Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to administer Resident 1's insulin (hormone that regulate the amount of glucose [sugar] in the blood) as prescribed by the physician.This deficient practice resulted in the omission of insulin which could have resulted in a hyperglycemic (a condition where the blood sugar levels are abnormally high) episode.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2025 with diagnoses that included cerebral infarction (stroke, loss of blood flow to a part of the brain) due to occlusion (the blockage or closing of an opening, blood vessel) or stenosis (abnormal narrowing of a blood vessel) of small artery (tiny blood vessel), type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, and long term use of insulin. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/6/2025, the MDS indicated the resident had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 1 required partial/moderate assistance from staff with eating, oral hygiene, required substantial/maximal assistance from staff personal hygiene, and is dependent on staff with toileting hygiene.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for insulin glargine solution 100 unit/milliliters (units/mL- unit of measurement), inject nine (9) units subcutaneously (under the skin) at bedtime for DM (hold if blood sugar [BS] less than 100 milligram/deciliter (mg/dL - units of measurement), ordered 8/7/2025.During a review of Resident 1's care plan (a document that summarizes a resident's needs, goals, and care/treatment), initiated 8/4/2025, the care plan indicated the resident has hyperglycemia related to DM. The care plan indicated an intervention for Lantus (brand name of insulin glargine) as ordered. During a concurrent interview and record review on 8/25/2025 at 12:06 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 1's Medication Administration Record (MAR, a report detailing the medication administered to a resident by the licensed nurses) dated 8/2025. RN 1 stated all medications should be given per physician's order. RN 1 stated that Resident 1 did not receive his glargine insulin on 8/14/2025. RN 1 stated that Resident 1's blood sugar on 8/14/2025 at 9:00 p.m. was 100 mg/dL. RN 1 stated Resident 1's blood sugar was within parameters (a set of defined limits) of administering Resident 1's glargine insulin and should have been administered.During a concurrent interview and record review on 8/25/2025 at 12:44 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 1's MAR dated 8/2025. The ADON stated that licensed nurses should be administering medication per physicians' orders and parameters given. The ADON stated since Resident 1's blood sugar on 8/14/2025 at 9:00 p.m. was 100 mg/dL, the licensed nurse should have administered Resident 1's glargine insulin. The ADON continued to state that if Resident 1 did not receive his glargine insulin, there could be a potential for Resident 1 to experience a hyperglycemic episode. During an interview on 8/25/2025 at 4:12 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that LVN 2 did not administer Resident 2's glargine insulin because LVN 2 overlooked the parameters of the order. LVN 2 stated that she (LVN 2) should have read the order in its entirety. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, review date 1/15/2025, the policy indicated medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer without unnecessary interruptions. Medications are administered in accordance with the prescriber orders, including any required time frame.

Based on observation, interview and record review, facility failed to ensure residents that are diabetic (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) were served sugar free gelatin and sugar free pudding for one of three sampled residents (Resident 1).This deficient practice had the potential for Resident 1 to experience hyperglycemic (occurs when glucose [sugar] levels in the blood become too high) episodes.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2025 with diagnoses that included cerebral infarction (stroke, loss of blood flow to a part of the brain) due to occlusion (the blockage or closing of an opening, blood vessel) or stenosis (abnormal narrowing of a blood vessel) of small artery (tiny blood vessel), type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, and long term use of insulin (hormone that regulate the amount of glucose in the blood).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/6/2025, the MDS indicated the resident had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 1 required partial/moderate assistance from staff with eating, oral hygiene, required substantial/maximal assistance from staff personal hygiene, and is dependent on staff with toileting hygiene.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for consistent carbohydrate/no added salt (NAS) diet (diet consistency that helps control blood sugar levels), ordered 8/11/2025.During a review of Resident 1's care plan (a document that summarizes a resident's needs, goals, and care/treatment), initiated 8/4/2025, the care plan indicated the resident has hyperglycemia related to DM. The care plan indicated an intervention to discuss meal times, portion size, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen and monitor compliance with diet and document any problems.During an observation on 8/25/2025 at 12:58 p.m., observed Resident 1's lunch tray with an orange gelatine cup that is unlabeled and observed a pudding cup with the letter R written on top of the pudding cup cover.During a concurrent observation and interview on 8/25/2025 at 12:59 p.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 1's room, observed Resident 1's lunch tray. LVN 1 stated that Resident 1's orange gelatine is regular gelatine and not sugar free. LVN 1 continued to state that the pudding served on Resident 1's lunch tray was regular pudding because there is an R written on the top cover of the pudding. LVN 1 stated that the orange gelatine is regular because there is no label that it is sugar free.During a concurrent observation and interview on 8/25/2025 at 1:15 p.m., with the Registered Dietician (RD), in Resident 1's room, observed Resident 1's lunch tray. The RD stated the RD was not sure if the orange gelatine was sugar free or regular because it is not labeled. The RD stated that the pudding served to Resident 1 is regular pudding because there is an R marked on the top cover. The RD stated that Resident 1's diet should be consistent carbohydrate diet and should have been served sugar free gelatine and sugar free pudding because Resident 1 is diabetic. The RD continued to state that serving residents with diabetes regular gelatine and/or regular pudding will affect the residents' blood sugar levels.During a review of the facility's policy and procedure (P&P) titled, Consistent Carbohydrate Diet, review date 1/15/2025, the policy indicated the consistent carbohydrate diet is indicated for residents with diabetes or prediabetes. It provides consistent meal patterns and portion sizes in order to assist residents in achieving blood glucose and weight goals. This diet is planned to meet the current dietary reference intakes within the limitations of the diet restrictions. Modifications of the diet may be necessary for complications of diabetes and associated diseases.