had no capacity to understand and make decisions. Review of Resident 82's Order Summary Report showed the following: - a physician's order dated 11/25/24, for dermatology consult with Physician 1 on 12/9/24 at 1530 hours; and - a physician's order dated 12/15/24, to cleanse left forearm open lesion with normal saline solution, pat dry, and cover with foam dressing every day for 30 days and was reordered on 1/14/25. Review of Resident 82's Care Plan initiated 11/15/24, showed a care plan problem addressing Resident 82's left forearm open lesion. The approach plans included a dermatology consult per the physician's order. Review of Resident 82's Non-Pressure Skin Condition Report dated 1/20/25, showed the left forearm lesion's size was decreased from 1.5 cm (length) x 1.5 cm (width) to 1.4 cm (length) x 1.4 cm (width), wound bed was pink, no drainage, and no odor. Further review of Resident 82's medical record failed to show documented evidence Resident 82's was seen by Physician 1 for a dermatology consult. On 1/23/25 at 1030 hours, a concurrent interview and medical record review was conducted with LVN 5. LVN 5 stated the facility requested a wrong transportation for Resident 82 on 12/9/24. LVN 5 stated a regular car was requested for Resident 82 instead of a van transportation. LVN 5 stated Resident 82 was wheelchair bound. LVN 5 further stated Resident 82 ended up not leaving the facility on 12/9/24. LVN 5 verified the dermatology consult for Resident 82 was not rescheduled. On 1/23/25 at 1108 hours, a telephone conversation was conducted with the Doctor's Clinic Medical Assistant. The Doctor's Clinic Medical Assistant verified Resident 82 had an appointment scheduled with Physician 1 on 12/9/24 at 1530 hours, but Resident 82 did not show up. The Doctor's Clinic Medical Assistant further stated Resident 82 did not have any new appointment scheduled with Physician 1 after that. On 1/23/25 at 1445 hours, a concurrent interview and medical record review was conducted with RN 3. RN 3 stated the licensed nurses should schedule the physician's appointment when an order was received and if the resident had no family member who could bring the resident to a physician's appointment, the facility will coordinate with the transportation. RN 3 stated if the resident missed the scheduled physician's appointment, the licensed nurses should make a new appointment for the resident and any follow up regarding this should be documented. RN 3 further stated the resident could not miss any physician's appointment. RN 3 verified there was no follow up done regarding Resident 82's dermatology consult. On 1/27/24 at 1445 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 82.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview, and facility P&P review, the facility failed to provide the necessary restorative nursing services for one of three final sampled resident (Resident 53) reviewed for positioning and mobility. * The facility failed to ensure Resident 53 was applied carrot splint to both hands, and AFO to both feet for four hours as tolerated, per the physician's order. This failure had the potential for Resident 53's hand and foot contractures to worsen. Findings: Review of the facility's P&P titled Splint Application revised date 5/2017 showed the following: -It is the policy of the facility that splints be applied correctly to maintain the resident's range of motion and prevent contractures and further loss of range of motion; -Once the orthosis is received, the RNA is responsible of the application and removal of the splint; and -The splint is usually left in place for six days a week for a period of two hours per day, as tolerated. On 1/21/25 at 0948 hours, during the initial tour of the facility, Resident 53 was observed in bed, and both hands were observed contracted. There were no splints observed to both hands. Resident 53 was observed with splints to both feet. Medical record review for Resident 53 was initiated on 1/21/25. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's MDS dated [DATE], showed Resident 53 had severe cognitive impairment, dependent to facility staff member assistance for self-care and mobility, and had impairment on upper and lower extremities. Review of Resident 53's Order Summary Report showed the following physician's orders dated 6/11/24: - RNA to apply left AFO splint for five days per week for four hours as tolerated; - RNA to apply left hand carrot splint for five days per week for hours as tolerated; - RNA to apply right AFO splint for five days per week for hours as tolerated; and - RNA to apply right hand carrot splint for four hours as tolerated. On 1/22/25 at 1214 and 1545 hours, Resident 53 was observed in bed, and with rolled towels were observed on both hands. On 1/23/25 at 0833 hours, Resident 53 was observed in bed, and with the carrot splints on both hands. On 1/23/25 at 1021 hours, an interview and concurrent medical record review for Resident 53 was conducted with RNA 1. RNA 1 stated the restorative nursing department was responsible for applying and removing the splints. RNA 1 stated they document the application of the splint in the Restorative Nursing form. Review of Resident 53's Restorative Nursing form for January 2025 showed Resident 53 was applied with the carrot splint on both hands, and AFO on both feet for two minutes daily for five days per week. RNA 1 verified the above findings. RNA 1 stated they only documented the number of minutes spent in the application of the splint, and not the number of hours Resident 53 had the splints on. RNA 1 failed to show documented evidence of how many hours Resident 53 had the carrot splints on both hands, and the AFO on both feet. On 1/27/25 at 0955 hours, an interview and concurrent medical record review for Resident 53 was conducted with the DON. The DON verified the above findings. The DON stated the RNAs should be documenting the number of hours Resident 53 had the carrot splint on both hands, and the AFO on both feet to know if the resident tolerated the splints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 28) reviewed for elopement was free from accident hazards. * The facility failed to document Resident 28's wandering and/or exit-seeking behaviors and failed to conduct her elopement assessment accurately. Resident 28 was not assessed to be a high risk for elopement; however, the facility staff had observations of the resident verbalizing she wanted to go home or she wanted to leave the facility with her daughter, wandering around the facility, episodes of going outside the facility, and standing by the locked front door to wait for her daughter so she could leave the facility. In addition, the facility failed to provide Resident 28 with an ID bracelet as per the elopement assessment plan. This failure had the potential to not follow the elopement protocol for Resident 28, and the risk for Resident 28 to not be identified immediately and could result to a delay to locate what facility Resident 28 belonged to in an elopement incident. Findings: Review of the facility's P&P titled Wandering/ Exit-Seeking Behavior revised 9/2019 showed the following: - The facility will evaluate residents for wandering and/or exit-seeking behavior and implement appropriate interventions as indicated via the evaluation process; and - If the resident exhibits wandering and/or exit-seeking behavior, the episodes should be documented in the progress notes of the medical record. Documentation should include interventions used and their effectiveness. On 1/21/25 at 0934 hours, during the initial tour of the facility, Resident 28 was observed in bed. Resident 28 was not observed with an ID bracelet. On 1/21/25 at 0936 hours, an interview was conducted with CNA 3. CNA 3 stated she was assigned to care for Resident 28. CNA 3 stated Resident 28 could get up by herself, and she wandered in the facility, and goes outside the facility. Medical record review for Resident 28 was initiated on 1/21/25. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's H&P examination dated 11/7/24, showed the resident had no capacity to understand and make decision. Review of Resident 28's Elopement Risk assessment dated [DATE], showed a score of 17 or higher is considered high risk for elopement. Resident 28 was assessed with no history of elopement and has accepted placement or a new admit, and had a score of 16. The assessment showed the plan for the resident was to have an ID bracelet, and the staff members were aware of the resident's risk. Review of Resident 28's plan of care failed to show a care plan problem to address the resident's risk for elopement. Review of Resident 28's medical record did not show documentation of Resident 28's wandering around the facility and episodes of going outside the facility. On 1/24/25 at 0847 hours, Resident 28 was observed in bed. Resident 28 was not observed with an ID bracelet. On 1/24/25 at 0902 hours, an interview for Resident 28 was conducted with CNA 6. CNA 6 stated Resident 28 wanted to get out of the facility, and the resident would often say she was leaving, and wanted to go outside with her daughter. CNA 6 stated Resident 28 had tried to leave the facility about a month ago, but she never got out, because the resident had always someone to get her back to her room. CNA 6 stated Resident 28 had a bracelet, and a Wander Guard. On 1/24/25 at 0915 hours, observation for Resident 28 and concurrent interview was conducted with CNA 6. Resident 28 was observed in bed. Resident 28 was not observed with an ID bracelet nor a Wander Guard. On 1/24/25 at 1033 hours, a follow-up interview was conducted with CNA 6. CNA 6 stated she spoke to the DSD about Resident 28, and per the DSD, Resident 28 did not have an ID bracelet because the resident refused, and it has been care planned. On 1/24/25 at 1034 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 stated Resident 28 had wandered around the facility, and stood by the front door at times. RN 1 verified there was no documentation Resident 28's wandering around the facility, behavior of verbalizing her desire to go home or to leave the facility with her daughter, nor her behavior of going to the locked front door to wait for her daughter so she could leave the facility. RN 1 also verified there was no documentation Resident 28 was provided with an ID bracelet nor a documentation to show Resident 28 had refused or had taken off her ID bracelet. RN 1 also verified there was no care plan developed when Resident 28 was non-compliant with her ID bracelet. On 1/24/25 at 1307 hours, an interview and concurrent medical record review for Resident 28 was conducted with the DSD. The DSD stated Resident 28 had history of saying she wanted to go home, or Resident 28 thought she was getting picked up. The DSD stated Resident 28 was observed packing her things while saying she was going home and would go to the locked front door. The DSD stated Resident 28 had never physically attempted to open the door or sneaked out of the facility but would stand by the door and would look for the person to pick her up. The DSD stated Resident 28 took off her ID bracelet and was non-compliant with the ID bracelet. The DSD verified there was no documentation Resident 28 was provided with an ID bracelet nor refused or had taken off her ID bracelet. The DSD also verified there was no care plan developed when Resident 28 was non-compliant with having an ID bracelet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to the GT feeding were provided for one of three final sampled residents (Resident 62) reviewed for tube feeding. * The facility failed to ensure Resident 62's GT feeding rate was updated according to the physician's orders and failed to ensure Resident 62's GT feeding care plans were revised. These failures posed the risk for not providing the necessary GT care and interventions to Resident 62. Findings: Review of the facility's P&P titled Gastrostomy Tube Feeding via Continuous Pump revised 1/2017 showed it is the policy of the facility to provide nourishment via continuous pump to the residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician. On 1/22/25 at 1413 hours, Resident 62's GT feeding formula was observed running at 60ml/hr via GT feeding pump. Medical record review for Resident 62 was initiated on 1/22/25. Resident 62 was readmitted to the facility on [DATE]. a. Review of Resident 62's Nutritional assessment dated [DATE], showed the RD recommendation to increase the Jevity 1.5 (a GT feeding formula) to 65 ml/hr for 20 hrs to provide 1300 cc/1950 kcal. Review of Resident 62's Order Summary Report showed the following physician's orders: - on 8/27/24, for Jevity 1.5 at 60 ml/hr (1200 ml/1800 kcal) via enteral feeding pump for 20 hours, to start at 1400 hours and off at 1000 hours or until dose is completed. - on 9/14/24, to infuse water at 35 ml/hr (700 ml/day) via enteral feeding pump for 20 hours, to start at 1400 hours and off at 1000 hours or until dose is completed. The Order Summary dated 9/14/24, further showed to increase the GT feeding to Jevity 1.5 at 65 ml/hour for 20 hours. b. Review of Resident 62's Plan of Care initiated on 4/7/24, showed a care plan problem addressing the use of the feeding tubes. The interventions included to provide the entering feeding formula, Jevity 1.5 at 60 ml/hr for 20 hours as per the RD recommendation on 8/27/24. On 1/22/25 at 1426 hours, a concurrent observation, interview, and medical record review was conducted with LVN 6. LVN 6 verified there were two conflicting GT enteral feeding orders for Resident 62. LVN 6 verified Resident 6's GT feeding pump was set and running at 60 ml/hr and acknowledged it was an incorrect rate. LVN 6 also verified Resident 6's GT feeding care plans were not revised to reflect the new order on 9/14/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident (Resident 37) reviewed for dialysis care. * The facility failed to ensure Resident 37's vital signs and weight were monitored post-dialysis. This failure had the potential for delay in the provision of care to Resident 37 for complications of the dialysis treatment. Findings: Review of the facility's P&P titled Dialysis Care revised 2/2018 showed the following: - The Pre-Dialysis Checklist will be completed by the facility each time the resident is scheduled for dialysis. This checklist includes the vital signs; - The Dialysis Unit Progress will accompany the resident to dialysis and requests that the dialysis unit complete with the pre- and post-dialysis weight and vital signs; and - The Post-Dialysis Checklist is to be completed by the facility upon the return of the resident. Information to be documented included the vital signs. Review of the facility's P&P titled Dialysis - Post Dialysis Care revised 4/2017 showed upon return from the dialysis facility, the resident's vital signs should be taken. Medical record review for Resident 37 was initiated on 1/21/25. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's Order Summary Report showed a physician's order dated 10/4/24, showed Resident 37 was scheduled to have dialysis on Tuesdays, Thursdays, and Saturdays. * Review of Resident 37's Pre and Post Dialysis Checklist did not show Resident 37's vital signs were monitored upon the resident's return from the dialysis facility on 12/21, 1/2, 1/4, 1/9, 1/14, 1/16, and 1/18/25. * Review of Resident 37's Dialysis Unit Progress form dated 1/18/25, did not show a post-dialysis weight for Resident 53 while in the dialysis unit. * Review of Resident 37's Weights and Vitals Exceptions did not show Resident 37's vital signs were monitored upon her return from dialysis on 12/21, 1/2, 1/4, 1/9, 1/14, 1/16, and 1/18/25. Review of Resident 37's Nurses Progress Notes did not show Resident 37's vital signs were monitored upon her return from the dialysis facility on 12/21, 1/2, 1/4, 1/9, 1/14, 1/16, and 1/18/25, and her post-dialysis weight on 1/18/25, was followed-up with the dialysis unit. On 1/24/25 at 1000 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 1. RN 1 verified the above findings. RN 1 verified there was no documentation to show Resident 37's vital signs were monitored upon her return from the dialysis facility on 12/21/24, and on 1/2, 1/4, 1/9, 1/14, 1/16, and 1/18/25, and her post-dialysis weight on 1/18/25. RN 1 also verified Resident 37's post-dialysis weight on 1/18/25, was not followed-up with the dialysis facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (nonsampled resident, Resident 13) reviewed for side rail use remained free from accident hazards due to the use of side rails. * The facility failed to obtain the physician's order and informed consent, review the risks and benefits, provide the least restrictive alternatives, and develop the plan of care for Resident 13's use of the side rails. This failure had the potential to place the resident at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Side Rails or Bed Rails revised 8/2018 showed the following: - Informed consent for the physical restraint, including the use of bed or side rails even for episodic use is required to be obtained from the resident or legal representative. Potential negative outcomes and benefits should be discussed. The use of anything attached to a normal bed (i.e. one-fourth rails as an enabler, grab bar attached to the bed, any assistive device, etc.) requires a comprehensive care assessment, physician's order, informed consent, and a care plan to address the use. - The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used even for episodic use, the facility will make sure that it is installed correctly, used correctly and maintained. The resident will be assessed for the risk of entrapment from bed rails prior to its installation. During the initial tour of the facility on 1/21/25 at 0958 hours, Resident 13 was observed awake and sitting in the wheelchair beside the bed. The bed was observed with the bilateral upper side rails elevated. Resident 13 stated he uses the side rails during turning or when he was getting out of the bed. On 1/22/25 at 0934 hours, a concurrent observation and interview was conducted with Resident 13. Resident 13 was observed awake and lying in the bed with the bilateral upper side rails elevated. Resident 13 stated he had been using the side rails for a long time and not just a month ago. Resident 13 further stated he needed the side rails to grab when turning from side to side or when he was getting out of the bed. Medical record review for Resident 13 was initiated on 1/22/25. Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 4/30/24, showed Resident 13 had the capacity to understand and make decisions. The H&P examination also showed Resident 13 had a significant diagnosis of morbid obesity. Review of Resident 13's MDS dated [DATE], showed Resident 13 required partial to moderate assistance from staff member for bed mobility. Further review of Resident 13's medical record failed to show documented evidence a physician's order for the use of the side rails, an informed consent were obtained, the least restrictive alternatives were attempted prior to the use of side rails, and the plan of care for the use of side rails was developed. On 1/22/25 at 1553 hours, a concurrent observation and interview was conducted with CNA 5. CNA 5 was observed getting out from Resident 13's room. CNA 5 stated when Resident 13 was in bed, the bilateral side rails were elevated at all times. CNA 5 further stated Resident 13 grabbed on the side rails when being assisted with turning. On 1/23/25 at 1418 hours, a concurrent interview and medical record review for Resident 13 was conducted with LVN 1. LVN 1 stated prior to the use of the side rails, the resident should be assessed initially for the need of side rails, and the least restrictive alternatives should be attempted first like two person assistance, or the use of pillows or overhead trapeze. LVN 1 stated a physician's order and informed consent should be obtained and the care plan should also be developed to address the use of the side rails. LVN 1 verified there were no physician's order, informed consent, the least restrictive alternatives were not attempted, and the plan of care was not developed for Resident 13's use of the bilateral side rails. On 1/27/24 at 1445 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 13. Cross reference to F909, example #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 82 was initiated on 1/23/25. Resident 82 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident's 82's H&P examination dated 7/3/24, showed Resident 82 had no capacity to understand and make decisions. Review of Resident 82's Order Summary Report showed a physician's order dated 6/27/24, for tramadol HCL (medication relieve pain) oral tablet, give 50 mg by mouth every six hours as needed for moderate pain (pain level 1-5, using the 0-10 pain scale; zero meaning no pain and 10 meaning worst pain). Review of Resident 82's Antibiotic or Controlled Drug Record showed one tablet of the tramadol HCL 50 mg tablet was dispensed and signed out on 12/15/24 at 0900 hours. Review of Resident 82's MAR for December 2024 showed the documentation of the administration for the tramadol HCL 50 mg dispensed and signed out on 12/15/24 at 0900 hours was missing. On 1/23/25 at 1400 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 verified the above findings and stated she pulled and signed the tramadol tablet and administered the medication to Resident 82, but forgot to document in the MAR. 3. Review of the facility's P&P titled Controlled Medication Storage dated 8/2014 showed at each of the shift change, a physical inventory of all the controlled medications is conducted by two licensed nurses and is documented on the controlled medication accountability record. Review of Medication Cart B's Controlled Substances Book showed the Narcotic Check Sheet had multiple missing nurses' signatures during the shift change on the following dates and times: - on 6/20, 6/23, 7/21, 7/26, 8/7, 8/16, 8/30, 9/22, 10/19, and 12/22/24 at 0700 hours; - on 6/7, 6/9, 6/22, 6/23, 7/17, 8/5, 8/7, 8/12, 8/19, 8/30, and 10/19/24; and 1/7/25 at 1500 hours; and - on 6/9, 6/15, 6/24, 7/14, 7/17 , 7/25, 8/5, 8/7, 8/12, 8/19, 9/21, 9/22/24; and 1/5 and 1/18/25 at 2300 hours. On 1/23/25 at 1418 hours, a concurrent interview and facility document review was conducted with RN 1. RN 1 reviewed Medication Cart B Narcotic Sheet Check and verified there were missing nurses' signatures during the narcotic inventory at the beginning of each shift for the above dates and times. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to one final sampled resident (Resident 82) and one nonsampled resident (Resident 20). * The facility failed to ensure Resident 20's medications were administered as ordered by the physician and accurately documented in the MAR. * The facility failed to ensure the documentation for Resident 82's controlled medication administrations were accurate and complete. * The facility failed to ensure the narcotic sheets inventory were properly conducted showing the nurses' initials and signatures for Medication Cart B. Theses failures had the potential for the resident not to receive the necessary medications and posed the risk for diversion of the medications. Findings: Reviewed of the facility P&P titled Medication Administration revised on 5/2019 showed the following: -Medications must be administered in accordance with the physician orders; -The licensed nurse administering the medication must initial the MAR for the resident on the appropriate line after giving the medication; and -The licensed nurse administering the medication will record on the MAR. 1. Medical record review for Resident 20 was initiated on 1/22/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 10/16/24, showed Resident 20 had the capacity to understand and make decisions. Review of Resident 20's MDS dated [DATE], showed Resident 20's Brief Interview for Mental Status (BIMS) score was 99 (indicates that the interview was incomplete. This can happen if the patient refused to participate, or if the patient's responses were nonsensical or not provided). On 1/21/25 at 0817 hours, a medication administration observation was conducted with LVN 1. LVN 1 prepared and administered the following medications for Resident 20: - allopurinol (a medication to prevent uric acid production in the body) 300 mg one tablet; - folic acid (vitamin) 1 mg one tablet; - furosemide (diuretic used to treat fluid retention) 40 mg one tablet - Keppra (medication to prevent seizure) 100 mg/ml solution, 5 ml; - Ingrezza (used to treat symptoms of tardive dyskinesia) 40 mg one capsule; - memantine (medication use to treat memory loss) 10 mg one tablet; - potassium chloride (supplement) solution 15 ml; - Zoloft (medication for depression) 25 mg one tablet; - aspirin (medication used to prevent blood clot) chewable 81 mg one tablet; - ferrous sulfate (mineral the body need to produce red blood cells) 7.5 ml solution; - multivitamins (supplement) one tablet; - vitamin B-1 (supplement) 100 mg one tablet; and - vitamin D (supplement) 25 mcg 1000 IU one tablet. a. During the medication preparation for Resident 20, LVN 1 stated would not administer the docusate sodium (stool softener) 250 mg capsule until she clarified the order with the physician. Review of Resident 20's Order Summary Report showed a physician's order dated 12/31/24, to administer docusate sodium capsule 250 mg, give one capsule via GT one time a day for bowel management. Hold with loose stools or diarrhea. Review of Resident 20's MAR for January 2025 did not show the administration of docusate sodium per physician's order on 1/21/25. On 1/22/25 at 1023 hours, a follow-up interview was conducted with LVN 1. LVN 1 was asked if she administered the docusate sodium on 1/21/25 after she clarified the medication from the physician and LVN 1 stated, No, I did not give a dose of docusate sodium yesterday. b. On 1/21/25 at 0847 hours, an interview was conducted with LVN 1. LVN 1 stated she completed the medication administration for Resident 20's morning medications. Asked LVN 1 if she must document after medication administration, LVN 1 stated she had documented on Resident 20's MAR while preparing the medications. Furthermore, LVN 1 stated her usual process was to document on the MAR prior to the administration of medications. Review of Resident 20's Medication Administration Audit Report dated 1/21/25, showed the administration time for the morning medications were documented prior to the administration completion time. On 1/23/25 at 1457 hours, an interview was conducted with the DON. The DON stated medication administration process expectation must be to pour, pass, and sign the MAR. Furthermore, the DON stated the licensed nurses should administer the resident's medications as ordered by the physician. On 1/27/25 1400 at hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of 24 final sampled residents (Residents 37 and 53) were free from unnecessary drugs. * The facility failed ensure Resident 37 was not administered metoprolol (medication to treat high blood pressure) and clonidine (medication to treat high blood pressure) medications when Resident 37's blood pressure was below the parameter prescribed by the physician. * The facility failed to ensure Resident 53 was administered with metoprolol medication when Resident 53's blood pressure was below the parameter prescribed by the physician. These failures had the potential for the residents to develop the significant side effects such as hypotension and negatively affect the residents' health condition and well-being. Findings: 1. According to DailyMed, the most common adverse effects of the metoprolol and clonidine medications included hypotension. Medical record review for Resident 37 was initiated on 1/21/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's Order Summary Report showed the following physician's orders dated 10/2/24: - To administer clonidine 0.2 mg one tablet by mouth in the morning for hypertension and hold if SBP is less than 110 mmHg; and -To administer metoprolol 100 mg one tablet by mouth for hypertension and hold if SBP is less than 110 mmHg or heart rate less than 60 beats per minute. Review of Resident 37's MARs for December 2024 and January 2025 showed Resident 37 was administered the metoprolol medication on the following: - dated 12/19/24 at 0900 hours, with a blood pressure of 109/57 mmHg; - dated 1/3/25 at 2100 hours, with a blood pressure of 104/56 mmHg, and - dated 1/14/25 at 0900 hours, with a blood pressure of 101/57 mmHg. In addition, the MAR showed Resident 37 was administered the clonidine medication on 12/26/24 at 0900 hours, with a blood pressure of 99/55 mmHg. The MARs for December 2024 and January 2025 showed the use of the metoprolol and clonidine medications ordered parameters were not followed. On 1/24/25 at 1000 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 1. RN 1 verified the above findings. RN 1 verified the metoprolol and clonidine medications were administered to Resident 37 when the resident's blood pressures were below the parameter prescribed by the physician. 2. Medical record review for Resident 53 was initiated on 1/21/25. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's Order Summary Report showed the following physician's order dated 5/12/24, to administer metoprolol 25 mg one tablet by mouth for hypertension and hold if SBP is less than 120 mmHg or heart rate less than 50 beats per minute. Review of Resident 53's MARs for December 2024 and January 2025 showed Resident 53 was administered the metoprolol medication on the following: - dated 12/1/24 at 0900 hours, with a blood pressure of 116/77 mmHg, - dated 12/13/24 at 0900 hours, with a blood pressure of 116/77 mmHg, - dated 12/26/24 at 1700 hours, with a blood pressure of 115/79 mmHg, and - dated 1/3/25 at 0900 hours, with a blood pressure of 114/78 mmHg. On 1/23/25 at 1325 hours, an interview and concurrent medical record review for Resident 53 was conducted with RN 3. RN 3 verified the above findings. RN 3 verified the metoprolol medication was administered to Resident 53 when the resident's blood pressures were below the parameter prescribed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure 7 of 11 final sampled residents (Residents 12, 13, 28, 37, 44, 53, and 73) reviewed for unnecessary medications were free from unnecessary psychotropic drugs. * The facility failed to ensure Resident 37's was accurately monitored related to the use of Remeron (antidepressant medication). Resident 37's meal intake documentation was inconsistent, showing either a % or a hashmark, and did not match the CNA's Documentation Survey Report. In addition, the monthly behavior summary of the episodes of Resident 37's meal intake less than 50% did not match the MAR nor the CNA's Documentation Survey Report. * The facility failed to renew the informed consent related to the use of Depakene (mood stabilizer medication), Remeron (antidepressant medication), and risperidone (antipsychotic medication) for Resident 53. In addition, the facility failed to monitor Resident 53's blood pressure for orthostatic hypotension was monitored as ordered by the physician related to the use of risperidone. * The facility failed to ensure Resident 73 was monitored for the side effects related to the use of lorazepam (antianxiety medication). * The facility failed to ensure the informed consent was obtained prior to the administration of risperidone for Resident 28. * The facility failed to ensure Resident 13's the informed consents for trazodone, Zyprexa, and bupropion were renewed after 6 months. * The facility failed to ensure Resident 12's informed consents for Seroquel and Depakote were renewed after 6 months. * The facility failed to ensure Resident 44's informed consents for Depakote ER, fluvoxamine maleate, olanzapine, and risperidone were renewed after six months. These failures had the potential for the residents to have adverse complications from the medications and the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents. In addition, these failures had the potential for the residents and their responsible parties not being informed of their medications and the potential side effects of the psychotropic medications. Findings: Review of the facility's P&P titled Informed Consent Policy revised 4/2024 showed the following: - There is a requirement for the facility to renew informed consent every six months. There is no need to renew the consent form if the dosage or therapy is being decreased unless it has been six months. There is no need to renew informed consent if the resident is transferred to a hospital and returns with no change in orders and the facility has a copy of the informed consent in the resident's clinical record unless it has been more than six months since consent has been renewed; and - The facility shall verify that informed consent has been informed prior to the administration of psychotherapeutic medication. Review of the facility's P&P titled Psychotropic Drug Treatment dated 9/2017 showed the following: - The resident or his/ her representative will be given information regarding the need for, the desired effect and the potential side effects of the medication. This enables the resident or his/ her representative to make an informed consent regarding the use of any psychoactive medication. The resident or their representative should be involved in the medication management process and aware of the benefits and risks of medications and the goals of treatment; and - Each resident's drug regimen review must be free from unnecessary drugs. Unnecessary drugs are any drugs when used without adequate monitoring. Review of the facility's P&P titled Informed Consent revised 4/2024 showed it is the policy of the facility that if the attending physician, physician assistant (PA), or nurse practitioner (NP) for a resident prescribes, orders, or increase an order for a psychotherapeutic medication the physician, PA or NP or the facility shall do the following: - There is a requirement for the facility to renew informed consent every six months. There is no need to renew the consent form if the dosage or therapy is being decreased unless it has been six months. 1. Medical record review for Resident 37 was initiated on 1/21/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's H&P Examination dated 10/4/24, showed Resident 37 had the capacity to understand and make decision. Review of Resident 37's Order Summary Order showed the following physician's orders dated 10/2/25: - To administer Remeron 22.5 mg by mouth at bedtime for depression manifested by poor oral intake less than 50% meal; and to - To monitor meal percentage less than 50% related to the use of Remeron. Review of Resident 37's MAR for December 2024 and January 2025 showed the following: - Resident 37 was administered Remeron 22.5 mg on 12/1 to 12/31/24, and from 1/1 to 1/22/25; and - Resident 37's meal intake was 10 on 12/30/24 at 1700 hours, and on 12/31/24 at 1200 and 1700 hours; 20 on 12/23/24 at 1200 hours, and 12/31/24 at 0700 hours; 50 on 12/26 and 12/27/24 at 0700 and 1200 hours, and on 12/26/24 at 1700 hours; and 60 on 12/28/24 at 0700 and 1200 hours, and 12/27/24 at 1700 hours. However, Resident 37's meal intake was 1 on 12/7/24 at 0700 hours, 12/14 and 12/19/24 at 1700 hours, 12/24/24 at 1200 hours, on 12/10, 12/11, 12/10, 12/11, 12/22, and 12/29/24 at 0700 and 1200 hours, and on 12/8, 12/15, 12/20, and 12/21/24 at 0700, 1200, ad 1700 hours. In addition, Resident 37 meal intake was 0 on 12/7/24 at 1200 hours, 12/10 12/11, 12/22, 12/23, 12/28 and 12/29/24 at 1700 hours, on 12/14, 12/19 and 12/30/24 at 0700 and 1200 hours, and on 12/1 to 12/6/25, 12/12, 12/13, 12/16, and 12/25/24 at 0700, 1200 and 1700 hours; and - Resident 37's meal intake was 20 on 1/1/25 at 0700, hours; 30 on 1/2/25 at 0700 and 1200 hours; 50 on 1/5/25 at 1700 hours; and 40 on 1/7/25 at 0700 hours. However, Resident 37's meal intake was X on 1/14/25 at 1700 hours, and 0 on 1/7 and 1/13 at 0700 hours, and on 1/3 and 1/4/25 at 1700 hours. In addition, Resident 37's meal intake was 1 on 1/2/25 at 1200 and 1700 hours, on 1/3, 1/4, 1/5 and 1/14/25 at 0700 and 1200 hours, on 1/6/25 at 1200 and 1700 hours, and on 1/8 to 1/12/25 at 0700, 1200, and 1700 hours, and in 1/14 to 1/22/25 at 0700, 1200, and 1700 hours. Review of Resident 37's CNA - Documentation Survey Report for December 2024 and January 2025 showed Resident 37 consumed less than 50% for 75 out of 93 meals for December 2024, and 59 out of 71 meals for January 2025. a. Further review of Resident 37's meal intake documentation in the MAR was inconsistent, showing either a % or a hashmark Resident 37's monitoring of meal intake at 0700, 1200 and 1700 hours, was documented either as NA, X, 0, 1, 10, 20, 30, 40, 50, or 60. In addition, Resident 37's meal intake documentation in the MAR did not match Resident 37's meal intake documentation in the CNA - Documentation Survey Report. Review of Resident 37's Behavior and Psychotropic Summary/Dosage Reduction for December 2024 for Resident 37's poor meal intake less than 50 % related to use of Remeron showed Resident 37 had 14 episodes at 0700 hours, 12 episodes at 1200 hours, and 10 episodes at 1700 hours, for a total of 36 episodes for December 2024. b. Further review of the monthly behavior summary of the episodes of Resident 37's meal intake less than 50% did not match the MAR nor the CNA - Documentation Survey Report. On 1/24/25 at 1000 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the licensed nurses should verify with the CNAs regarding Resident 37's meal intake, and the licensed nurses should be documenting the percentage of Resident 37's meal intake in the MAR. 2. Medical record review for Resident 53 was initiated on 1/21/25. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's H&P examination dated 5/14/24, showed Resident 53 had no capacity to understand and make decision. Review of Resident 53's Order Summary Order showed the following physician's orders: - dated 5/12/24, to administer Depakene 250 mg/ml 10 ml via GT two times a day for mood stabilizer/ labile mood. This physician's order was discontinued on 1/10/25. - dated 5/27/24, to monitor blood pressure lying and sitting for orthostatic hypotension every week on Tuesday in 1500 to 2300 hours shift related to the use of risperidone. Notify the physician if the difference in SBP of 20 mmHg or if the difference in DBP of 10 mmHg or greater. - dated 12/12/24, to administer Remeron 7.5 mg via GT at bedtime for depression; - dated 12/12/24, to administer risperidone 0.5 mg via GT at bedtime; and a. Review of Resident 53's Informed Consent dated 5/16/24, showed an informed consent was obtained for the Risperdal (risperidone), Depakene, and Remeron medications. However, the informed consent for Risperdal, Depakene, and Remeron medications was not renewed after six months. b. Review of Resident 53's MAR for December 2024 and January 2025 showed the following: - Resident 53 was administered Depakene 250 mg/5 ml 10 ml via GT on 12/1 to 12/31/24 at 0900 and 1700 hours, on 1/1 to 1/9/25 at 0900 and 1700 hours, and on 1/10/25 at 0900 hours; - Resident 53 was administered Remeron 7.5 mg via GT on 12/12 to 12/31/24 at 2100 hours, and on 1/1 to 1/22/25 at 2100 hours; - Resident 53 was administered risperidone 0.5 mg via GT on 12/12 to 12/31/24 at 2100 hours, and on 1/1 to 1/22/25 at 2100 hours; and - Resident 53's blood pressures were monitored for orthostatic hypotension related to the use of risperidone. However, the blood pressure readings for both positions (lying and sitting) were the same as follows: - On 12/3/24, the blood pressure readings were 128/78 mmHg for the lying position and 128/78 mmHg for the sitting position; - On 12/17/24, the blood pressure readings were 140/75 mmHg for the lying position and 140/75 mmHg for the sitting position; - On 12/31/24, the blood pressure readings were 131/77 mmHg for the lying position and 131/77 mmHg for the sitting position; - On 1/14/25, the blood pressure readings were 133/75 mmHg for the lying position and 133/75 mmHg for the sitting position; and - On 1/22/25, the blood pressure readings were 142/83 mmHg for the lying position and 142/83 mmHg for the sitting position. On 1/23/25 at 1043 hours, an interview and concurrent medical record review for Resident 53 was conducted with RN 1. RN 1 verified the above findings. RN 1 acknowledged the informed consent for the Risperdal, Depakene, and Remeron medications was not renewed after six months. RN 1 also verified the licensed nurses were not checking for orthostatic hypotension accurately because of the same blood pressure readings for both sitting and lying positions. 3. Medical record review for Resident 73 was initiated on 1/21/25. Resident 73 was readmitted to the facility on [DATE]. Review of Resident 73's H&P Examination dated 7/20/24 showed Resident 73 could make needs known but cannot make medical decisions. Review of Resident 73's Order Summary Order showed the following physician's orders: - dated 1/14/25, to monitor behavior of striking out towards the staff during care every shift. - dated 1/17/25, to administer lorazepam 0.5 mg one tablet two times a day for anxiety manifested by striking out, for 14 days; Review of Resident 73's MAR for January 2025 showed Resident 73 was administered the lorazepam medication from 1/19 to 1/20/25 at 1700 hours, and on 1/22 to 1/25/25 at 0900 and 1700 hours. Further review of Resident 73's medical record did not show Resident 73 was monitored for the side effects related to the use of the lorazepam medication. On 1/27/25 at 0948 hours, an interview and concurrent medical record review for Resident 53 was conducted with the DON. The DON verified the above findings. The DON stated the licensed nurses had to make sure the resident was monitored for the behavior and side effects related to the use of psychotropic medications. 4. Medical record review for Resident 28 was initiated on 1/21/25. Resident 28 was readmitted to the facility on [DATE]. Review of Resident 28's H&P Examination dated 11/7/24, showed Resident 28 had no capacity to understand and make decision. Review of Resident 28's Order Summary Order showed the following physician's orders dated 1/21/25: - To administer risperidone 0.5 mg by mouth one time a day for schizophrenia and - To administer risperidone 1 mg by mouth at bedtime for schizophrenia. Review of Resident 28's Informed Consent dated 1/21/25, for risperidone 0.5 mg by mouth one time a day for schizophrenia and risperidone 1 mg by mouth at bedtime for schizophrenia, but the informed consent form was not signed by the physician. Further review of Resident 28's medical record failed to show an informed consent for the risperidone medication was obtained from the resident or her responsible party. On 1/24/25 at 1033 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the physician who ordered the medications obtained the consent, and the facility had to fax the informed consent to the physician's office. RN 1 reviewed Resident 28's medical record and was unable to find documentation the informed consent was obtained from the resident or their responsible party for the use of the risperidone medication. 5. Medical record review for Resident 13 was initiated on 1/22/25. Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 4/30/24, showed Resident 13 had the capacity to understand and make decisions. Review of Resident 13's Order Summary Report showed the following physician's orders dated 4/29/24: - to administer trazodone 100 mg two tablets by mouth at bedtime for depression as manifested by inability to sleep; - to administer Zyprexa 15 mg one tablet by mouth at bedtime for schizoactive disorder (mental health condition) as manifested by paranoid delusion (false belief that someone is being threatened or mistreated); and - to administer bupropion hydrochloride extended release 200 mg one tablet by mouth two times a day for depression as manifested by withdrawal from activities of interest. Review of Resident 13's MAR for November 2024, December 2024 and January 2025, showed Resident 13 received the following: - trazodone medication from 11/1 to 11/30/24 at 21 hours, 12/1 to 12/31/24 at 2100 hours, and 1/1 to 1/21/25 at 2100 hours; - Zyprexa medication from 11/1 to 11/30/24 at 2100 hours, 12/1 to 12/31/24 at 2100 hours, and 1/1 to 1/21/25 at 2100 hours; and - bupropion hydrochloride extended release medication from 11/1 to 11/30/24 at 0900 hours and 1700 hours, 12/1 to 12/31/24 at 0900 hours and 1700 hours, 1/1 to 1/21/25 at 0900 hours and 1700 hours, and 1/22/25 at 0900 hours. Further review of Resident 13's medical record did not show documented evidence the informed consents for the trazodone, Zyprexa, and bupropion hydrochloride extended release medications were renewed six months after 5/1/24. On 1/24/25 at 1327 hours, a concurrent interview and medical record review for Resident 13 was conducted with RN 2. RN 2 stated the informed consents for psychotropic medications should be obtained initially once the physician's ordered it and it should be renewed every six months. RN 2 verified the consents for the trazodone, Zyprexa, and bupropion hydrochloride extended release medications were not renewed after 6 months. On 1/27/24 at 1445 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 13. 7. Review of Resident 44's medical record was initiated on 1/24/25. Resident 44 was admitted on [DATE]. Resident 44's MDS asseesment showed the resident's BIMS score was 99 (indicates that the Brief Interview for Mental Status (BIMS) was incomplete. This can happen if the patient refused to participate, gave nonsensical answers, or the interview was stopped. ). Review of Resident 44's Order Summary Report showed the following physician's orders: - dated 12/20/24, to administer Depakote ER 500 mg by mouth two times a day for mood stabilizer, - dated 5/23/24, to administer fluvoxamine maleate 100 mg tablet at bedtime for depression, - dated 5/23/24, to administer olanzapine 5 mg tablet one tablet by mouth two times a day for schizophrenia (a mental illness that is characterized by disturbances in thought), and - dated 12/20/24, to administer risperidone oral tablet 2.5 mg two times daily for schizophrenia. Review of Resident 44's informed consents showed consents were obtained for the above medications from Resident 44's daughter on 5/24/24 Review of Resident 44's MAR for January 2025 showed: - Resident 44 was administered Depakote ER from 1/1/25 to 1/23/25. - Resdient 44 was administered fluvoxamine maleate from 1/1/25 to 1/23/25. - Resdient 44 was administered olanzapine 5 mg tablet from 1/1/25 to 1/23. - Resident 44 was administered risperidone from 1/1/25 to 1/23/25 Review of the facility's P&P on Informed Consent dated 4/2024 showed there is a requirement for the facility to renew informed consent every six months. The facility shall verify the informed consent has been obtained prior to the administration of psychotherapeutic medications. On 01/24/25 at 1333 hours, an interview and concurrent review of Resident 44's informed consent was conducted with RN 2. RN 2 showed informed consent dated 5/24/24, for the following medications: Depakote ER, fluvoxamine maleate, olanzapine, and risperidone. When asked for the renewal of the informed consents as per the facility's P&P, RN2 stated no, that's it for the consents. RN 2 acknowledged and verified Resident 44's consents were supposed to be renewed every six months. On 01/27/25 833 hours, interview with the DON was conducted. The DON acknowledged and verified Resident 44's consents were not renewed on the Depakote ER, fluvoxamine maleate, olanzapine and risperidone medications use. 6. Medical record review for Resident 12 was initiated on 1/24/25. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed the following physician's orders: - dated 3/12/24, to administer Depakote 500 mg by mouth two times a day for mood stabilizer for labile mood m/b yelling and screaming without provocation - dated 10/7/24, to administer Seroquel 25 mg by mouth in the morning for schizoaffective disorder m/b paranoid delusions people are stealing his money - dated 10/7/24, to administer Seroquel 200 mg by mouth at bedtime for schizoaffective disorder m/b paranoid delusions people are stealing his money Review of the Informed Consent dated 6/4/24, showed Seroquel 50 mg and Depakote 500 mg. Further review of Resident 12's medical record did not show documented evidence the informed consents for the Seroquel and Depakote were renewed six months after 6/4/24. On 1/24/25 at 1041 hours, a concurrent interview and medical record review for Resident 12 was conducted with RN 2. RN 2 stated the informed consents for psychotropic medications should be obtained upon admission, with an increase in medication, and every 6 months. RN 2 verified the informed consents for the Seroquel and Depakote were not renewed after 6 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 20) was free from the significant medication errors. * The facility failed to provide Resident 20's Zyprexa (antipsychotic medication) as ordered by the physician and accurately document the Zyprexa administration. This failure placed Resident 20 at risk for medical complications. Findings: Review of the facility's P&P titled Medication Administration dated 5/2019 showed the medications are administered in a safe and timely manner, and as prescribed. The medications must be administered in accordance with prescriber orders, including any required time frame. Review of the facility's P&P titled Physician Services and Orders dated 1/2017 showed: - Signed orders for drugs shall be transmitted to the issuing pharmacy within 48 hours of the receipt of the order; - The charge nurse or the DON shall place the order for all prescribed medications; and - Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy no less that three days prior to the last dosage being administered to assure that the refills are on hand. Medical record review for Resident 20 was initiated on 1/22/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's Order Summary Report showed a physician's order dated 1/17/25, to administer Zyprex 10 mg one tablet medication via GT at bedtime for schizoaffective disorder (a severe brain disorder in which people interpret reality abnormally) manifested by paranoid delusion (a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion) with angry outburst from responding to internal stimuli. Review of Resident 20's MAR for January 2025 showed the following: - on 1/17 to 1/19/25 at 2100 hours, the section to document for the Zyprexa medication administration were blank. - on 1/20 and 1/21/25 at 2100 hours, the section to document for the Zyprexa medication administration were signed by the nurse. The MAR failed to show documentation to explain why the Zyprexa medication was not admistered from 1/7 to 1/19/25 at 2100 hours. a. On 1/22/25 at 1023 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified the missing documentations on Resident 20's MAR on 1/17 to 1/19/25 at 2100 hours. On 1/23/25 at 1030 hours, a follow-up interview was conducted with LVN 1. LVN 1 stated Resident 20 was in the facility between 1/17 to 1/19/25. Furthermore, LVN 1 stated the Zyprexa 10 mg medication was received last night by the night shift nurse. LVN 1 verified the Zyprexa 10 mg bubble pack was still complete and the label showed the medication was filled on 1/22/25 from the pharmacy. On 1/23/25 at 1059 hours, an interview was conducted with the Pharmacy Technician. The Pharmacy Technician was asked if the pharmacy received the new order for the Zyprexa 10 mg tablet medication and when was it delivered. The Pharmacy Technician stated the pharmacy received an order for the Zyprexa 10 mg on 1/20/25, however, the medication was not sent. The Pharmacy Technician further stated the pharmacy received another faxed order of Zyprexa on 1/22/25 at 1110 hours and medication was delivered on 1/22/25 at 2315 hours. b. On 1/23/25 at 1313 hours, an interview was conducted with LVN 2. LVN 2 was asked if she administered Resident 20's Zyprexa 10 mg on 1/17 to 1/19/25 at 2100 hours, and the reason for the missing documentations on the MAR. LVN 2 stated the medication did not arrive on 1/17/25 and she did not administer the Zyprexa medication. LVN 2 stated she documented on the nurse's progress notes the medication was not received. Furthermore, LVN 2 was asked if the Zyprexa 10 mg was available on 1/20 and 1/21/25. LVN 2 stated she worked on 1/21/25 and Resident 20's Zyprexa medication was not available. LVN 2 verified she signed the MAR without administering the medication. LVN 2 acknowledged it was a medication error and supposed to make sure medications were given as ordered. On 1/23/25 at 1457 hours, an interview was conducted with the DON. The DON stated if the medications were not received, the charge nurses or RN should follow up with the pharmacy. Furthermore, the DON stated it was unacceptable for the charge nurses to document in the MAR to show the medications were administered when the residents' medications were not available or on hand. On 1/7/25 at 1334 hours, an interview was conducted with DON and Administrator. The DON and Administrator verified and acknowledged above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of the medications for two of five Medication Cart (Medication Carts A and B) when: * The facility failed to ensure the orally administered medications were stored separate from externally used medications and supplies in Medication Cart A. * The facility failed to ensure Medication Cart B was not left unlocked and unattended by the licensed nurses while parked in the hallway. These failures had the potential to negatively impact the residents' well-being and opportunities for drug diversion or drug misuse. Findings: Reviewed of the facility's P&P titled Storage of Medications effective date 4/2008 showed the following: - Orally administered medications are kept separate from externally used medications. - Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 1. On 1/23/25 at 1320 hours, a medication cart inspection for Medication Cart A was conducted with LVN 1. The following medications were observed stored in one compartment: - a box of loperamide HCL tablets (antidiarrheal medication); - a bottle of sodium chloride tablets (normal salt supplement); - Salonpas patches (topical pain medication); and - one tube of Refresh Celluvisc (lubricant eye gel). LVN 1 verified the above findings. LVN 1 further stated those medications should not be stored together because they were administered in different route. 2. On 1/27/25 at 0901 hours, Medication Cart B parked in the hallway was observed unlocked and unattended. The facility staff members and residents were observed passing by. On 1/27/25 at 0909 hours, the DON and LVN 1 verified Medication Cart B was unlocked and unattended. LVN 1 stated she opened the cart and took the narcotic medications from Medication Cart B and forgot to lock it.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff were competent in their position related duties when: 1. Two of 13 kitchen employees (Dietary Aides 2 and 3) were unable to correctly test the sanitizing solution used to sanitize the food preparation surfaces in the kitchen and sanitize the food preparation equipment washed in the manual ware washing sink. 2. One of 13 kitchen employees (Cook 1) did not know the correct cutting board to be use when preparing raw poultry. These failures posed the risk for exposure to unsafe food handling practices which could lead to food borne illness in the 94 vulnerable residents who received food prepared in the kitchen. Findings: Review of the facility's undated matrix showed 94 residents received food prepared in the kitchen. 