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure clear storage cups of gelatin were dated and labeled according to the facility's policy.This deficient practice had the potential to place 142 out of 148 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). During an observation of the facility's kitchen refrigerator on 8/25/2025 at 1:45 p.m., observed open food items not in its original packaging and placed in clear storage cups. Observed several clear storage cups labeled SF and several clear storage cups with no labels. During a concurrent observation and interview on 8/25/2025 at 1:46 p.m., with the Dietary Supervisor (DS), the DS stated that the clear storage cups are cups of gelatine for the residents. Observed the DS count the clear storage cups. The DS stated 35 of the clear storage cups had no label and counted 11 clear storage cups labeled SF. The DS stated that SF meant sugar free and is served to residents with consistent carbohydrate diet (diet consistency that helps control blood sugar levels). The DS stated that when a food item is not in its original packaging, the food item must be labeled with the specific name of the food item and the date when the food item was opened/prepared. When asked about the importance of accurate labeling, the DS stated that it is important to accurately label food items to make sure that the food item is what it is and for the safety of the residents. The DS further stated that the person preparing the gelatine is responsible for labeling. During a review of the facility's policy and procedure (P&P) titled, Food Safety Product Labeling & Dating Guide, review date 1/15/2025, the policy indicated under storing prepared food; Applies to: Purchased, ready-to-eat food removed from original container. Product storage label: Name of product, date of preparation and/or use-by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two of three sampled residents Resident 2 and Resident 3) received care and services to promote wound healing by:1.Failing to ensure Resident 2's low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure injuries [PI - an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was properly set to the correct setting.2.Failing to ensure licensed nurses obtained clarification from the physician regarding Resident 2 and Resident 3's LAL mattress order. 3.Failing to ensure licensed nurses were knowledgeable on how to check for functionality of Resident 2 and Resident 3's LAL mattress.These failures had the potential to place the residents at risk of developing or worsening pressure ulcers. 1.During a review of Resident 2's admission Record, the admission Record indicated the facility readmitted Resident 2 on 3/16/2025 with diagnoses including pressure ulcer of sacral region (the bottom of the spine), stage 4 (a severe, full-thickness tissue loss where the injury extends down to the bone, tendon, or muscle), need for assistance with personal care, and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 5/2/2025, the MDS indicated Resident 2 had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 2 was dependent on oral hygiene, toileting hygiene, shower/bathing, and personal hygiene. During a review of Resident 2's Order Summary Report dated 3/16/2025, the Order Summary Report indicated an order for the low air loss (LAL) mattress to be set based on [Specify: setting on comfort OR weight] of resident and to check the setting and functionality of the LAL mattress every shift. During a review of Resident 2's Braden scale (a widely used assessment tool in healthcare to predict the risk of a patient developing pressure injuries) for predicting pressure sore risk dated 8/1/2025 timed at 2:09 p.m., the Braden scale indicated Resident 2 was at high risk for developing a pressure injury.During an observation on 8/7/2025 at 8:30 a.m., in Resident 2's room, observed Resident 2 in bed with the LAL mattress settings set to static mode (function that stops the mattress from alternating pressure).During a concurrent observation and interview on 8/7/2025 at 8:32 a.m. with Treatment Nurse 1 (TN 1), in Resident 2's room, observed Resident 2 in bed with the LAL mattress settings set to static mode. TN 1 stated that Resident 2's LAL setting is not correct and that the LAL mattress setting should be on alternate mode. TN 1 stated that the LAL mattress setting should be in alternating mode because Resident 2 currently has a pressure injury and if the correct setting is not set Resident 2's pressure injury could worsen and delay the healing process.2. a. During a concurrent interview and record review on 8/7/2025 at 9:43 a.m. with TN 1, TN 1 reviewed Resident 2's LAL mattress order dated 3/16/2025. When asked if Resident 2's LAL mattress setting is based on Resident 2's comfort or weight, TN 1 stated that the order does not specifically indicate whether the LAL mattress should be set according to Resident 2's comfort or weight. TN 1 continued to state that TN 1 should have called Resident 2's physician to clarify the order. The order should state the LAL mattress for Resident 2 is based on her weight because Resident 2 currently has a pressure injury. TN 1 stated that it is important to clarify if an LAL mattress order is for comfort or weight because if a resident has a pressure injury, the pressure injury can worsen if the LAL mattress is not set correctly. b. During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted Resident 3 on 11/12/2024 with diagnoses including pressure ulcer of right buttock, stage 4, pressure ulcer of left buttock, and need for assistance with personal care.During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had moderately cognitive impairment. The MDS indicated Resident 3 was dependent on oral hygiene, toileting hygiene, shower/bathing, and personal hygiene.During a review of Resident 3's Order Summary Report, the Order Summary Report indicated an order dated 11/13/2024 for low air loss mattress set based on [Specify: setting on comfort OR weight] of resident and to check the setting and functionality of the LAL mattress every shift. During a review of Resident 3's Braden scale for predicting pressure sore risk dated 7/11/2025 timed at 8:33 a.m., the Braden scale indicated Resident 3 was at high risk for developing a pressure injury.During a concurrent interview and record review on 8/7/2025 at 9:43 a.m. with TN 2, TN 2 reviewed Resident 3's LAL mattress order dated 11/13/2024. When asked if Resident 3's LAL mattress setting was set for Resident 3's comfort or weight, TN 2 stated that Resident 3's LAL mattress was set for Resident 3's comfort. TN 2 stated that the order does not specifically indicate whether the LAL mattress should be set based on Resident 3's comfort or weight. TN 3 stated that she needs to clarify the order with Resident 3's physician because TN 2 does not know the correct setting for Resident 3's LAL mattress.3.a. During an interview on 8/7/2025 at 9:57 a.m. with TN 1, TN 1 stated that the functionality of Resident 2's LAL mattress is checked daily. When asked how to check for the functionality of Resident 2's LAL mattress, TN 1 stated that Resident 1's LAL mattress will beep and flash a red light if the mattress was not functioning correctly.During a review of the LAL's manual titled, Power Pro Elite Mattress System User Manual, the manual indicated, check to see if the suitable pressure is selected by sliding one hand between a deflated air cell and the patient's buttocks areas and there should be minimum contact. Always leave at least 1 in space between a deflated air cell and patient's buttocks areas to prevent bottoming-out. According to the weight of the patient, adjust the pressure setting to the most suitable level without bottoming-out. User can determine an appropriate pressure by adjusting the Comfort level. Please consult with your physician for proper setting. b. During an interview on 8/7/2025 at 12:32 a.m. with TN 2, TN 2 stated that the functionality of Resident 3's LAL mattress is checked daily. When asked how to check for the functionality of Resident 3's LAL mattress, TN 2 stated that she would check Resident 3's LAL mattress machine to see if all the lights were on. She further stated that if the lights were not on, then the mattress was not functioning correctly. TN 2 further stated that she would then unplug and re-plug the machine and if the problem persisted, she would call the LAL mattress company. During an interview on 8/7/2025 at 1:45 p.m. with the Director of Nursing (DON), the DON stated to check the functionality of a LAL mattress, staff should place their hand on the LAL mattress and apply pressure. If staff are able to feel the bed frame, the setting is incorrect. During a review of the LAL's manual titled, Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss, the manual indicated, Hand Check Procedure: A suitable way to verify that the patient is not bottoming out is to perform a hand check as described below: 1) Ensure that the patient is lying supine (on his/her back) in the middle of the mattress. 2) Place hand with four (4) fingers stacked vertical beneath the air cell directly underneath the sacral region. 3) Ensure that the 4 fingers can slide with minimal resistance between the patients' sacral region and the lower portion of the mattress. 4) Adjust the comfort setting as needs. 5) Wait for the mattress to adjust to the selected range. 6) Revaluate with the hand check and adjust to patients' comfort level. During a review of the facility's policy and procedure (P&P) titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, reviewed 1/15/2025, the P&P indicated the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing, and application of topical agents. During a review of the facility's P&P titled Low Air Loss Mattress, reviewed1/15/2025, the P&P indicated, law air loss mattress has been an integral tool for wound care management as a facility protocol to enhance healing and treatment of pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that two of three sampled residents (Resident 3 and Resident 4) received the necessary treatment and services to promote healing and/or prevent pressure ulcer or injuries (PU/Is- injury to skin and underlying tissue resulting from prolonged pressure on the skin) when on 7/24/2025 staff placed multiple layers of linen over the residents' low air loss mattresses (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts), compromising the effectiveness of the pressure-relieving support surfaces. This deficient practice placed the residents at increased risk of pressure ulcers/injuries worsening or developing further and delayed wound healing. 1. During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 8/30/2023 and readmitted on [DATE] with diagnoses including pressure induced deep tissue damage (a type of pressure ulcer that occurs when pressure or shear forces damage the underlying tissues) of the right heel and PU of sacral region (sacrum - at the bottom of the spine and lies between the fifth segment of the lumbar spine [L5] and the coccyx [tailbone]) Stage four (ST 4 - full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 5/2/2025, the MDS indicated Resident 4's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were severely impaired. The MDS indicated that Resident 4 was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, bed mobility (movement) and transfer. The MDS further indicated that Resident 4 was at risk for developing PUs/Is and had one or more unhealed PUs/Is. During a review of Resident 4's Physician Order Summary dated 3/16/2025, the Physician's Order Summary indicated an order for LALM with alternating mode and setting based on comfort or weight of the resident. During a review of Resident 4's Skin and Wound Evaluation (SWE) form dated 7/16/2025, the SWE indicated that Resident 4 had ST 4 PU on the sacrococcyx (refers to the fused bone formed by the sacrum and the coccyx) and the wound size area was 1.2 by 2 centimeter (cm - a unit of measurement), length - 1.3 cm, width - 0.9 cm, depth - 1.3 cm, and undermining (a type of wound where the edges of the wound have separated from the surrounding healthy tissue, creating a pocket or area of tissue damage beneath the surface of the skin) - 1.6 cm. The SWE form indicated LALM was provided to Resident 4. During a concurrent observation and interview on 7/24/2025 at 2:22 p.m., with Certified Nursing Assistant 2 (CNA 2), observed Resident 4 laying on a LALM on top of multiple layers of linen between Resident 4 and the LALM; from the top of the LALM toward the resident skin, a fitted sheet, four layers of the bedsheet made by folding the bed sheet twice, and Resident 4 was wearing an adult incontinence brief. CNA 2 stated that only two layers of linen were permitted when using a LALM however, Resident 4 had a total of six layers of linen in use. During a concurrent observation and interview on 7/24/2025 at 2:37 p.m., with CNA 2 and Treatment Nurse 2 (TN 2), TN 2 observed that multiple layers of linen were being used with the LALM and observed a total of six layers. TN 2 stated that using excessive linen on a LALM could negatively impact the wound healing process. TN 2 stated that she (TN 2) would address the issue with CNA 2. 2. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 7/14/2022 and readmitted on [DATE] with diagnoses including cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death) and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were severely impaired. The MDS indicated that Resident 3 was dependent on staff for eating, oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, bed mobility and transfer. The MDS further indicated that Resident 3 was at risk for developing PUs/Is. During a review of Resident 3's Physician Order Summary dated 7/24/2025, the Physician's Order Summary indicated an order for LALM with alternating mode and setting based on comfort or weight of the resident. During a review of Resident 3's Care Plan Report (untitled), which was initiated on 4/17/2024 and last revised on 2/18/2025, the Care Plan Report indicated that Resident 3 had a history of ST 4 PU to the sacrococcyx and was at risk for slow or delayed healing and/or further decline in skin integrity. Resident 4 was on a LALM, and the family preferred the use of briefs instead of breathable pads. The LALM protocol indicated only one sheet, one breathable pad, and one sheet to cover the resident were permitted. During a concurrent observation and interview on 7/24/2025 at 2:42 p.m., with Licensed Vocational Nurse 3 (LVN 3) and the Director of Nursing (DON), LVN 3 stated that although Resident 3 did not have a PU at the time, there was a history of PU, and the LALM was being used as part of a skin management strategy. LVN 3 counted the layers of linen used for Resident 3 and stated a total of six linen layers between the surface of the LALM and the resident's skin. LVN 3 stated that there should be no more than two layers of linen used to effectively prevent the development of another PU. The DON stated that immediate in-service training would be provided to nursing staff to reinforce the facility's policy of limiting linen layers to two when using a LALM. During an interview on 7/24/2025 at 4:05 p.m., the Assistant Director of Nursing (ADON) stated that using more than two layers of linen with a LALM would defeat the purpose of the LALM. During a review of the facility's policy and procedure (P&P) titled, Low Air Loss Mattress last reviewed on 1/15/2025, the P&P indicated, Low air mattress has been an integral tool for wound care management as a facility protocol to enhance wound healing and treatment of pressure ulcer. Multiple layer approach: one sheet over the mattress, one breathable pad, resident on the top of the breathable pad and one sheet to cover the patient.