1. Review of the facility's document titled Employee Evaluation Form dated 10/3/24, signed by the CDM and Dietary Aide (DA) 2 showed DA 2 met expectations in quality of work; work was completed accurately (few or no errors) efficiently and within deadlines with minimal supervision. Review of the facility's document titled Dietary Competency Evaluation dated 10/3/24, signed by the CDM and DA 2, did not include a competency evaluation on the testing of the sanitizing solution used to sanitize the food preparation surfaces. Review of the sanitizing solution test strip instructions located on the container of the sanitizing solution test strips showed to immerse the test strip in the sanitizing solution for ten seconds then compare the wet test strip to the color chart located on test strip container. On 1/21/25 at 1418 hours, an observation and concurrent interview was conducted with DA 2. DA 2 was asked to demonstrate how to test the sanitizing solution used to sanitize food preparation surfaces in the kitchen. DA 2 obtained a test strip, held it in the sanitizing solution for two seconds then compared the test strip to the color chart. The test strip read 150 parts per million (ppm), a measurement used to determine concentration of the sanitizing chemical. DA 2 was asked if 150 ppm was ok. DA 2 did not respond. DA 2 was asked to test the sanitizing solution a second time and hold the strip in the sanitizing solution for ten seconds. DA 2 inserted a clean test strip into the sanitizing solution for four seconds then compared the test strip to the color chart. The test strip read 150 ppm. DA 2 confirmed 150 ppm was not ok. On 1/23/25 at 0956 an interview was conducted with the CDM. The CDM was asked how he ensured the kitchen employees were competent in their job duties. The CDM stated he gave in-service training however the CDM confirmed he had not given in-service training on testing the sanitizing solution for kitchen staff. On 1/23/25 at 1020 hours, a telephone interview was conducted with the RD. The RD stated she was not involved in regular in-service training for the kitchen employees. a. Review of the facility document titled Employee Evaluation Form dated 8/6/24 signed by the CDM and DA 3 showed, DA 3 met expectations in quality of work; work was completed accurately (few or no errors) efficiently and within deadlines with minimal supervision. Review of the facility document titled Dietary Competency Evaluation dated 8/19/24 signed by the CDM and DA 3, did not include a competency evaluation on the manual dishwashing procedure. Review of the facility's job description titled Dishwasher signed by DA 3 on 8/19/18, showed General Duties and Responsibilities: wash and clean utensils as directed and perform dishwashing/cleaning procedures. Review of the facility document titled Record of Departmental In-service and Trainings, Three Compartment Washing dated 9/25/24, showed DA 3 was in attendance. On 1/21/25 at 1426 hours, an interview was conducted with DA 3 using the COTA as a translator and the CDM present. DA 3 was asked to describe the manual dishwashing procedure used in an emergency when the automatic dishwasher was not operable. DA 3 was not able to demonstrate or describe how to test the concentration of the sanitizing solution used to sanitize the dishes or what the correct concentration of the sanitizing solution should be. The CDM then asked DA 3 in English how to check the concentration of the sanitizing solution however DA 3 was not able to provide the correct information. On 1/21/24 at 1435 hours, an interview was conducted with the CDM. The CDM was asked if DA 3 had been trained on the manual dishwashing procedure. The CDM stated he provided an in-service in September and December of 2024. DA 3 attended the in-service in September 2024. The CDM was asked how he evaluated the employee's competency. The CDM stated he demonstrated the manual ware washing process and provided the process in writing in the appropriate language of the employee. The CDM confirmed he did not however, require a return demonstration from the employee on the manual dishwashing process to evaluate the employee's competency. On 1/23/25 at 1020 hours, a telephone interview was conducted with the RD. The RD stated she was not involved in regular in-service training for the kitchen employees. 2. Review of the facility document titled Dietary Competency Evaluation dated 10/4/24 and signed by the CDM and [NAME] 1, showed [NAME] 1 was competent in demonstrating preparation of food. Review of the facility's job description titled [NAME] signed by [NAME] 1 on 8/5/18, showed General Duties and Responsibilities: Prepare food in accordance with sanitary regulations and as well as with our policies and procedures. Review of the facility document undated titled, US Cutting Board Color Chart showed, Red - raw beef, pork, lamb, and other types of raw meat; Yellow - raw poultry, such as chicken, turkey and duck; Blue - raw fish, shellfish, and other seafood products; [NAME] - dairy and baked goods; [NAME] - fruits, vegetables and salads; [NAME] - cooked meat, such as roast, beef or ham. During the initial inspection of the kitchen on 1/21/25 at 0800 hours, an observation of [NAME] 1 and concurrent interview was conducted with Diet Aid 1. [NAME] 1 was observed using a red cutting board for raw poultry. When asked if it was ok to use a red cutting board for raw poultry, [NAME] 1 did not respond. DA 1 confirmed raw poultry should be prepared using a yellow cutting board. On 1/23/25 at 0956 hours, an interview was conducted with the CDM. The CDM was asked how he ensured the kitchen employees were competent in their job duties. The CDM stated he gave in-service training however the CDM confirmed he had not given in-service training on the proper use of cutting boards in 2024. On 1/23/25 at 1020 hours, a telephone interview was conducted with the RD. The RD stated she was not involved in regular in-service training for the kitchen employees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure the nutritional needs were met for two of 82 nonsampled residents (Residents 11 and 70) who received a vegetarian diet preference when the lunch meal served provided nine grams of protein vs 28 grams of protein per the regular menu. This failure posed the threat of the nutritional needs; specifically the protein needs for Residents 11 and 70 to not be met which could lead to medical complications. Findings: 1. According to the California Health and Safety Code Section 1265.10: Effective 1/1/19, the skilled nursing facilities must make available wholesome, plant-based meals of such variety as to meet the needs of patients in accordance with their physicians' orders. Review of the facility's document titled Cooks Spreadsheet showed the following: Week 4 Wednesday dated 1/22/25, showed for the lunch meal, four ounces Old Fashioned Meatloaf for the entrée for regular diets. The lunch meal entrée served for 1/22/25, was equivalent to 28 grams (gm) of protein. Review of the facility's document titled Recipe: Grilled Cheese Sandwich Week 4 Tuesday undated, showed one sandwich was equivalent to two ounces of protein. The Grilled Cheese Sandwich recipe showed Do not use American Cheese. Directions: 1) Make sandwiches: two ounces of cheese per sandwich. Review of the nutritional information for the American Cheese used to make the Grilled Cheese Sandwiches showed one slice of cheese provided 60 calories and three grams of protein. Medical record review for Residents 11 and 70 was intiated on 1/22/25. * Review of the medical record for Resident 11 showed Resident 11 was admitted to the facility on [DATE] with medical diagnoses which included vitamin D deficiency and hypocalcemia (low blood calcium). Further review of the medical record showed a physcian's order dated 10/10/24, for a Regular diet, regular texture no meat, no fish diet. During the lunch meal tray line service on 1/22/25 at 1144 hours, the following was observed: Res 11's lunch meal tray consisted of one grilled cheese sandwich, peas, orange juice and cranberry juice. * Review of the medical record for Resident 70 showed Resident 70 was admitted to the facility on [DATE] with medical diagnoses which included severe protein calorie malnutrition and pulmonary (lung) disease. Further review of the resident's medical record showed a physician's order dated 1/6/25, for a Vegetarian Lacto (dairy products) diet, regular texture. During the lunch meal tray line service on 1/22/25 at 1144 hours, the following was observed: Resident 70's lunch meal tray consisted of one grilled cheese sandwich, peas, jello, milk, and juice. On 1/22/25 at 1200 hours, an interview was conducted with [NAME] 2. [NAME] 2 was asked how he prepared the grilled cheese sandwiches for the lunch meal. [NAME] 2 stated he used three slices of American cheese for each grilled sandwich which was equivalent to nine grams of protein. On 1/22/25 at 1550 hours an interview was conducted with [NAME] 3 and the CDM. When asked if the facility provided a vegetarian diet, [NAME] 3 stated he provided meal entrees such as a grilled cheese sandwich, cheese ravioli, grilled quesadilla or tofu. [NAME] 3 confirmed the menu spreadsheet did not include a vegetarian diet. When asked how he determined the appropriate portion size for a vegetarian diet, [NAME] 3 confirmed there were no portion sizes for vegetarian diets available. On 1/23/25 at 1020 hours, a telephone interview was conducted with the RD. The RD stated the facility did not have a vegetarian menu but stated ideally there should be a menu and a therapeutic spreadsheet with appropriate portions sizes available. The RD confirmed the facility served meal entrees such as grilled cheese sandwiches or tofu for vegetarian diets. The RD further stated that vegetarian meal entrees should be nutritionally equivalent to the regular menu entrée.

Based on observation, interview, and facility P&P review, the facility failed to ensure food brought to the facility from family members or visitors was stored, prepared and safe food handling practices were followed. This failure had the potential for unsafe food handling which could lead to food borne illness in the 94 residents receiving an oral diet who resided in the facility. Findings: Review of the facility P&P titled Food and Liquids from Outside Sources or Other Than the Dietary Department revised 7/2019 showed the food and liquids brought in by visitors for the residents is discouraged due to problems of infection control and conflicts between diets and consistency .Visitors are discouraged from bringing in potentially hazardous foods, i.e. meat, fish, eggs, custards, milk products, etc. If such foods are brought to the resident, they should be consumed immediately and not shared with other residents within the facility .Food items brought into the facility for residents cannot be reheated or stored. They are to be consumed or discarded. On 1/21/25 at 1115 hours, an interview was conducted with RN 1. When asked about how the food brought to the facility for the residents from the visitors was handled, RN 1 stated the food from the visitors could be stored for 24 hours. RN 1 was asked if she had received training on safe food handling. RN 1 stated she had not received training on safe food handling recently. RN 1 was asked if the facility allowed food from the resident's visitors to be heated. RN 1 stated there was a microwave at Nursing Station 1. On 1/21/25 at 1121 hours, an interview was conducted with RN 4 at Nursing Station 1. RN 4 confirmed the food from the resident's visitors could be heated in the microwave located at Nursing station 1. The microwave at Nursing Station 1 was observed to have a brown burned residue on the inside top of the microwave. RN 4 stated she would have the microwave removed. RN 4 was asked if the information on safe food handling was provided to the visitors. RN 4 stated she was not aware of any information on safe food handling for the visitors, but she would check with the Admissions Coordinator. On 1/21/25 at 1127 hours, an interview was conducted with the DSD. The DSD was asked if she had given an in-service training to the staff members on safe food handling. The DSD stated she would check her records. On 1/21/25 at 1130 hours, an interview was conducted with the admission Coordinator. When asked if he was aware of any information on safe food handling provided to the residents or visitors, the admission Coordinator stated he was not aware of any. On 1/22/25 at 0854 hours, an interview was conducted with the DON. The DON was asked to explain the process when the visitors brought food for the residents from the outside. The DON stated when the visitors brought food for the residents from the outside, the residents were encouraged to finish the food right away however, there was a refrigerator where the food could be stored until the following day. The DON added no sharing of food with other residents was allowed. When asked about the staff member education of the safe food handing, the DON stated the DSD and Infection Preventionist (IP) gave in-service training on safe food handling. The DON was asked how visitors were educated on safe food handling. The DON stated she was not aware how the visitors were educated on the safe food handling. On 1/22/25 at 0921 hours, the DON confirmed the facility did not provide any information in writing to the visitors on the safe food handling. On 1/22/25 at 0938 hours, an interview was conducted with the IP. The IP was asked if he had provided any education for the facility staff member on the safe food handling. The IP stated he could not recall but would check his education records. On 1/22/25 at 1107 hours, the IP confirmed he had not provided the facility staff members with the education on the safe food handing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident reviewed for hospice services (Resident 49). * The facility failed to ensure Resident 49 received the hospice care visits three times a week by the Certified Home Health Aid and one to three visits a week from the Skilled Nurse. * The facility failed to assign a designated hospice coordinator for Resident 49. These failures posed the risk for delays in the communication between the hospice provider and the facility which may affect resident care. Findings: Review of the facility's P&P titled Hospice Care revised 9/2018 showed the following: - The facility is responsible for ensuring that hospice services meet professional standards and the timelines of the services. - The facility must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the facility staff and hospice staff. Medical record review for Resident 49 was initiated on 1/22/25. Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 49's physician's order dated 10/2/24, showed resident was admitted to Hospice Agency 1 under routine level of care with primary diagnosis of senile degeneration of brain, unspecified. Review of Resident 49's Physician Order Summary Report dated 12/31/24, showed an order for the Hospice Certified Home Health Aide (CHHA) visits three times a week and Hospice Skilled Nurse (SN) visits one to three times a week and as needed for change of condition. Review of Resident 49's Visit Record and Vital Signs Sheet from Hospice Agency 1 showed the following visits were conducted by the hospice nurses: - During the week of 9/29/24 to 10/5/24, there were CHHA visits on 10/2 and on 10/3/24, instead of three visits as ordered. There was no documented evidence of the SN visit during this week. - During the week of 10/6/24 to 10/12/24, there were CHHA visits on 10/9 and on 10/12/24 instead of three visits as ordered. There was no documented evidence of the SN visit during this week. - During the week of 10/13/24 to 10/19/24, there were no visits from the CHHA and SN. - During the week of 10/20/24 to 10/26 24, there was only one visit conducted by CHHA on 10/23/24, instead of three visits as ordered. There was no documented evidence of the SN visit during this week. - During the week of 10/27/24 to 11/2/24, there was only one visit conducted by CHHA on 10/30/24, instead of three visits as ordered. There was no documented evidence of the SN visit during this week. - During the week of 11/3/24 to 11/9/24, there was no CHHA visit conducted during this week. - During the following weeks there were only one visit a week conducted by the CHHA: week of 11/10/24 to 11/16/24, week of 11/24/24 to 11/30/24, week of 11/24/24 to 11/30/24, week of 12/8/24 to 12/14/24, and week of 12/22/24 to 12/28/24. In addition, there was no documented evidence of the SN visit was conducted to the resident. On 1/23/25 at 1417 hours, an interview and concurrent Hospice Visit Record and Vital Signs Sheet review was conducted with the DON. The DON verified the visitation logs have not been reviewed and the facility did not have a designated Hospice Coordinator to follow up with the plan for the hospice visitations for Resident 49. On 1/23/25 at 1429 hours, an interview and concurrent Hospice Visit Record and Vital Signs Sheet review was conducted with the MDS Coordinator. The MDS Coordinator verified that the facility did not have a Hospice Coordinator and stated the facility needed to have a Hospice Coordinator to make sure the plan for the visitations were conducted by the hospice company.

2. Review of facility's P&P titled Storage of Medications effective 4/2008 showed the medication storage areas are kept clean. On 1/22/25 at 1200 hours, an observation of Medication Carts B and C was conducted. Spoon containers used for medication administration on the side of the Medication Carts were observed as follows: - Medication Cart B's spoon container had some parts of it with broken pieces of plactic and - Medication Cart C spoon's container, the middle compartment was cracked and was taped. In addition, Medication Cart B and C's spoons containers was observed with dirt and brown dry substance on the outside and inside. On 1/22/25 at 1210 hours, an interview with an IP, who verified Medication Cart B and C spoon container were not clean, broken and has tape on them. The IP further stated the spoons were used to give medications, and the spoon container should be clean to prevent the spread of infection. Based on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented as evidenced by: * The employees and residents' personal belongings were in the laundry room's clean folding area. * The facility failed to clean the spoon container on the Medication Carts for two of five medication carts inspected (Medication Carts B and C). These failures had the potential for spread of infection. Findings: Review of the facility's P&P titled Infection Control Program System revised 1/2023 showed the personnel must handle, store, process, and transport linens to prevent the spread of infection. Review of the facility's P&P titled Policy for Laundry - Nursing P&P Manual revised 8/2016 showed the linens are handled, stored, processed, and transported in such a manner as to prevent the spread of infection. 1. On 1/27/25 at 1245 hours, a concurrent observation of the laundry room and interview was conducted with the Environmental Services Director (ESD). The following items were observed in the clean folding area: - a large pink purse; - a white cellphone charger; - a plastic botttle of lotion; - an eye goggle; - two plastic bottled water; - a black remote control; and - two reading eye glasses. The ESD verified the above findings. The ESD stated the two reading eye glasses and remote control were mixed from the soiled linens which were taken out from the residents' rooms. The ESD was unable to answer when asked if the reading eye glasses and remote control were sanitized since it came from the soiled linens. The ESD stated the rest of the items were owned by the laundry staff. The ESD stated these items should not be in the clean folding area because it could cause contamination to the clean clothes and linens used by the residents. On 1/27/25 at 1347 hours, a interview was conducted with the IP. The IP stated the laundry room's clean folding area should be free of any employees and residents' personal belongings to prevent spread of infection and contamination of linens. The IP was informed and acknowledged the above findings.