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent (having no or insufficient voluntary control) of bladder and bowel (B&B) function, received appropriate care and services for one of four sampled residents (Resident 1) by failing to implement its policy and procedures (P&P) on Perineal (the area of the body between the anus and the genitals) Care when Certified Nursing Assistant (CNA 3) used a soiled towel to wipe the perineal area and did not rinse the perineal area while providing perineal care. This deficient practice had the potential to result in urinary tract infection (UTI- an infection in any part of the urinary system), skin irritation, and unpleasant odor.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including malignant (to describe a cancerous tumor or a very serious medical condition) neoplasm (an abnormal growth of tissue) of right female breast and secondary malignant neoplasm of brain. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/15/2025, the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were intact. The MDS indicated that Resident 1 was dependent on staff for toileting hygiene and shower, required maximal assistance from staff with lower body dressing, and moderate assistance from staff with toilet transfer. The MDS further indicated Resident 1 was frequently incontinent of bladder (urine), occasionally incontinent of bowel, and at risk for developing pressure ulcer or injury (PU/I - injury to skin and underlying tissue resulting from prolonged pressure on the skin). During a concurrent observation and interview on 7/25/2025 at 10:21 a.m., with Certified Nursing Assistant 3 (CNA 3), observed CNA 3 providing perineal care to Resident 1 while Resident 1 was in bed. CNA 3 prepared a big towel by wetting it in the bathroom within Resident 1's room and placed it in a basin. During perineal care, observed CNA 3 used the same towel throughout the process. CNA 3 first wiped the front perineal area, then folded the towel and proceeded to wipe away bowel movement (BM). CNA 3 continued using the same towel, refolding it to use different sections - first to clean the front perineal area and then again to wipe the anal and buttocks area. CNA 3 did not rinse or dry Resident 1's perineal area during perineal care. When CNA 3 was further interviewed after completing Resident 1's perineal care, CNA 3 stated that only one big wet towel with warm water was used to clean Resident 1's perineal area from front to back following an episode of bladder and bowel incontinence. During a concurrent interview on 7/25/2025 at 10:49 a.m., with CNA 3, the Infection Preventionist (IP), and the Director of Nursing (DON), in the conference room, CNA 3 described the proper clinical procedures for perineal care and stated that a separate towel with soap and water should have been used to clean the front and back areas of the perineal area. However, CNA 3 stated that she (CNA 3) only used one big wet towel during Resident 1's perineal care. The DON stated that CNA 3 was aware of the correct perineal care procedures but failed to follow while providing perineal care to Resident 1. During a review of the facility's P&P titled, Perineal Care last reviewed on 1/15/2025, the P&P indicated, The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin conditions. Wet washcloth and apply soap or skin cleansing agent. Gently dry perineum. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttock. Rinse and dry thoroughly.

Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure one of four sampled staff (Certified Nursing Assistant 3 [CNA 3]) performed hand hygiene (HH -cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) after providing Resident 1's perineal (the area of the body between the anus and the genitals) care and before touching Resident 1's body to change the resident's clothing and position while in the bed. These deficient practices had the potential to result in the spread of infection placing residents, staff, and visitors at risk of being infected with germs. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including malignant (to describe a cancerous tumor or a very serious medical condition) neoplasm (an abnormal growth of tissue) of right female breast and secondary malignant neoplasm of brain. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/15/2025, the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were intact. The MDS indicated that Resident 1 was dependent on staff for toileting hygiene and shower, required maximal assistance from staff with lower body dressing, and moderate assistance from staff with toilet transfer. The MDS further indicated Resident 1 was frequently incontinent of bladder (urine), occasionally incontinent of bowel, and at risk for developing pressure ulcer or injury (PU/I - injury to skin and underlying tissue resulting from prolonged pressure on the skin). During a concurrent observation and interview on 7/25/2025 at 10:21 a.m., with Certified Nursing Assistant 3 (CNA 3), observed CNA 3 providing perineal care to Resident 1 while Resident 1 was in bed. CNA 3 prepared a big towel by wetting it in the bathroom within Resident 1's room and placed it in a basin. During perineal care, observed CNA 3 used the same towel throughout the process. CNA 3 first wiped the front perineal area, then folded the towel and proceeded to wipe away bowel movement (BM). CNA 3 continued using the same towel, refolding it to use different sections - first to clean the front perineal area and then again to wipe the anal and buttocks area. CNA 3 began assisting Treatment Nurse 3 (TN 3) with wound dressing changes without performing HH or changing into new gloves. After TN 3 completed the wound dressing changes for Resident 1, CNA 3 covered Resident 1 with a new brief, changed into new clothing, and repositioned Resident 1. CNA 3 performed HH after discarding the soiled brief and linen, which were placed in a plastic bag. When CNA 3 was asked how many times HH was performed from the start of Resident 1's perineal care to the completion of the brief and clothing change, CNA 3 stated that she performed HH once before starting Resident 1's perineal care and once after discarding Resident 1's soiled brief and linen. CNA 3 stated that HH was performed twice during the process of providing Resident 1's perineal care, including the change to the new brief and clothing. During a concurrent interview on 7/25/2025 at 10:49 a.m., with CNA 3, the Infection Preventionist (IP), and the Director of Nursing (DON), in the conference room, CNA 3 stated that she was supposed to wash her hands and change gloves after cleaning Resident 1's perineal area, including the BM and after handling the soiled linens, before touching Resident 1's body, a new brief, or new clothing. However, CNA 3 performed HH twice during the process: once while providing Resident 1's perineal care and once after changing Resident 1 into the new brief and clothing. During an interview on 7/25/2025 at 11:08 a.m., the IP stated that CNA 3 did not perform HH after cleaning Resident 1's BM and before touching new things including the resident's body or clothing. The IP stated this failure to follow proper HH procedures violated the infection prevention control program and increased the risk of spreading the germs. During a review of the facility's policy and procedures (P&P) titled, Handwashing/Hand Hygiene last reviewed on 1/15/2025, the P&P indicated, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. HH is indicated. after contact with blood, body fluids, or contaminated surface, after touching a resident. before moving from work on a soiled body site to clean body on the same resident, During a review of the facility's P&P titled, Infection Prevention and Control last reviewed on 1/15/2025, the P&P indicated, The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and mange transmission of disease and infections. The extent of personal training on new or revised P&P is consistent with job responsibilities and complexity of the P&P, Competency demonstrations may be required for certain P&Ps,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement their policy and procedure for Advanced Directive (AD-a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) for one (1) of 13 sampled residents ( Resident 11) by not obtaining a copy of the resident`s Living Will (a document that specifies a residents preferences about measures that are used to prolong life when there is a terminal prognosis) and maintain it in the resident`s medical record. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment. Findings: During a review of Resident 11's admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 9/30/2017, and readmitted on [DATE], with diagnoses including weakness, atrial fibrillation (a condition when the heart beats irregularly and rapidly), and heart failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs). During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool) dated 11/28/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 11 requires partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering, and bathing. During a review of Resident 11's Advance Directive Acknowledgement Form (ADA-a document provided by the facility that indicates whether a resident has an Advance Directive, would like information regarding creation of an advance directive, or refusal to create an advance directive) dated 5/28/2024, the ADA form indicated that the resident had executed a Living Will and have provided the document to the facility. During a concurrent interview and record review on 2/25/2025 at 2:21 p.m., with Social Worker 1 (SW1), Resident 11's ADA form was reviewed. SW 1 stated that Resident 11`s ADA form signed by his Responsible Party (RP) on 5/28/2024, indicated that the resident has a Living Will. SW1 stated that a copy of Resident 11`s living will should be in his medical chart. SW1 stated she did not follow up attempts with Resident 11 or his RP to ensure the facility has a copy of Resident 11`s AD in the medical chart. SW1 stated staff are required to obtain a copy of the resident`s AD and place it in medical chart in a location that it can be easily seen so that all direct care staff are aware of the resident`s wishes. During a concurrent interview and record review on 2/26/2025 at 9:10 a.m., with the Director of Social Services (DSS), Resident 11`s ADA and social service assessments were reviewed. The DSS stated that Resident 11 ADA form signed on 5/28/2024, indicated that the resident has a living will. The DSS stated a copy of Resident 11`s AD is not available in his chart. The DSS stated if a resident has executed an Advance Directive, a copy of it should be placed in the resident's chart. The DSS stated the potential outcome of not having a copy of the resident`s AD in the medical chart is that the resident's wishes may not be honored. During review of the facility's Policy and Procedure (P&P) titled, Advance Directives, last reviewed on 1/15/2025, the P&P indicated that prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written AD. If the resident or the resident`s representative has executed one or more ADs, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. The residents wishes are communicated to the residents direct care staff and physician by placing the AD documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility: 1. Failed to notify the resident's representative when the resident's medication Gemtesa (medication for overactive bladder [an organ that holds urine]) was no longer covered by insurance and before it ran out on 2/11/2025, for one of five sampled residents (Resident 112) reviewed under unnecessary medications. This deficient practice had the potential to negatively affect Resident 112 and their representative's right to be informed of a change in their medication. 2. Failed to notify the resident's representative of a change of condition for one of one resident (Resident 27) reviewed under Notification of Change care area when Resident 27's family member (FM 2) was not notified when Resident 27 had a diagnosis of Methicillin- Resistant Staphylococcus aureus (MRSA- type of bacteria that is resistant to the antibiotic). This deficient practice had the potential to violate Resident 27's representative the right to be informed of a change in the resident's condition. Findings: 1. During a review of Resident 112's admission Record, the admission Record indicated the facility admitted Resident 112 on 6/15/2023 with diagnoses including Alzheimer's Disease (progressive state of decline in mental abilities), Parkinson's Disease (a progressive neurological [relating to the brain, spinal cord, and nerves] disorder that affects movement, balance, and coordination), major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness), and a history of falling. During a review of Resident 112's Physician's Progress Note, dated 1/7/2025, the Physician's Progress Note indicated Resident 112 had the capacity to understand and make decision and had urinary incontinence (inability to control urine flow) with improvement in bladder spasms (sudden uncontrollable squeezing of the bladder) and urination when on Gemtesa. The progress note further indicated the resident to continue using Gemtesa. During a review of Resident 112's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/18/2024, the MDS indicated Resident 112 was able to understand others and make herself understood. The MDS indicated Resident 112 needed moderate assistance on staff for bathing, dressing, and toileting. During a review of Resident 12's Physician's Orders, the order indicated Gemtesa oral tablet - give 75 milligrams (mg - a unit of measurement) by mouth one time a day for overactive bladder was discontinued on 2/19/2025. During a review of Resident 112's Bladder Incontinence (inability to control the flow of urine from the bladder) Care Plan (CP) initiated on 6/26/2023 and last revised on 7/8/2024, the CP indicated goals to keep Resident 112 clean, dry and free of odors and to reduce episodes of incontinence through the next review date of 03/18/2025. During a review of Resident 112's Electronic Medical Administration Record (EMAR - online charting system), the EMAR indicated the charting code 3 entered by the Licensed Vocational Nurses (LVN) indicates Hold/Progress Note MD Notification, The EMAR further indicated for the medication Gemtesa: - On 2/11/2025 at 9:00am a code of 3 was documented by LVN 4. During a review of Resident 112's Progress Notes for the medication Gemtesa: - On 2/11/2025 LVN 4 entered awaiting refill from RX, medicine NA. During an interview on 2/26/2025 at 11:40 am with Resident 112's family member (FM 2), FM 2 stated he was disappointed when LVN 4 told him on 2/18/2025 that Resident 112 went without Gemtesa for over 5 days. FM 2 further stated he was never told insurance did not cover the medication anymore and had he known, he would have called to get a similar medication that is covered. FM 2 stated it is unacceptable for the facility to not communicate with him. During a phone interview on 2/26/2025 at 1:47 pm with LVN 4, LVN 4 stated on 2/11/2025 the bubble pack (a card that packages doses of medication within small, clear, plastic bubbles that is punched out to administer to a resident) for Gemtesa was completely empty and indicated a 3 in the EMAR and wrote that the medication