3.a. On 01/22/25 at 1022 hours, a medication storage inspection for Station 1 was conducted with the DON. The ice buildup was observed on the back wall of medication refrigerator in Station 1. The DON verified the finding. b. On 01/22/25 at 1046 hours, a medication storage inspection for Station 3 was conducted with the DON. The ice buildup was observed in the freezer compartment of medication refrigerator in Station 3. The DON verified the finding. c. On 01/23/25 at 0814 hours, during an inspection of the specimen refrigerator with the Infection Preventionist, the freezer compartment of the specimen refrigerator was observed with ice buildup. The Infection Preventionist verified the finding. Based on observation, interview, and facility document and facility's P&P review, the facility failed to ensure the essential equipment was maintained in proper working order when: * The ice machine manufacturer's guidelines for cleaning and sanitizing were not followed. * The microwave located on Station 1 was not maintained in a safe operating condition. * Two medication refrigerators and one specimen refrigerator were observed with ice buildup. These failures had the potential for equipment hazards or unsafe practices which could affect the residents' well-being in the facility. Findings: 1. Review of the facility's P&P titled Cleaning the Ice Machine revised date of 4/2022 showed the ice machine shall be cleaned for maintenance of sanitary conditions in order to prevent food contamination and the growth of disease- producing organism and toxins. The ice machine shall be cleaned in accordance with the manufacturer's requirements. Review of the [Manitowoc] ice machine model 1-300/420/620 manufacturer's instructions located on the inside panel of the ice machine cover showed in part, the following: - Step 5- Remove parts for the cleaning. - Step 6- Mix a solution of cleaner and lukewarm water .one gallon water to 16 ounces(oz) cleaner. - Step 7- Use half of the cleaner mixture to clean all components . Rinse all components with clean water. Sanitizing Procedure: - Step 9- Mix a solution of two ounces sanitizer with three gallons of lukewarm water. - Step 10- Use half of the sanitizer/water solution to sanitize all removed components. Use a spray bottle to liberally apply the solution to all the surfaces of the removed parts or soak the removed parts (top, bottom, and sides), bin or dispenser. Do not rinse parts after sanitizing. On 1/21/25 at 907 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the facility's ice machine was cleaned monthly by the facility's maintenance staff and annually by the company and the ice machine manufacturer instructions were followed. The Maintenance Director further stated to clean the ice machine, he used five ounces of the descaler (a chemical solution that removes mineral deposits, or scale, from surfaces) mixed with one gallon of water. To sanitize the ice machine, he used one gallon of water mixed with three ounces of descaler. However, the Maintenance Director's methods of cleaning and sanitizing were not in accordance with the manufacturer's guidelines. 2. Review of the facility's P&P titled Sanitation dated 2018 showed all utensils, counters, shelves and equipment shall be kept clean, maintained and in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. On 1/21/25 at 1121 hours, an interview regarding heating food brought for the residents from the outside and concurrent inspection was conducted with RN 1. RN 1 stated the facility used the microwave located at Station 1 to heat food brought from the outside for the residents. The microwave was observed to have charred, burnt interior. RN1 confirmed the finding and stated she would have maintenance removed the microwave right away. On 1/21/25 at 1145 hours, an interview with the Maintenance Director was conducted on how the maintenance department was notified of any faulty equipment. The Maintenance Director stated there was a maintenance logbook in the nurses' stations or they called directly. The Maintenance Director further stated, they just called me now and I removed it when asked about the microwave in Station 1. On 1/23/25 at 1430 hours, an interview was conducted with the Administrator, Assistant Administrator, DON and CDM regarding the above findings. The Administrator, Assistant Administrator, DON and CDM acknowledged and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/21/25 at 0900 hours, during the initial tour of the facility, Resident 37 was observed in bed with bilateral grab rails elevated. Resident 37 stated she used the grab rails when turning and repositioning during incontinence care. Medical record review for Resident 37 was initiated on 1/30/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's MDS dated [DATE], showed Resident 37 was cognitively intact, with impairment to the upper extremities, and required partial/moderate assistance for mobility. Review of Resident 37's Bedrail/ Grab bar use and Entrapment Risk Evaluation dated 1/3/25, showed the following: - The grab bars were requested by the resident, and the resident demonstrated the ability to use the grab bars; - The possible risks of entrapment were discussed, and verbalized understanding and agreement for continued use. - The Entrapment Zones 1 to 4, and the boxes for yes were checked off; and - The IDT recommended bilateral grab bars for bed mobility/repositioning. Review of Resident 37's Informed Consent for the Use of Anything Attached to a Bed dated 1/3/25, showed if a bed rail or side rail is used, the facility will make sure that it is installed correctly, used correctly and maintained. The resident will be assessed for entrapment from the bed rails/[NAME] ails prior to their installation and the facility will make sure that the bed's dimensions are appropriate for the resident's size and weight. Review of Resident 37's Order Summary Report showed a physician's order dated 1/3/25, to provide grab bars on bilateral sides of the bed as enabler for bed mobility, turning and repositioning secondary to generalized weakness. Review of Resident 37's plan of care showed a care plan problem dated 1/3/25, addressing the use of grab bar as an enabling device that does not limit freedom of movement. The approach plan included to assess the resident for risk for entrapment prior to installation, ensure bed dimensions appropriate for the resident's size and weight, and for the maintenance to check grab bars monthly. On 1/22/25 at 1215 and 1544 hours, and 1/23/25 at 0835 hours, Resident 37 was observed in bed with bilateral grab rails elevated. On 1/23/25 at 0932 hours, an interview was conducted with CNA 3. When asked about Resident 37's use of bed rails, CNA 3 stated Resident 37 required extensive assist with mobility, but she could hold on to the grab bars when turning. On 1/23/25 at 1351 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 3. When asked about the entrapment assessment related to the use of grab bars, RN 3 stated the CNAs conducted the assessment to the make sure the resident was safe in using the grab bars. RN 3 stated, if there are concerns, then it will be delegated to the charge nurses, or if there was a problem, such as when the resident was tired from dialysis and could not grab the rails, then the CNAs would have to report to the charge nurse. When asked about the bed evaluation of Zones 1 to 4 marked yes in the evaluation form, RN 3 stated the bed evaluation was self-explanatory. When asked to elaborate, RN 3 was not able to identify and explain the zones of entrapment, specifically Zones 1 to 4. RN 3 stated RN 1 checked the bed and completed the grab bar evaluation form. RN 3 stated was not shown how to do the bed evaluation. On 1/24/25 at 1225 hours, a concurrent interview and facility document review for Resident 37 was conducted with the ESD. The ESD stated the maintenance department was responsible for the monthly bed inspection of all the beds in the facility, where they checked the whole bed, bed functionality, frame, bed control and the grab bars. The EDS stated the maintenance department also installed the grab bars. When asked what was used to measure the entrapment zones on each bed, the Environmental Services Director showed a piece of wood marked with different measurements. When asked to show the documentation of the results of bed inspection including the entrapment assessment, the Environmental Services Director showed the Siderail or Bedrail Assessment Guidance to Reduce Entrapment forms. Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for November 2024 showed Resident 37's bed was inspected on 11/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a for Resident 37's bed. Further review of the form showed other beds were left blank. Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for December 2024 showed Resident 37's bed was inspected on 12/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a for Resident 37's bed. Further review of the form showed other bed were marked with vertical lines. Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for January 2025 showed Resident 37's bed was inspected on 1/20/25. The form showed Zones 1, 2, 3, 4, and 7, and frame were marked ok and Zones 5 and 6 were marked N/A for Resident 37's bed. Further review of the form showed other beds were marked with vertical lines. The ESD verified the above findings. The ESD stated the entrapment assessment was conducted when the resident was not in the bed. The ESD stated they only marked ok when the bed passed the inspection, and n/a or not applicable. The ESD verified Zone 2 should have been checked. When asked about the other beds that were marked with vertical lines, the ESD stated those were the beds without grab bars, but the ESD was not able to explain why those rooms were marked with vertical lines. The ESD was not able to show a documented evidence of the regular inspection conducted for the beds without grab bars. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for four of four sampled residents (Residents 5, 13, 29, and 37) reviewed for side rails use. The facility also failed to ensure all the beds in the facility were regularly inspected. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety revised 8/2018 showed to try to prevent death/injury from the beds and related equipment (including frame, mattress, side rails, grab bars, headboard, footboard, and bed accessories), the facility shall promote the following approaches: - Inspection by maintenance staff of all beds and related equipment as part of the facility's regular bed safety program to identify any risks or problems including potential entrapment risks; - Review to ensure that gaps in the bed system do not present a hazard to the resident due to the resident's height and/or weight or due to the resident's movement or bed position; and - Ensure that if a grab bar or bed side rails are to be utilized those are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, ensure proper distance from the headboard and footboard, etc.). Review of the facility's P&P titled Side Rails or Bed Rails revised 8/2018 showed if a bed or side rail is used even for episodic use, the facility will make sure that it is installed correctly, used correctly, and maintained. The resident will be assessed for the risk of entrapment from the bed rails prior to its installation and the facility will make sure that the bed's dimensions are appropriate for the resident's size and weight. Review of the facility's P&P titled Side Rail or Bed Rail Assessment Guidance to Reduce Entrapment revised 8/2018, showed the facility had to assess the resident's risk for entrapment prior to the installation of side rails or bed rails to ensure the bed dimensions are appropriate for the resident's size and weight. The facility will assess the resident's risk for entrapment for the use of a grab bar using the facility's grab bar assessment. A concurrent observation, medical record review, and facility document review for Residents 5, 13, 29, and 37 showed the residents' bed entrapment assessments were not completed or the bed inspection gap measurement for Zone 2 was recorded. For example: 1. During the initial tour of the facility on 1/21/25 at 0958 hours, Resident 13 was observed awake and sitting in the wheelchair beside the bed. The bed was observed with bilateral upper side rails elevated. Resident 13 stated he grabbed the side rails during turning or when he was getting out of the bed. Medical record review for Resident 13 was initiated on 1/22/25. Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 4/30/24, showed Resident 13 had the capacity to understand and make decisions. The H&P examination also showed Resident 13 had a significant diagnosis of morbid obesity. Review of Resident 13's MDS dated [DATE], showed Resident 13 required partial to moderate assistance for bed mobility. Further review of Resident 13's medical record failed to show documented evidence an entrapment assessment was completed prior to installation of the side rails. On 1/22/25 at 0934 hours, an observation and concurrent interview was conducted with Resident 13. Resident 13 was observed awake and lying in the bed with the bilateral upper side rails elevated. Resident 13 stated he had been using the side rails for a long time and not just a month ago. Resident 13 further stated he needed the side rails to grab when he turned from side to side or when he was getting out of bed. On 1/22/25 at 1553 hours, a concurrent observation and interview was conducted with CNA 5. CNA 5 was observed leaving Resident 13's room. CNA 5 stated she just assisted Resident 13 with the bedpan. CNA 5 stated when Resident 13 was in bed, the bilateral side rails were always elevated. CNA 5 further stated Resident 13 grabbed on the side rails when being assisted with turning. On 1/23/25 at 1418 hours, a concurrent interview and medical record review for Resident 13 was conducted with LVN 1. LVN 1 stated an entrapment risk assessment should be completed prior to installation of side rails. LVN 1 stated the maintenance department was responsible for installing the side rails and measuring the gaps in bed. LVN 1 verified no assessment for the risk of entrapment from elevated side rails was done for Resident 13 prior to installation. 2. During the initial tour of the facility on 1/21/25 at 0855 hours, Resident 29 was observed awake and lying in the bed with the bilateral upper side rails elevated. Resident 29 stated she grabbed on the side rails when being turned for care provided or when she needed to get in or out of the bed. Medical record review for Resident 29 was initiated on 1/21/25. Resident 29 was readmitted to the facility on [DATE]. Review of Resident 29's H&P examination dated 10/25/24, showed Resident 29 had the capacity to understand and make decisions. The H&P also showed Resident 29 had a diagnosis of left hip fracture status post left hip replacement. Review of Resident 29's MDS dated [DATE], showed Resident 29 required partial to moderate assistance for bed mobility. Review of Resident 29's Order Summary Report showed a physician's order dated 10/28/24, for grab bars on both sides of the bed as enabler for turning/repositioning due to osteoporosis (a condition in which bones become weak and brittle)/rheumatoid arthritis (a chronic inflammatory disorder that affects the joints). Review of Resident 29's Bedrail/Grab bar use and Entrapment Risk Evaluation dated 10/28/24, showed the following: - The grab bars were requested by the resident, and the resident demonstrated the ability to use the grab bars; - The possible risks of entrapment were discussed, and verbalized understanding and agreement for continued use. - The Entrapment Zones 1 to 4, and the boxes for yes were checked off; and - The IDT recommended bilateral grab bars for enabler, turning/repositioning on bed. Review of Resident 29's Informed Consent for the Use of Anything Attached to a Bed dated 10/28/24, showed if a bed rail or siderail is used, the facility will make sure that it is installed correctly, used correctly and maintained. The resident will be assessed for entrapment from the bedrails/side rails prior to their installation and the facility will make sure that the bed's dimensions are appropriate for the resident's size and weight. Review of Resident 29's plan of care showed a care plan problem dated 10/28/24, to address the use of grab bar as an enabling device that does not limit freedom of movement. The approach plan included to assess the resident for risk for entrapment prior to installation, ensure bed dimensions appropriate for the resident's size and weight, and maintenance to check grab bars monthly. On 1/22/25 at 1041 hours, a concurrent observation of Resident 29 and interview with CNA 4 was conducted. Resident 29 was transferring from the wheelchair to the bed and being assisted by CNA 4. Resident 29 was observed grabbing to the right grab rail. CNA 4 stated Resident 29 had always have the side rails. CNA 4 stated Resident 29 held on the rails during repositioning or when she was getting out or in the bed. On 1/23/25 at 1446 hours, a concurrent interview and medical record review for Resident 29 was conducted with RN 3. When asked about the entrapment assessment related to the use of grab bars, RN 3 stated the CNAs could conduct the assessment to the make sure the resident was safe in using and really in need of the grab bars. RN 3 stated the licensed nurses would verify the assessment as well. When asked about the bed evaluation of Zones 1 to 4 marked yes in the evaluation form, RN 3 stated the maintenance staff was the one who was filling up the sections for Zones 1 to 4. On 1/24/25 at 1225 hours, a concurrent interview and facility document review for Residents 13 and 29 was conducted with the Environmental Services Director (ESD). The ESD stated the maintenance department was responsible for the monthly bed inspection of all the beds in the facility, where they checked the whole bed, bed functionality, frame, bed control, and grab bars. The ESD stated the maintenance department also installed the grab bars. When asked what was used to measure the entrapment zones on each bed, the Environmental Services Director showed a piece of wood marked with different measurements. When asked to show the documentation of the results of bed inspection including the entrapment assessment, the ESD showed the Siderail or Bedrail Assessment Guidance to Reduce Entrapment forms. Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for November 2024 showed the following: - Resident 13's bed was inspected on 11/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a. - Resident 29's bed was inspected on 11/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a. Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for December 2024 showed the following: - Resident 13's bed was inspected on 12/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a. - Resident 29's bed was inspected on 12/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a. Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for January 2025 showed the following: - Resident 13's bed was not inspected. - Resident 29's bed was inspected on 1/20/25. The form showed Zones 1, 2, 3, 4, and 7, and frame were marked ok and Zones 5 and 6 were marked n/a. The ESD verified the above findings. The ESD stated the entrapment assessment was conducted when the resident was not in the bed. The ESD stated they only marked ok when the bed passed the inspection, and n/a or not applicable. The ESD verified Zone 2 should have been checked. When asked about the other rooms that were marked with vertical lines, the ESD stated those were the rooms with beds without grab bars but was not able to explain why those rooms were marked with vertical lines. The ESD was not able to show documented evidence of the regular inspection of the beds without grab bars. On 1/27/24 at 1445 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Medical record review for Resident 5 was initiated on 1/22/25. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 2/3/24, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's MDS dated [DATE], showed Resident 5s BIMS score was not conducted due to the resident rarely or never understood. Review of Resident 5's Order Summary Report dated 12/31/24, showed to use bilateral half side rails on both sides of the bed due to poor trunk control secondary to brain injury or seizures. On 1/22/24 at hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 verified Resident 5 had the bilateral side rails elevated while in bed. CNA 1 stated Resident 5 required total assistance from staff with ADL cares. On 1/24/25 at 1225 hours, a concurrent interview and record review was conducted with the ESD. Review of the Side rail or Bed Rail Assessment Guidance to Reduce Entrapment Logs of Resident 5 dated 12/8/24, did not show Zone 2 entrapment assessment was completed. The ESD verified the finding. The ESD stated Zone 2 was not measured because it was close to the bed. On 1/27/24 at 0856 hours, a concurrent observation and interview was conducted with LVN 3. LVN 3 verified Resident 5 had bilateral half side rails elevated while resident in bed. On 1/27/25 1400 at hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the correct cutting board was used for raw poultry. * The facility failed to ensure the sanitizing solution used to sanitize food preparation surfaces was the proper concentration. * The facility failed to ensure kitchen equipment and utensils were clean . * The facility failed to ensure kitchen equipment and utensils were air dried . * The facility failed to ensure maintenance tools were stored in a sanitary manner . These failures had the potential to cause bloodborne illness in a medically vulnerable resident population of 94 who consumed food prepared from the kitchen. Findings: Review of the facility's undated matrix showed 94 of 106 residents received food prepared in the kitchen. 1. According to US Food and Drug Administration (USFDA) Food Code Section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) Food shall be protected from cross contamination by: (2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (a) Using separate equipment for each type. Review of the facility's document titled US Cutting Board Color Chart undated showed Red - raw beef, pork, lamb, and other types of raw meat; Yellow - raw poultry, such as chicken, turkey and duck; Blue - raw fish, shellfish, and other seafood products; [NAME] - dairy and baked goods; [NAME] - fruits, vegetables and salads; [NAME] - cooked meat, such as roast, beef or ham. On 1/21/25 at 805 hours, during the initial inspection of the facility's kitchen with Dietary Aide (DA) 1, [NAME] 1 was observed cutting raw chicken using a red cutting board. [NAME] 1 was asked if it was okay to use the red cutting board for raw chicken, [NAME] 1 did not answer. DA 1 verified a yellow cutting board must be used for the raw poultry. 2. According to the USFDA Food Code Section 3-304.14 Wiping Cloths, Use Limitation. (B) Cloths in-use for wiping counters and other surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114. Review of the facility's P&P titled Quaternary Ammonium Log Policy dated 2018 showed . the quaternary solution will be replaced when the reading is below 200 parts per million (ppm). On 1/21/25 at 1419 hours, DA 2 was asked to test the sanitizing solution in the sanitizing bucket. DA 2 used the sanitizing test strip to check the concentration of the sanitizing solution. The sanitizing solution test strip showed the concentration of the sanitizing solution was 150 ppm. DA 2 confirmed the concentration of the sanitizing solution was not the correct concentration. On 1/23/25 at 956 hours, an interview was conducted with the CDM. The CDM stated the sanitizing solution should be changed every four hours and as needed. 3. According to USFDA Food Code 2022 Section 4-601.11Equipment, Food Contact Surfaces, Non- Food Contact Surfaces and Utensils. (A) Equipment, food- contact surfaces and utensils shall be clean to sight and touch. On 1/21/24 at 805 hours, during the initial tour of the kitchen with DA 1, the following were observed: - a blender had a brown residue on the inside of the pitcher; - a microwave had food residue on the turntable and inner part of the microwave door; - a toaster with a thick brown, greasy build up; and - a robocoupe (a device used to chop and puree food), blade and bearing assembly had a brown residue. DA 1 confirmed the above findings. 4. According to the USFDA Food Code 2022 Annex, Section 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. On 1/21/24, at 0805 hours, during the initial tour of the kitchen with DA 1, the following were observed - six steam table pans stacked and stored wet, - the robot coupe, was stored wet with the top on, and - the blender was stored wet with the top on . DA 1 confirmed the above findings. 5. According to the USDA Food Code 2022 section 6- 501.113 Storing Maintenance Tools. Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: A Stored so that they do not contaminate food, equipment, utensils. On 1/21/25 at 805 hours, during the initial kitchen inspection with DA 1, two brooms were observed on the floor, DA1 verified and moved the brooms to the designated storage by the wall. On 01/23/25 1430 hours, a concurrent interview was conducted with the Administrator, Assistant Administrator, DON, and CDM. The Administrator, Assistant Administrator, DON and CDM were informed and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) remained free from the accident hazards. * CNA 1 had provided ADL care to Resident 1 in bed by herself instead of two or more persons to assist as per the resident's MDS and plan of care. When CNA 1 turned the resident to the right side, the resident rolled and fell off the bed to the floor sustaining multiple bruises and a skin tear to the right cheek. This failure had the potential for Resident 1 to sustain serious injury. Findings: Review of the facility's P&P titled Fall Risk/Prevention revised 7/2018 showed the policy of the facility is to identify the residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. Upon admission, a Fall Risk Assessment will be completed for all residents. If the Fall Risk Assessment score is 10 or above, the resident is at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls. Review of the facility's P&P titled Safety and Supervision of Residents revised 2/2019 showed the policy of the facility is to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The resident-oriented approach to safety addresses safety and accident hazards for individual residents. The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for each resident. The care team shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented, and documenting interventions. Closed medical record review for Resident 1 was initiated on 1/23/24. Resident 1 was admitted to the facility on [DATE], and discharged on 1/16/24, to the acute care hospital. Review of Resident 1's H&P examination dated 7/10/23, showed Resident 1 could make needs known but could not make medical decisions. Resident 1's MDS, Section G Functional Status dated 8/15/23, showed Resident 1 required two or more persons for physical assistance for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed) and transfers (how resident moves between surfaces including to and from: bed, chair, wheelchair). Resident 1's MDS, Section C, dated 11/14/23, showed Resident 1 had severely impaired cognition. Resident 1's Fall Risk assessment dated [DATE], showed Resident 1 was a high risk for falls. Review of Resident 1's care plan titled Need Assistance with ADL care updated 11/16/23, showed Resident 1 needed two to three staff to assist with toileting hygiene, toilet transfers, and chair/bed transfers. Review of Resident 1's Weekly Summary dated 1/12/24, showed the resident needed two or more persons' assistance for ADL support for bed mobility and transfers. Review of Resident 1's Nurses Progress Notes dated 1/16/24 at 1110 hours, showed Resident 1 sustained a fall while receiving ADL care from CNA 1. Resident 1 was placed on her right side while being cleaned in bed and Resident 1 fell onto the floor before CNA 1 was able to catch her. Resident 1 was observed to have the following wounds: - right check ecchymosis (bruising) with skin tear - right below the ear scratch - right elbow ecchymosis - right upper arm bluish-purplish skin discoloration - right forearm ecchymosis - right 3rdtoe purplish discoloration - right 4thtoe purplish discoloration - left lateral knee bluish discoloration Review of Resident 1's Body/Skin Check form dated 1/16/24, showed Resident 1 had the above wounds. Review of Resident 1's care plan titled Status Post Fall dated 1/16/24, showed an intervention for the resident to always need two-person assist during care. On 1/18/24 at 1500 hours, an interview was conducted with Resident 1's DPOA for healthcare (Family Member 1). Family Member 1 stated she was not contacted regarding Resident 1 sustaining a fall while in the facility. On 1/23/24 at 0900 hours, an interview was conducted with CNA 1. CNA 1 stated she was assigned to care for Resident 1 at the time of her fall on 1/16/24 at 1110 hours. CNA 1 stated she provided one-person assist during transfers in and out of bed and ADL care for Resident 1. CNA 1 stated she knew Resident 1 was a two-person assistance. CNA 1 stated at the time of Resident 1's fall, she was cleaning the resident after the resident had a bowel movement and had placed Resident 1 on her right side with Resident 1's back toward CNA 1. CNA 1 stated Resident 1 then rolled away from her, off the bed, and fell onto the floor. CNA 1 stated she left Resident 1's room to call LVN 1 for assistance. On 1/23/24 at 0940 hours, an interview was conducted with LVN 1. LVN 1 stated she was assigned to care for Resident 1 at the time of her fall on 1/16/24 at 1110 hours. LVN 1 stated Resident 1 was a two-person assist with transfers and ADL care. LVN 1 stated after Resident 1 had fallen, he entered Resident 1's room. LVN 1 stated he saw Resident 1 laying on her side on the floor next to her bed. LVN 1 stated Resident 1 had sustained the above wounds. LVN 1 stated Resident 1 should have been provided with two-person assist during the time of Resident 1's fall. LVN 1 stated Resident 1 was then transferred back onto her bed using four staff members with the use of Hoyer lift. On 1/23/24 at 1015 hours, an interview was conducted with RN 1. RN 1 stated she was assigned to care for Resident 1 at the time of her fall on 1/16/24 at 1110 hours. RN 1 stated Resident 1 was a two-person assist with transfers and ADL care. RN 1 stated after Resident 1 had fallen and transferred back onto her bed, she entered Resident 1's room. RN 1 stated LVN 2 was providing wound treatment to the above wounds. On 1/24/24 at 0830 hours, an interview was conducted with CNA 2. CNA 2 stated she had been previously assigned to Resident 1 prior to her sustaining the fall on 1/16/24 at 1110 hours. CNA 2 stated Resident 1 was a two-person assist for transfers and ADL care. On 1/24/24 at 1315 hours, an interview was conducted with LVN 2. LVN 2 stated he provided wound treatment to Resident 1 after her fall on 1/16/24 at 1110 hours. On 1/24/24 at 1530 hours, an interview was conducted with the DON. The DON stated Resident 1 was a two- person assist with transfers and ADL care. The DON stated there was a note in Resident 1's closet stating she was a two-person assist. The DON stated CNA 1 should not have been providing assistance to Resident 1 by herself and there should have been one additional staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop and implement the individualized resident-centered plans of care for one of two sampled residents (Resident 2). * Resident 2's care plan interventions were not implemented as recommended in PASRR Level II evaluation. * Resident 2's desire to be discharged to a lower level of care was not assessed by the IDT team and reflected in the plan of care. These failures posed the risk of not providing appropriate and individualized care to Resident 2 to maintain her highest practicable physical well-being. Findings: Review of the facility's P&P titled Comprehensive Care Planning revised 3/2019 showed there should be coordination of the assessment with the Preadmission Screening and Resident Review (PASRR) to ensure that residents with a mental disorder, intellectual disability or a related condition receive care and services in the most integrated setting appropriate to their needs. Coordination includes incorporating recommendations from the PASRR level II determination and the PASRR evaluation report into the resident's assessment, care planning and transitions of care. When the resident has no family or responsible party and is unable to make his/her own health care decisions, the IDT will act as surrogate decision maker. Review of the facility's P&P titled Discharge Planning Process revised 10/2017 showed to identify the discharge needs of each resident and result in the development of a discharge plan. If a resident expresses an interest in returning to the community, the facility should document any referrals to local contact agencies or other appropriate entities for this purpose. If discharge to the community is determined to not be feasible, the facility will document who made the determination and why this determination was made. Medical record review for Resident 2 was initiated on 10/24/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE],with a diagnosis of psychosis. Review of Resident 2's Individualized Determination Report following PASRR Level II dated 7/13/23, under the Recommended Specialized Services section, showed the social workers could also arrange for the safe and orderly transition to alternative levels of care when appropriate and facilitate the communication with other caregivers. The alternative placements and services included Residential Care Facility for the Elderly, Adult Residential Facility and Program of All Inclusive Care for the Elderly. Review of Resident 2's History and Physical Examination dated 7/15/22, showed Resident 2 could make needs known but could not make medical decisions. Review of Resident 2's Order Summary Report for October 2023 showed the following physician's orders: - dated 9/7/23, for Depakote (anticonvulsant) 500 mg 250 mg by mouth in the morning for mood stabilizer for labile mood m/b striking out. - dated 7/7/23, for Aripiprazole (antipsychotic) 5mg by mouth a day for psychosis m/b responding to internal stimuli. Review of Resident 2's Behavior and Psychotropic Summary/Dosage Reduction for Depakote and Aripiprazole showed Resident 2 did not have behavioral episodes of striking out or responding to internal stimuli from 2/21/23 to 9/30/23. Review of Resident 2's Care Plan updated 10/12/23, showed the care plan problem addressing PASRR evaluation Level II on 7/12/23. The DHCS reviewed the findings and made determination about the most suitable setting for the resident's care and needs for specialized services based on the resident's medical and social history, strength, and personal goals. The approaches showed alternative community settings and features included Residential Care Facility for Elderly, Adult Residential Facility, Program of All inclusive Care for the Elderly, Residential Care Facility for Mentally Ill and Senior Living Facility. Review of Resident 2's Nurse Practitioner Progress Notes dated 5/17, 6/21, 9/13, and 10/11/23, showed Resident 2 asked to be discharged . Review of Resident 2's social services notes dated 7/19, 7/23, and 8/21/23, showed Resident 2 desired to move out of the facility. Review of Resident 2's Psychiatric Following up Note dated 8/28/23, showed Resident 2 would like to be discharged from the facility and speak to a social worker. Resident 2 was diagnosed with dementia with behavioral disturbance and depression. Review of Resident 2's Weekly Summary dated 10/6/23, under the ADL Self-Performance/ADL Support section showed Resident 2 was able to perform bed mobility, dressing, eating, toileting, personal hygiene, bathing and walking with supervision. On 10/24/23 at 1125 hours, an interview was conducted with Resident 2. Resident 2 was observed alert, oriented, calm, and ambulated independently. Resident 2 stated he felt he could never leave the facility and needed help. Resident 2 stated he wanted the physician to let him find somewhere else to live. On 10/24/23 at 1215 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated Resident 2 had no contact information, and the IDT was authorized for Resident 2's medical decision. The SSD confirmed Resident 2's request to be discharged inJuly 2023 was not followed up. The SSD stated they needed to get the psychiatrist to re-evaluate Resident 2 to discharge him to a lower level of care such as a memory care assisting living. The SSD stated she also needed to drive the resident to DMV to get an ID to start with the process of discharge. The SSD confirmed the IDT discharge planning was not met for Resident 2. On 10/31/23 at 1045 hours, a follow-up telephone interview was conducted with the SSD. The SSD stated she needed to contact the Care Coordinator from public guardian office to go over the resident's information to decide if Resident 2 needed a public guardian and application for conservatorship. The SSD stated Resident 2 had no family member to apply for a public guardian. On 11/1/23 at 1215 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator stated the care plan was updated based on the recommendation from the PASRR. The IDT team would meet to see if the resident was capable of being discharged . If Resident 2 had no family and had no capacity to make decision, Resident 2 would need help to apply for the conservatorship to medical decision and discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to obtain a copy of advance directive for one of 22 final sampled residents (Resident 44). This had the potential for the residents' advanced care planning decisions regarding the health care and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 4/2017 showed prior to, or upon admission, the residents will be provided with written information concerning the residents' rights under State law to accept or refuse medical or surgical treatment and the residents' right to prepare an advance directive. The resident or their responsible party will be asked if the resident has completed an advance directive, and to provide a copy of the document for the resident's clinical record. Medical record review for Resident 44 was initiated on 4/18/22. Resident 44 was admitted to the facility on [DATE]. Review of the POLST dated 2/12/22, showed Resident 44 had an advance directive dated 1/6/22, and the Public Guardian was named as the Health Care Agent. The POLST was signed by Resident 44's daughter who identified herself on the POLST form as the conservator. However, there was no copy of the advance directive available to review in Resident 44's medical record. On 4/21/22 at 0848 hours, a concurrent interview and medical record review was conducted with the SSD. The SSD was asked regarding the facility's process when the POLST showed the resident had an advance directive. The SSD stated the facility collected the information from the responsible party and asked to provide a copy of the advance directive. The SSD verified Resident 44's advance directive was not in the medical record. On 4/21/22 at 0923 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator and the Admissions Coordinator. The Admissions Coordinator verified Resident 44's POLST dated 2/12/22, showed Resident 44 had an advance directive dated 1/16/22. When was asked if a copy of Resident 44's advance directive was requested, the Admissions Coordinator stated she called the Public Guardian's office when Resident 44 was admitted in February 2022, but did not document in the resident's medical record. When asked if she had followed through to request for a copy, the Admissions Coordinator stated no. The MDS Coordinator was asked what could potentially happen when the copy of Resident 44's advance directive was not available in the medical record, the MDS Coordinator stated it may result in a conflict with the resident's wishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 60's medical record was initiated on 4/21/22. Resident 60 was admitted to the facility on [DATE]. Review of the PASRR evaluation dated 2/24/22, showed Resident 60 had a positive Level I Screening and a Level II Mental Health Evaluation was required. Further review of Resident 60's medical record did not show the result for the Level II Mental Health Evaluation. On 4/21/22 at 1630 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified Resident 60 required to have PASRR level II evaluation. When asked about the result of the level II mental health evalutiona, RN 2 verified there was none. Based on interview, medical record review, facility document review, and DHCS PASRR guidelines review, the facility failed to ensure PASRR Level II Mental Health Evaluation was conducted as required for two of 22 final sampled residents (Residents 44 and 60). This failure had the potential for the residents to not receive the specialized care and services appropriate for their condition. Findings: 1. According to the DHCS, federal law requires all individuals seeking admission to a Medicaid Certified Nursing Facility (NF) to receive a Level 1 Screening. The Level 1 Screening identifies if an individual has a suspected Mental Illness (MI) or an Intellectual/Developmental Disability or Related condition (ID/DD/RC). If MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services. This process is known as the Preadmission Screening and Resident Review (PASRR). Review of the facility's P&P titled PASRR (Preadmission Screening Resident Review) revised 03/2019, showed if the result of the level 1 screening is positive due to a diagnosed or suspected mental illness identified, the level 1 screening will automatically be sent to the DHCS Contractor for a level II prescreening call. Review of the facility document titled DHCS PASRR Updates dated 3/14/22, showed to submit medical records to within 48 hours upon submitting a positive Level 1 screening. The following medical records are to be requested: facesheet; History and Physical; most recent and complete MDS; Medication Administration Records; current physician orders; current notes from physicians/nursing/specialist; social services notes, psychosocial and discharge plan if available; discharge summary from previous acute hospital or psychiatric, if applicable; and care plans. If the medical records are not received within 48 hours from submitting the positive case, the case will be closed and the nursing facility will be required to submit a new Level 1 screening Review of Resident 44's medical record was initiated on 4/18/22. Resident 44 was admitted to the facility on [DATE]. Review of the PASRR evaluation dated 2/8/22, showed Resident 44 had a positive Level 1 Screening and the Level II Mental Health Evaluation was required. Further review of Resident 44's medical record did not show the result for the Level II Mental Health Evaluation. On 4/21/22 at 1546 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated she was responsible in conducting the PASRR Level 1 screening on the day of the resident's admission to the facility and submitted online. RN 2 verified the PASRR Level 1 evaluation dated 2/8/22, showed the Level II Mental Health Evaluation was required for Resident 44. When asked what the result was for the Level II screening, RN 2 stated she did not know what happened and was not aware if the Level II screening was done or not. On 4/21/22 at 1601 hours, an interview and concurrent medical record review was conducted with the BOM. The BOM stated she was in charge of printing the results for the PASRR Level II Mental Health Evaluation. The BOM stated the PASRR evaluator would call the facility to check if the resident was still in the facility or had been discharged . The BOM verified Resident 44's PASRR Level II Mental Health Evaluation was not conducted. The BOM verified there was no documentation to show the attempts were made by the facility to reach out to the DHCS to inquire about Resident 44's Level II Mental Health Evaluation. On 4/21/22 at 1715 hours, an interview and concurrent medical record review was conducted with the Administrator and MRD. The Administrator verified and acknowledged the information received from the DHCS. The MRD stated she was responsible for sending documents to the PASRR. The MRD stated she was not able to send the documents to the PASRR because the documents were never requested. However, the letter from the DHCS showed to efficiently complete the PASRR Level II Evaluations, the DHCS requested the SNFs send medical records to Kepro within 48 hours upon submitting a positive Level 1 screening. The Administrator acknowledged the findings and stated she would call the DHCS to follow up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 22 final sampled residents (Resident 36) and one nonsampled resident (Resident 35). * Resident 36's Floranex (probiotic supplement) was not administered as ordered by the physician. * Resident 35's florastor (probiotic supplement) and carbonyl iron (supplement) were not administered as ordered by the physician. These failures posed the risk for possible complications related to residents not receiving the prescribed medications. Findings: Review of the facility's P&P titled Preparation and General guidelines IIA2: Medication Administration - General Guidelines dated 10/2017, under the section for Administration, showed the medications are administered in accordance with the written orders of the attending physician. 1. On 4/20/22 at 0929 hours, a medication administration observation for Resident 36 was conducted with LVN 2. LVN 2 prepared and administered the following medications: - 30 ml of active liquid protein (supplement), - 7.5 ml of ferrous sulfate (iron supplement) 220 g/5 ml, - 15 ml of lactulose solution (laxative)10 g/15 ml, - one tablet of metoprolol tartrate (medication for hypertension) 25 mg, - 10 ml of valproic acid (antiseizure medication) 250 mg/5 ml, - one tablet of acetaminophen (analgesic) 325 mg. Review of Resident 36's medical record was initiated on 4/20/22. Resident 36 was admitted to the facility on [DATE]. Review of the Physician Order Report showed a physician's order dated 8/6/19, to administer Floranex one million cells tablet via gastric tube (a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications) once a day for supplement. Review of the MAR dated April 2022 showed the Floranex medication was not administered to Resident 36 for the entire month. On 4/20/22 at 1315 hours, an interview was conducted with LVN 2. LVN 2 verified Resident 36's Floranex was not administered as ordered by the physician. 2. On 4/20/22 at 0838 hours, a medication administration observation for Resident 35 was conducted with LVN 1. LVN 1 prepared and administered the following medications: - one tablet of Trajenta (medication for blood sugar control) 5 mg, - one tablet of oxybutynin chloride ER (urinary bladder medication)5 mg, - one tablet of Tamsuloatsin HCL (Urinary retention medication) 0.4 mg, - 15 ml of potassium chloride (supplement) 10% 20 meq/15 ml, - one tablet of buspirone (antianxiety medication) 5 mg, - one and half tablets of midodrine HCL (blood pressure medication) 10 mg, - one tablet of vitamin with mineral (supplement), - one tablet of senna (stool softener) 8.6 mg, - one tablet of sodium chloride (supplement) 1 gm, and - one tablet of magnesium oxide (laxative) 400 mg. Review of Resident 35's medical records was initiated on 4/20/22. Resident 35 was admitted to facility on 1/25/21. Review of the Physician Order Report showed the following: - the order dated 2/22/21, to administer florastor (supplement) 250 mg by mouth once a day for supplement - the order dated 6/30/21, to administer carbonyl iron (supplement) 50 mg by mouth once a day for supplement. On 4/21/22 at 1449 hours,an interview was conducted with LVN 1. LVN 1 verified Resident's 35's florastor and carbonyl iron were not administered as ordered by the physician. Cross reference to F842.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 22 final sampled residents (Resident 45). * Resident 45 who had bilateral ½ sides in bed was not assessed for risk for entrapment. This failure posed the risk for injury from side rail use. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and ed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. According to the facility's P&P titled Siderails or Bedrails revised 8/2018, the residents will be assessed for risk for entrapment from the bedrails prior to installation. On 4/18/22 at 1432 hours, and 4/20/22 at 0838 hours, Resident 45 was observed lying in bed. Resident 45 had ½ siderails up on both side of the bed. Review of Resident 45's medical record was initiated on 4/20/22. Resident 45 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Physician's Orders dated 12/4/14, showed to provide ½ bilateral side rails in bed due to poor trunk control. Review the MDS dated [DATE], showed Resident 45 was totally dependent on one staff for bed mobility. Review of the Physical Restraints Form dated 2/14/22, showed Resident 45 had poor trunk control. The recommendation for Resident 45 was to continue to provide 1/2 padded bilateral side rails for safety. Review of the Bedrail/Grab Bar use and Entrapment Risk Evaluation dated 2/14/22, showed Resident 45 had 1/2 padded side rails on both sides of the bed. The documentation did not show Resident 45 was assessed for the risk for entrapment. Review of the care plan showed a care plan problem addressing Resident 45 risk for falls updated on 8/18/21, showed the interventions to provide the padded 1/2 side rails on both sides of the bed. On 4/20/22 at 0909 hours, an interview conducted with CNA 1. CNA 1 stated Resident 45 was totally dependent on the staff with his ADL care. CNA 1 stated Resident 45 had been using the bilateral side rails for safety. On 4/20/22 at 1518 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. When asked about the process for the residents who used the side rails, the MDS Coordinator stated the licensed nurses and DON were responsible for conducting the side rail assessments. The MDS Coordinator stated the residents using the side rails had to be assessed for their risk for entrapment. When asked to show if Resident 45 was assessed for the risk for entrapment, the MDS Coordinator verified there was none. Cross reference to F909.

Based on the observation, interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one nonsampled resident (Resident 35). * LVN 1 documented on the MAR for Resident 35's Florastor (supplement) and carbonyl iron (iron supplement) as given when they were not administered during the medication administration observation. In addition, LVN 1 documented both of Resident 35's medications as administered even when they were not available. These failures had the potential for the resident's care not being met as his medication administration was inaccurate. Findings: According to the facility's P&P titled Preparation and General guidelines IIA2: Medication Administration - General Guidelines dated 10/2017, under the section for Documentation, it showed the following: - if a dose of a regularly scheduled medication is withheld, refused or given at other than the schedule time (e.g. the resident is not in the facility at scheduled dose time, or a started dose of antibiotic is needed, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. On 4/20/22 at 0838 hours, a medication administration observation for Resident 35 was conducted with LVN 1. Resident 35's Florastor (supplement) and carbonyl iron (supplement) were not administered to the resident. Review of Resident 35's medical records was initiated on 4/20/22. Resident 35 was admitted to facility on 1/25/21. Review of Physician Order Report showed the following: - the order dated 2/22/21, to administer florastor (supplement) 250 mg by mouth once a day for supplement, - the order dated 6/30/21, to administer carbonyl iron (supplement) 50 mg by mouth once a day for supplement. Review of the MAR dated April 2022 showed LVN 2's initials for Resident 35's Florastor and carbonyl iron indicating the two medications were administered on the following dates: - 4/18/22 - 4/19/22 - 4/20/22 - 4/21/22 On 4/21/22 at 1449 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 stated during the medication administration observation conducted on 4/20/22, Resident 35's florastor and carbonyl iron were not administered because they were not available. LVN 1 stated both medications were not available since 4/18/22. When asked about her initials on both medications in the MAR from 4/18-4/21/22, LVN 1 acknowledged she wrote her initials on Resident 35's florastor and carbonyl iron but did not administer the medications. LVN 1 stated she should have encircled her initials for Resident 35's florastor and carbonyl iron and documented the reason for not administering the medications on the back of the MAR. LVN 1 verified Resident 35 had run out of the medications since 4/18/22, and the medications were documented as administered in the MAR. 4/22/22 1415 hours, an interview was conducted with the DON. The DON stated when a resident's medication was not given, the nurse should encircle her initial on the date as it was not administered and documented the reason for not administering the medication on the back of MAR. Cross reference to F684, example #2.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment were implemented. * The facility failed to use the appropriate disinfectant to clean the porous foam on Resident 45's bilateral siderails. This posed the risk for not adequately cleaning and disinfecting the resident's equipment. Findings: Review of the facility's P&P titled Infection Control revised 5/2018 showed the facility has established infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the manufacturer's information for Clorox Bleach Germicidal Wipes showed the recommended use is for hard, non-porous surfaces. On 4/20/22 at 0838 hours, Resident 45 bed was observed with the bilateral side rails padded with a gray porous (full of tiny holes or opening, where fluids could go through) material. The pads were attached to the bed with a tape. The pads were frayed and torn. On 4/20/22 at 0909 hours, an interview was conducted with CNA 1. When asked what the side rail padding was for, CNA 1 stated the padding was to protect Resident 45 from developing skin tears. When asked who was responsible for cleaning the side rail paddings, CNA 1 stated the housekeeping staff was responsible for cleaning but did not know how often it was cleaned. On 4/20/22 at 0921 hours, an interview was conducted with LVN 3. When asked what type of material was used for the padding, LVN 3 stated she did not know. When asked about how the padding was cleaned, LVN 3 stated the housekeeper was responsible for cleaning the pads. LVN 3 stated the Clorox sanitizer was used for cleaning the paddings. LVN 3 showed the Clorox container with information on the label showing for cleaning the hard and nonporous surfaces. When asked what if the pads were not cleaned properly, LVN 3 stated it would smell and put the resident at risk for infection from the bacteria building up in the pads. On 4/20/22 at 0940 hours, an observation and concurrent interview was conducted with Housekeeper 1. When asked how the pads on the side rails were cleaned, Housekeeper 1 stated she used the Clorox wipes. When asked what type of material was the padding made of, the Housekeeper 1 stated it was made of porous material. Reviewed the label of the Clorox container with Housekeeper 1 and she acknowledged it was only for cleaning and disinfecting hard and nonporous surface. When asked if the Clorox wipes would be appropriate for cleaning the padding, Housekeeper 1 stated no. When asked what could potentially happen when the pads were not thoroughly cleaned, Housekeeper 1 stated the microorganism would remain in the paddings.