was NA (LVN 4 clarified NA meant not available) and waiting for delivery from RX (LVN 4 clarified RX meant pharmacy). LVN 4 then stated when she worked again on 2/18/2025, the bubble pack was still empty and indicated a 3 in the EMAR again, requested a refill from the pharmacy again and then spoke with Resident 112's family member to inform him that the medication has been unavailable for several days. LVN 4 stated Resident 112's family member stated he was never told in advance that the medication was out and Resident 112's family member was going to call Resident 112's pharmacy. LVN 4 stated she was unaware why other LVNs indicated they administered Gemtesa on 2/12/2025 -2/16/2025 on the EMAR when the medication was not available on 2/11/2025 and 2/18/2025. LVN 4 further stated the refill of Gemtesa should have been followed up by the other LVNs to minimize the number of days the Resident 112 went without Gemtesa. During an interview on 2/26/2025 at 2:15 pm with Registered Nurse (RN) 1, RN 1 stated medicine in bubble packs must be reordered when there are about 7 tablets left to give time for any insurance issues and for the medication to arrive before the current stock runs out. RN 1 stated Resident 112's Gemtesa should have never run out without replenishment or replacement because Resident 112's incontinence could worsen and possibly lead to skin breakdown. RN1 further explained the resident, or their representative must be informed if a medication is not available so they can participate in getting an alternate medication. During a review of the facility's policy and procedure (P&P) titled, Change in a resident's condition or status, last reviewed on 1/15/2025, the P&P indicated: our facility promptly notifies the resident, his or her attending physician, and the resident representative of change in the resident's medical /mental condition and /or status. During a review of the facility provided P&P titled, Medication Administration, last reviewed 1/15/2025, the P&P indicated medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. The P&P further indicted if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document/initial and circle the MAR space provided for that drug and dose. 2. During a review of Resident 27's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/17/2024, and readmitted on [DATE], with diagnoses including acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 27's Minimum Data Set (MDS - a resident assessment tool) dated 1/7/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was maidly impaired (mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS indicated that Resident 27 was dependent on the staff (helper does all the effort) for showering/bathing and lower body dressing, and moderate- to- maximal assistance for all other of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 27's Physician Orders, the Physician Orders indicated an order dated 2/21/2025, to place the resident under contact precautions related to MRSA in the urine. During an observation on 2/24/2025 at 8:48 a.m. outside Resident 27's room, observed a sign posted which indicated that Resident 27 was placed on Contact Preauction (steps taken to prevent the spread of infections that can be passed by touching an infected person or contaminated surfaces) and required the wearing of Personal Protective Equipment (PPE) before entering the resident's room. During a phone interview on 2/24/2025 at 2:31 p.m. with Resident 27's family member (FM 3), FM 3 stated that she was not notified about Resident 27 developing MRSA. FM 3 stated that she was notified by staff about Resident 27 developing a urinary tract infection (UTI- an infection in any part of the urinary system) and a room change that was unaware about Resident 27 having MRSA. FM 3 stated no one notified her when Resident 27 was diagnosed with MRSA. During a concurrent record review and interview on 2/26/2025 at 11:39 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 reviewed Resident 27's nursing progress notes, dated 2/20/2025, which indicated Resident 27 's FM was notified of Resident 27's being seen by an MD with new orders being received. LVN 2 stated that he did not notify FM 3 that Resident 27 was diagnosed with MRSA. During an interview on 2/26/2025 at 12:15 p.m. with Social Worker 2 (SW 2), SW 2 stated that she called Resident 27's FM on 2/21/2025 to notify them about Resident 27's room change. SW 2 stated that she did not mention anything about Resident 27's diagnosis of MRSA. During a concurrent record review and interview on 2/26/2025 at 12:46 p.m. with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 27's Change of Condition Report (COC) dated 02/21/2025. The COC indicated that Resident 27 was noted with decline in oral intake, was recently diagnosed with MRSA in urine, and was on oral antibiotics. LVN 1 stated that she notified MD and family member about the decline in oral intake but did not notify FM 2 about Resident 27's diagnosis of MRSA. LVN 1 stated it is important to notify FM 3 about the resident's change of condition, so that FM 3 can understand the disease process and participate in Resident 27's care planning. During an interview on 2/27/2025 at 11:35 a.m. with the Infection Preventionist (IP), the IP stated that Resident 27's FM should be notified by licensed nurses about the change of condition including the diagnosis of MRSA so that FM 3 can understand and participate in Resident 27's care planning. The IP stated that not notifying FM 3 about Resident 27's infection may increase the potential of the spread of infection in the facility. During an interview on 2/27/2025 at 12:03 PM with the Director of Nursing (DON), the DON stated that Resident 27's FM should have been notified about the resident's the MRSA diagnosis. The potential outcome of not notifying FM 3 about the resident's the MRSA diagnosis is the spread of infection in the facility. During a review of the facility's policy and procedure (P&P) titled, Change in a resident's condition or status, last reviewed on 1/15/2025, the P&P indicated: our facility promptly notifies the resident, his or her attending physician, and the resident representative of change in the resident's medical /mental condition and /or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one (1) out of one (1) sampled residents (Resident 30). This deficient practice had the potential to result in delayed services to Resident 30. Findings: During a review of the admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnosis including periprosthetic fracture around internal prosthetic left knee (a type of fracture that occurs in the bone surrounding a knee replacement implant), osteoarthritis (a condition where the protective cartilage in the joints wear down over time, causing pain, stiffness, and swelling), and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). During a review of the physician order dated 11/3/2024, the physician order indicated an order to discharge Resident 30 on 11/3/2024 to a board and care facility with Home Health Care (HHC). During a review of the Minimum Data Set assessment dated [DATE], (MDS, a standardized assessment and care screening tool), the MDS indicated Resident 30 had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS indicated Resident 30 required moderate assistance for all activities of daily living (ADL- basic tasks that must be accomplished every day for an individual to thrive). During a concurrent interview and record review on 2/27/2025 at 2:45 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), Resident 30`s MDS assessments were reviewed. The MDSC 1 stated it is required to complete a MDS assessment when a resident is being discharged from