Based on observation, interview, and facility P&P review, the facility failed to ensure regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents in the facility. Findings: According to the facility's P&P titled Siderails or Bedrails revised 8/2018, the facility will make sure the bed dimensions are appropriate for the resident's size and weight. The maintenance department will check side rails and bed rails prior to resident's use and monthly for proper installation and functioning. The maintenance department will maintain a log of the side rails check. On 4/18/22 at 1432 hours, and 4/20/22 at 0838 hours , Resident 45 was observed lying in bed. Resident 45 had ½ siderails up on both side of the bed. On 4/20/22 at 1610 hours, an interview was conducted with the Maintenance Supervisor. When asked what the process was for the residents who needed a side rail installed, the Maintenance Supervisor stated the licensed nurses would inform him if the resident will need one. The Maintenance Supervisor stated he would just install the side rail and check if the bed was working properly. The Maintenance Supervisor stated he would also check if there was a gap between the mattress and the grab bars or side rails. When asked why it was necessary to check the beds prior to the installation of bed rails, the Maintenance Supervisor stated the resident could get stuck in between the bed and rail. On 4/20/22 at 1711 hours, a follow-up interview was conducted with the Maintenance Supervisor and MDS Coordinator. The Maintenance Supervisor verified he had not been checking the beds and siderails for entrapment zones for the past two years. The MDS Coordinator stated the facility had been moving a lot of beds and were not able to follow up on checking the residents' beds. The Maintenance Supervisor acknowledged he had no documentation to show Resident 45's bed was checked on a regular basis to ensure safety of the siderail use. Cross reference to F700.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine was maintained in sanitary condition. * The facility failed to follow proper sanitation and food handling practices to prevent a potential outbreak of foodborne illnesses during the preparation of pureed foods. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: 1. Review of the form CMS-672 titled Resident Census and Conditions of residents completed by the DON dated 4/18/22, showed 106 of 106 residents residing in the facility received food prepared in the kitchen. According to the FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility form titled Monthly Cleaning and Sanitation of the Ice Machine with multiple dates showed the ice machine cleaning was completed on 3/23/22. On 4/19/22 at 1547 hours, an observation and concurrent interview was conducted with the Maintenance Director/Supervisor. The ice machine was observed with black substance when the inside of the ice machine was wiped with a white paper towel. The Maintenance Director/Supervisor verified and acknowledged above findings. 2. According to the facility's P&P titled Food Preparation dated 2011, the employees will prepare food in a clean and safe manner to protect residents and staff from foodborne illness. On 4/20/22 at 1038 hours, a puree preparation observation was conducted with the Cook. The [NAME] stated the puree food preparation was for 24 residents. The [NAME] took out a pan of garden meatloaf from the oven and proceeded to slice the meatloaf. The [NAME] picked up a portion of the meatloaf and placed it on the weighing scale. A piece of the meatloaf dropped on the kitchen counter. The [NAME] picked up the piece of meatloaf and placed it back on the weighing scale. The [NAME] then poured the meatloaf in the blender. After blending the meatloaf, the [NAME] transferred the pureed meatloaf in the serving pan. On 4/20/22 at 1110 hours, an interview was conducted with the Cook. When asked what to do when the food was dropped on the kitchen counter, the [NAME] stated the food should be thrown away and not be served since it could make the resident sick. The [NAME] acknowledged he dropped a piece of the meatloaf on the kitchen counter and placed it back in the blender when he prepared the puree food. On 4/20/22 at 1310 hours, an interview was conducted with the Assistant DSS. The Assistant DSS acknowledged the above findings and stated she saw the [NAME] dropped a piece of meatloaf on the kitchen counter and should not have been placed back in the blender. The Assistant DSS verified the above findings and stated the piece of meatloaf that dropped on the kitchen counter should not have been put into the blender.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to develop the comprehensive person-centered care plans for two of 21 final sampled residents (Residents 23 and 439). * Resident 23 was hearing impaired and required hearing aids. The facility failed to develop a care plan problem to address the resident's hearing deficit and use of hearing aids. This had the potential of Resident 23 not having their needs met due to inefficient communication. * The facility failed to develop a care plan problem to address Resident 439's use of an IV and increased sodium. This failure posed the risk of not providing appropriate, consistent, or individualized care to Resident 439. Findings: 1. Medical record review for Resident 23 was initiated on 12/13/19. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's history & physical examination dated 12/4/19, showed Resident 23 was hearing impaired. Review of the MDS dated [DATE], under Section B, showed Resident 23 had moderate hearing difficulty. Under the section for options showed the speaker had to increase their volume and had to speak distinctly. The MDS showed Resident 23 did not require hearing aids. Review of the plan of care showed a care plan problem dated 12/1/19, to address Resident 23's impaired communication. The interventions did not include the use of hearing aids. On 12/13/19 at 1127 hours, an observation of Resident 23 was conducted in the dining room during relaxing music time. When asked how he was enjoying the music, Resident 23 did not answer. On 12/13/19 at 1130 hours, an interview was conducted with LVN 2. LVN 2 verified Resident 23 was hearing impaired and had hearing aids. LVN 2 verified the hearing aids were not listed as an intervention in the care plan. On 12/13/19 at 1138 hours, an interview was conducted with CNA 1. CNA 1 verified Resident 23 was hard of hearing and had hearing aids locked in the medication cart. On 12/13/19 at 1421 hours, an interview was conducted with LVN 4. LVN 4 verified Resident 23 had hearing aids. LVN 4 stated resident 23 had pulled the hearing aids from his ears in the past and was at risk for losing them. On 12/17/19 at 0928 hours, an interview was conducted with the DON. The DON verified Resident 23's care plan failed to address the use of hearing aids. 2. On 12/12/19 at 1346 hours, and on 12/13/19 at 0717 hours, Resident 439 was observed with an IV fluids and an IV access to the left forearm. Medical record review for Resident 439 was initiated on 12/12/19. Resident 439 was admitted to the facility on [DATE]. Review of Resident 439's Physician Orders for Infusion Therapy showed an order dated 12/11/19, for D5 ½ NS (5% dextrose in half amount of normal saline, for fluid and electrolyte replenishment) one liter IV at 60 ml per hour for 72 hours for increased sodium. Review of Resident 439's plan of care did not show a care plan problem was developed to address Resident 439's use of a peripheral IV and for increased sodium. On 12/13/19 at 1543 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 439's IV and increased sodium were not addressed in Resident 439's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure a vascular access site was maintained and assessed as per the facility's P&P for one of 21 final sampled residents (Resident 76). This had the potential to place the resident at risk for developing a complication related to vascular access associated infections. Findings: Review of the facility's P&P titled IV Therapy dated 6/2018 showed peripheral IV sites will be rotated at least every 96 hours and as needed. Documentation of IV therapy should include IV site assessment. On 12/12/19 at 1540 hours, an observation was conducted of Resident 76. Resident 76 was observed lying in bed with a peripheral IV inserted into her right wrist. The IV site dressing was unlabeled. Medical record review for Resident 76 was initiated on 12/12/19. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's medical record failed to show an order for IV therapy. On 12/12/19 at 1546 hours, a concurrent observation, interview, and medical record review was conducted with RN 3. RN 3 verified Resident 76's peripheral IV on her right wrist was unlabeled. RN 3 stated Resident 76 was at the acute care hospital for approximately eight days, and RN 3 had readmitted Resident 76 to the facility on [DATE]. RN 3 stated Resident 76 was readmitted with a peripheral IV to her right wrist. RN 3 stated she was uncertain as to whether Resident 76 needed the peripheral IV. RN 3 stated when Resident 76 was readmitted to the facility, she contacted the physician. RN 3 stated she failed to ask the physician whether or not Resident 76 needed the peripheral IV. RN 3 reviewed Resident 76's medical record and was unable to determine when Resident 76's peripheral IV was inserted or how long Resident 76 had the peripheral IV. RN 3 stated the facility's P&P for residents with peripheral IV's was to assess the IV site every shift for redness, infiltration, and infection. RN 3 reviewed Resident 76's medical record and verified the facility failed to document any IV site assessments for Resident 76 since her readmission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care and services for one of 21 final sampled residents (Resident 438). The facility failed to ensure the oxygen treatment was documented. In addition, the facility failed to develop a care plan for the oxygen and nebulizer treatment. These failures posed the risk for complications related to respiratory care. Findings: Medical record review for Resident 438 was initiated on 12/12/19. Resident 438 was readmitted to the facility on [DATE]. Review of Resident 438's Physician and Telephone Orders showed the following physician's orders: - 12/9/19, administer Duoneb (a bronchodilator, relaxes muscles in the airway) one unit dose every eight hours as needed for two weeks. - 12/10/19, apply oxygen inhalation 3 liters per minute via nasal cannula (flexible tube to deliver oxygen into the nose) to maintain the oxygen saturation above 90%. a. Review of Resident 438's Medication Record for December 2019 showed an entry dated 12/10/19, to adminster oxygen three liters per minute via nasal cannula to maintain the oxygen saturation above 90%, FYI (for your information). The Medication Record did not show the licensed nurses documented the administration of oxygen to Resident 438. b. Review of Resident 438's plan of care failed to show a care plan problem to address the use of oxygen and Duoneb. On 12/17/19 at 1031 hours, an interview and concurrent medical record review was conducted with LVN 1, with RN 2. LVN 1 and RN 2 verified the above findings. When asked about the oxygen administration for Resident 438, LVN 1 stated Resident 438 was receiving three liters of oxygen via nasal cannula. When asked where she documented the oxygen administration for Resident 438, LVN 1 reviewed the medication record and verified the medication record did not show the oxygen administration was documented. LVN 1 stated the licensed nurses did not have to sign the medication record because it was just an FYI. LVN 1 verified Resident 438's plan of care did not show the use of oxygen and Duoneb were addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure ferrous sulfate (an iron supplement) was administered as per the physician's order for one nonsampled resident (Resident 72). * Resident 72 had a physician's order for ferrous sulfate delayed release/enteric coated (DR/EC) 325 mg orally twice a day for anemia. Resident 72 received the incorrect dose (330 mg) and the incorrect form (non DR/EC) of ferrous sulfate on 10 occasions. This posed the risk of Resident 72 not receiving the therapeutic effect of the prescribed supplement. Findings: Medical Record review for Resident 72 was initiated on 12/12/19. Resident 72 was admitted to the facility on [DATE]. Resident 72 had a diagnosis of anemia. On 12/17/19 at 0815 hours, LVN 3 was observed administering Resident 72's prescribed medications. LVN 3 stated Resident 72's medications needed to be crushed before being administered to Resident 72. Resident 72 had a physician's order dated 6/14/19, for ferrous sulfate DR/EC 325 mg tablet orally twice a day for anemia. As LVN 3 prepared Resident 72's medications to be administered, LVN 3 stated ferrous sulfate DR/EC tablets could not be crushed, and she needed to clarify the order with Resident 72's physician. LVN 3 then obtained a new physician's order for ferrous sulfate liquid 330 mg/7.5 ml to be administered orally twice a day for anemia. LVN 3 then administered ferrous sulfate liquid 330 mg (7.5 ml) to Resident 72. Review of the December 2019 Medications Flowsheet showed documentation LVN 3 administered ferrous sulfate DR/EC 325 mg tablet orally to Resident 72 at 0900 hours on the following dates: 12/3, 12/4, 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/15, and 12/16/19. LVN 3 verified the findings; however, LVN 3 stated she did not administer ferrous sulfate DR/EC 325 mg tablet orally as ordered by the physician, to Resident 72 at 0900 hours, on 12/3, 12/4, 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/15, and 12/16/19. LVN 3 stated she had instead administered ferrous sulfate liquid (non DR/EC) 330 mg/7.5 ml orally to Resident 72 at 0900 hours, on 12/3, 12/4, 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/15, and 12/16/19. LVN 3 verified Resident 72 received the incorrect dose (330 mg) of ferrous sulfate (physician's order was for 325 mg) and the incorrect form (non DR/EC) on 12/3, 12/4, 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/15, and 12/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 438 was initiated on 12/12/19. Resident 438 was readmitted to the facility on [DATE]. Review of Resident 438's Physician's Orders showed the following orders: - 12/4/19, Ativan 0.5 mg via GT at bedtime for anxiety manifested by yelling or calling out for no reason. - 12/4/19, Ativan 1 mg via GT daily for anxiety manifested by yelling or calling out for no reason. Review of Resident 438's Physician Orders showed an order dated 12/4/19, to monitor episodes of yelling or calling out for no reason related to the use of Ativan. Review of Resident 438's Medication Record failed to show Resident 438's behavioral episodes of yelling or crying out for no reason were monitored. On 12/17/19 at 1046 hours, an interview and concurrent medical record review was conducted with LVN 1, with RN 2 present. LVN 1 and RN 2 verified the above findings. LVN 1 stated the behavioral episodes of yelling or crying out for no reason were monitored each shift and documented on the medication record. LVN 1 could not locate any documentation showing the monitoring for Resident 438's behavior episodes of yelling or crying out for no reason related to the use of Ativan. Based on interview and medical record review, the facility failed to ensure two of 21 final sampled residents (Residents 53 and 438) were free from unnecessary psychotropic medications. * The facility failed to ensure two psychotropic medications had a specific behavior manifestation for Resident 53 and failed to accurately monitor the behavior. * The facility failed to ensure the behavior manifestations were monitored for Resident 438 related to the use of Ativan (antianxiety medication). These failures had the potential to negatively impact the residents' well-being. Findings: 1. Medical record review for Resident 53 was initiated on 12/13/19. Resident 53 was admitted to the facility on [DATE]. Review of Resident 53's Physician Order Report showed an order dated 7/29/29, for Depakene solution (a psychotropic medication used to treat mood disorders) 500 mg twice daily for yelling/screaming without provocation. Review of Resident 53's Physician Order Report showed another order dated 9/23/19, for buspirone (a psychotropic medication used to treat mood disorders) 5 mg daily for yelling/screaming. Review of Resident 53's Behavior & Psychotropic Summary/Dosage Reduction for Depakene showed the following: - For 10/1 - 10/31/19, there were 63 documented episodes of yelling/screaming. - For 11/1 - 11/30/19, there were 76 documented episodes of yelling/screaming. Review of Resident 53's Behavior & Psychotropic Summary/Dosage Reduction for buspirone showed the following: - For 10/1 - 10/31/19, there were 54 documented episodes of yelling/screaming. - For 11/1 - 11/30/19, there were 62 documented episodes of yelling/screaming. On 12/13/19 at 1635 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 was asked about Resident 53's behaviors. RN 3 reviewed Resident 53's medical record and stated Resident 53 had episodes of yelling/screaming. RN 3 stated Resident 53 was on both the above medications for the yelling/screaming behavior. RN 3 stated each medication should have specific behavior monitoring in order to tell if the medication was effective. On 12/20/19 at 1117 hours, a telephone interview and concurrent medical record review was conducted with RN 4. RN 4 reviewed Resident 53's Behavior & Psychotropic Summary/Dosage Reduction sheets for Depakene and buspirone. RN 4 verified the episodes of yelling/screaming did not match for the medications for the months of October and November 2019. RN 4 stated the number of episodes should be the same since the monitoring was for the same behavior. RN 4 was unable to state why the number of episodes were inconsistent.

2. On 12/13/19 at 1414 hours, an interview and concurrent inspection of the medication cart on Station 3 was conducted with LVN 3. Resident 67's Lantus solution pen was observed in the cart. LVN 3 stated insulin pens were stored in the refrigerator, then once opened, would be stored in the medication cart. LVN 3 stated the open date was to be written on the pen once opened. The label on the Lantus solution pen for Resident 67 showed to discard unused portion after 28 days. The medication also showed a delivery date of 12/5/19. LVN 3 stated she knew the Lantus solution pen had been used because the pen showed a dose had been administered. No open date was observed written on the pen. LVN 3 verified the above and stated the medication should have been labeled with an open date to ensure it would be discarded after 28 days. Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. The facility failed to ensure the proper labeling of an insulin medication. * The facility failed to ensure orally administered medications were stored separate from externally used medications and failed to ensure the alcohol wipes were stored separately from medications. This posed the risk for cross-contamination of the medications. * The facility failed to ensure an insulin medication was accurately labeled with an open date for one of 21 final sampled residents (Resident 67). Findings: 1. Review of the facility's P&P Storage of Medications dated 4/2008 showed orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. Potentially harmful substances such as urine test reagent tablets, household poisons, cleaning supplies, and disinfectants are clearly identified and stored in a locked area separately from medications. On 12/13/19 at 1400 hours, an inspection of Station 2's medication cart was conducted with LVN 2. The following was observed: a. An opened tube of Refresh lacrilube eye ointment, and clonidine patches were stored in the same compartment with ibuprofen (nonsteroidal anti-inflammatory drug, used to treat fever and pain) tablets, omega-3 (supplement) capsules, and vitamin B12 (supplement) tablets. b. An opened box of acetaminophen suppositories (over the counter pain medication) was stored in the same compartment with an opened box of sudogest PE (nasal decongestant) tablets. c. An opened tube of muscle rub cream was stored in the same compartment with the thickener and fiber powder d. Albuterol (a bronchodilator, relaxes muscles in the airway) medications were stored in the same compartment with oral liquid medications. e. Two containers of sanitizing wipes were observed stored in the same compartment with residents' oral medications in bubble packs (pre-formed plastic blister packaging). LVN 2 verified the above findings.

3. On 12/13/19 at 1430 hours, an interview and concurrent inspection of the resident refrigerator, located in the medication room, was conducted with RN 1. RN 1 stated the food brought in for the residents was to be labeled with the resident's name and discard date. The freezer contained one croissant package, unlabeled and undated. The croissant package was observed with no manufacturer's expiration date. RN 1 stated she did not know who the item belonged to. RN 1 stated it could belong to the facility staff or a resident. RN 1 verified the above and stated the item should have been appropriately labeled and dated. Based on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure food in the walk-in freezer was free from contamination. * There was a lack of glaze observed on the dishware. * The facility failed to ensure a refrigerated food item was properly labeled and dated. These failures had the potential to contaminate the food which could lead to food borne illness in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 12/13/19, showed 90 of 97 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017 Section 3-305.11 Food Storage, pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate .can be sources of microbial contamination for stored food. Review of the facility's P&P titled Food Storage (undated) showed proper food storage procedures are followed to allow for effective, safe, and sanitary kitchen operations. On 12/12/19 at 1249 hours, during the initial tour of the kitchen with the DSS, the walk-in freezer pipes were observed with ice build-up and a pan under the pipes. The DSS stated the pan was used to catch the dripping water. On 12/16/19 at 0904 hours, an observation of the walk-in freezer pipes and a concurrent interview was conducted with the Environmental Director (ED). The ED stated the freezer pipes collect condensation formed from warm air. The freezer pipes were covered with insulated tape to prevent the condensation from dripping; however, the freezer pipes still dripped condensation. The pan was used to catch the dripping condensation, but the pan did not catch all the drips. An opened box of hot dogs was observed directly under the dripping pipes. The opened box of hot dogs had an accumulation of one inch of ice on the box. The ED confirmed ice should not be on an opened box of food. On 12/16/19 at 1445 hours, and interview was conducted with the RD. The RD confirmed ice cannot be on an opened box of food. 2. According to the USDA Food Code 2017 Section 4-202.11 Food Contact Surfaces, food contact surface should be free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Review of the facility's P&P titled Food Handling (undated) showed dishware was to be free of cracks, chips or broken areas and should not have lost its glaze/finish. On 12/16/19 at 0910 hours, an observation of the maroon colored plastic bowls used for resident food and a concurrent interview was conducted with the DSS. More than ten maroon colored plastic bowls were observed to be scratched and the glaze was worn off the inside of the bowls. The DSS stated the maroon colored plastic bowls were ordered once in three years. The DSS agreed the maroon colored plastic bowls should be replaced. On 12/16/19 at 1445 hours, an interview was conducted with the RD. The RD confirmed resident dishware should not be scratched or have glaze worn off the inside of the bowls.