the facility. MDSC 1 stated, We have 14 days to complete the discharge MDS. MDSC 1 stated Resident 30 was discharged from the facility on 11/3/2024, however the MDS for discharge was not completed and not submitted to Center for Medicaid Services (CMS). During an interview on 2/27/2025 at 3:15 p.m., with Director of Nursing (DON). The DON stated the discharge assessment has to be done by the MDSC and submitted to CMS in 14 days. The DON stated the potential outcome of not completing discharge the MDS assessment on time is a delay in care and payment for Resident 30. During a review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.19.1 dated October 2024, indicated all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS completion date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the use of floor or landing mats (a cushioning pad placed by a resident's bed to absorb the force of a resident falling) for a resident who was at high risk for falls for one out of three sampled residents (Resident 1) investigated for accidents and hazards. This deficient practice had the potential to increase the resident's risk for injury in the event of a fall. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including fall and neuropathy (disease or dysfunction of one or more nerves, typically causing numbness, weakness, or pain in the hands and feet). During a review of Resident 1' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/15/2025, the MDS indicated Resident 1 had a fall since the last MDS assessment. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for upper and lower body dressing and putting on or taking off footwear. During a review of Resident 1's Fall Risk Evaluation, dated 2/03/2025, the evaluation indicated the resident was at high risk for falls. During a review of Resident 1's Care Plan (CP) for Falls Risk, initiated 2/03/2025, the CP indicated a goal that Resident 1 will be free of significant injury secondary to falls through the review date. One of the interventions, added 2/24/2025, indicated a floor/landing pad to be placed next to bed bilaterally (on both sides). During an observation and interview with Resident 1 and Certified Nursing Assistant 3 (CNA 3) on 2/24/2025 at 2:45 p.m., observed Resident 1 in their bed. Resident 1 stated he had a floor mat that was on his right side but is now placed on the left side. CNA 3 stated they use only one landing mat on the floor for Resident 1. During an interview with Licensed Vocational Nurse 6 (LVN 6) on 2/24/2025 at 3:03 p.m., they stated it is usually just one landing mat in Resident 1's room for that resident. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/24/2025 at 3:44 p.m., reviewed Resident 1's Post Fall Accident Assessment, dated 12/17/2024. The ADON stated Resident 1 does not currently have an order for any landing mat but will follow up and, if indicated, Resident 1 would most likely need a landing mat on each side since Resident 1 fell on the left side when they attempted to get from their wheelchair to bed without assistance. The ADON stated for Resident 1 staff would not know which side Resident 1 would fall on which is why two landing mats are needed. During a concurrent interview and record review with the Director of Nursing (DON) on 2/26/2025 at 4:29 p.m., reviewed the facility's policy and procedure titled, Fall Prevention - Potential Interventions, last reviewed 1/15/2025. The policy indicated fall reduction methods included placing a mattress placed on the floor. The DON stated this intervention includes the use of floor/landing mats placed next to residents' beds. The DON stated the process is for the Interdisciplinary Team (IDT, a group of health professionals from different disciplines who work together to treat a resident) accesses for a need for one or two landing mats for a resident to prevent falls. The DON stated the IDT should have assessed the resident for landing mats before the one landing mat was placed. The DON stated after assessment, where there is a new intervention, it should be added to the care plan. The DON stated Resident 1 needed two landing mats because they had a fall from wheelchair to the floor on the left side on 12/16/2025. The DON stated Resident 1 might attempt to get out of bed on either side so two landing mats are needed. The DON stated the importance of having the landing mats is to prevent any injuries if the resident has a fall. The DON confirmed that the intervention for bilateral floor/landing pad was added to the Falls Risk Care Plan after being brought to attention by the survey team on 2/24/2025. During a review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Plans, last reviewed 1/15/2025, indicated the following: -The IDT, in conjunction with the resident and his/her family develops and implements a comprehensive, person-centered care plan for each resident -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to maintain or improve the resident's ability to carry out the activities of daily living for one (Resident 48) of two residents investigated under vision and hearing by failing to ensure Resident 48's hearing aid was functioning to allow the resident to better hear and improve her ability to communicate. This deficient practice had the potential to prevent the resident from communicating with staff and had the potential for the delay of providing the resident the necessary care, treatment or services. Findings: During a review of Resident 48's admission Record, the admission Record indicated that the facility originally admitted the resident on 03/29/2020 and readmitted on [DATE], with diagnoses including muscle weakness and hearing loss. During a review of Resident 48`s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/16/2024, the MDS indicated that Resident 48 had the ability to usually makes self-understood and had the ability to understand others. The MDS indicated Resident 48 is using a hearing aid. The MDS indicated that the resident required maximal assistance with toileting hygiene, shower, upper body dressing, putting on and taking off footwear and personal hygiene. During an observation and concurrent interview on 02/25/2025 at 8:58 a.m., Resident 48 was in her bed awake and when spoken to, Resident 48 stated she cannot hear, and her hearing aid is broken. During an interview and record review on 02/26/25 at 8:25 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 48`s MDS Section B dated 12/16/2025. The the MDS Section B indicated that Resident 48 can hear adequately with a hearing aid. During an observation and interview on 02/26/2025 at 8:35 a.m., with Resident 48 in the presence of the ADON in Resident 48`s room, observed the ADON asked Resident 48 whether her hearing aid is working. Resident 48 repeatedly stated that she cannot hear, and her hearing aid is not working. During an interview on 02/26/2025 at 8:40 a.m., with Certified Nurse Assistant 1 (CNA1) in Resident 48`s room and in the presence of the ADON. CNA1 stated she does not now when Resident 48's hearing aid stopped working. During a follow-up interview on 02/26/2025 at 08:45 a.m., with the ADON, the ADON stated that hearing aids helps resident communicate their needs to the caregivers. The ADON stated that it would be frustrating to not be able to hear and understand when conversing with the staff. The ADON stated that the resident`s needs will not be met if her ability to communicate is impaired due to the malfunctioning hearing aid. The ADON stated that the CNA should have reported the broken hearing aid so that Social Services Department can address the issue. The ADON stated there is nothing in the notes of the Social Services Department pertaining to the broken hearing aid. During a review of the facility`s policy and procedures titled Hearing Aid, Care of, last reviewed on 1/15/2025, indicated that The purpose of this procedure is to maintain the resident`s hearing at the highest attainable level .notify the supervisor if hearing aid is damaged or needs to be sent to the dealer for cleaning .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 98) reviewed under the Activities care area was provided activities according to his/her activity preferences. This deficient practice violated the resident`s right to have access and receive activity services important to the resident which had the potential to affect the resident`s sense of self-esteem and self-worth. Findings: During a review of Resident 98's admission Record, the admission Record indicated that the resident was originally admitted on [DATE] and readmitted to the facility on [DATE], with diagnoses that included but not limited to, hepatomegaly (an enlarged liver) and benign prostatic hyperplasia (a condition in which the prostate gland, located below the bladder in men, enlarges). During a review of Resident 98`s admission Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/30/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and required maximal assistance from staff for oral hygiene, toileting hygiene, shower, dressing. The MDS also indicated in Section F that it is important to the resident to go outside to get fresh air when the weather is good. During an interview and record review on 02/26/2025 at 10:03 a.m., with the Activity Director (AD), reviewed Resident 98`s Activity Participation (AP) attendance for the month of January and February 2025 and Section F of the MDS, dated [DATE]. The AD stated that Resident 98 had not been provided outdoor activity for the past two months as reflected in the AP. The AD stated that they should have provided the resident`s preferred activity of wanting to be out in the sun to enjoy the weather. The AD stated that having an outdoor activities is physically beneficial and good for the resident`s well-being. During a review of the facility`s policy and procedure titled Activity Programs, last reviewed on 01/15/2025, the policy and procedure indicated that Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident .activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident received care consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure) from developing by failing to notify the physician prior to the treatment stop date that the treatment needed to continue, as the resident's pressure ulcer had not fully healed for one of one resident (Resident 98) reviewed under the Pressure Ulcer/Injury care area. This deficient practice had the potential for worsening of the pressure ulcer. Findings: During a review of Resident 98's admission Record, the admission Record indicated that the resident was originally admitted on [DATE] and readmitted to the facility on [DATE], with diagnoses that included but not limited to, hepatomegaly (an enlarged liver), benign prostatic hyperplasia (a condition in which the prostate gland, located below the bladder in men, enlarges) and pressure ulcer Stage 2 (when the wound extends into the bottom layers of the skin) of sacral region (located at the lower end of the spine, below the lumbar vertebrae and above tailbone). During a review of Resident 98`s admission Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/30/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and required maximal assistance from staff for oral hygiene, toileting hygiene, shower, dressing. During a review of the Skin and Wound Evaluation on 01/20/2025, the evaluation indicated that Resident 98 was admitted with stage 2 pressure ulcer to the sacral region measuring 0.9 centimeter (cm) in length and 0.9 cm in width. During a review of Resident 98`s Physician`s Order dated 01/21/2025, the Physician Order indicated an order to cleanse sacrum with normal saline, pat dry, apply zinc oxide and cover with dry dressing every day shift for pressure injury for 21 days (21st day is 02/10/2025). During a review of Resident 98`s Treatment Administration Record (TAR) for the month of February 2025, the TAR indicated that the last day of the treatment to the pressure ulcer in the sacral region was on 02/10/2025 (21st day). The TAR indicated that the same treatment was resumed on 02/20/2025 until 02/26/2025. During an interview and record review on 02/26/2025 at 11:22 a.m., with Treatment Nurse 1 (TN1), reviewed Resident 98`s Physician`s Order dated 01/21/2025 (cleanse sacrum with normal saline, pat dry, apply zinc oxide and cover with dry dressing every day shift for pressure injury for 21 days) and TAR for the month of February 2025. TN 1 stated that the treatment to the stage 2 pressure ulcer in the sacral region ended on 02/10/2025 and no treatment was provided from 02/11/2025 to 02/19/2025. TN 1 stated that the same treatment was resumed on 02/20/2025 and ended on 02/26/2025. TN 1 stated that she did not inform the physician one day prior (2/10/2025) to the stop date of the treatment that the pressure ulcer has not resolved or fully healed. TN 1 stated that the wound could have worsen and could have resulted to infection when no treatment was provided from 02/11/2025 to 02/19/2025. TN 1 stated she overlooked and failed to notify the physician and obtain an order to continue the treatment. During a review of the facility`s policy and procedure titled Medication and Treatment Orders, last reviewed on 01/15/2025, indicated that Orders for medications and treatments will be consistent with principles of safe and effective order writing .one day prior to the date the stop order is to become effective, the nurse supervisor/charge nurse on duty must contact the prescriber or attending physician to determine if the medication/treatment is to be continued .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure a resident, who was assessed as unsafe to self-administer medications, was not left unattended with a Diclofenac Gel 1% (also known as Voltaren, a medication applied to the skin to reduce pain by reducing inflammation [swelling]) at the bedside one of one sampled resident (Resident 1). This deficient practice had the potential for other residents to enter the room and take the medication or for Resident 1 to apply too much of the medication too often. 2. Ensure a resident who was at high risk for falls had floor mats (a cushioning pad placed by a resident's bed to absorb the force of a resident falling) as ordered by the physician for one out of three sampled residents (Resident 1) investigated for accidents and hazards. Findings: 1. During a review of Resident 1's Face sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including neuropathy (disease or dysfunction of one or more nerves, typically causing numbness, weakness, or pain in the hands and feet). During a review of Resident 1's Census List (a list of a resident's admissions, room changes, discharges to the hospital, and re-admissions) indicated Resident 1 was transferred to a General Acute Care Hospital (GACH, or simply hospital) 1/15/2025 and re-admitted to the facility on [DATE]. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for upper and lower body dressing and putting on or taking off footwear. During a review of Resident 1's Physician's Orders, the Physician Ordered indicated the following orders: -Voltaren, apply to affected area topically every eight hours as needed for pain management, dated 10/05/2023. (The order was discontinued when Resident 1 was discharged to the GACH on 1/15/2025.) -Voltaren, apply to affected area topically every eight hours as needed for pain management, dated 1/29/2025. During an observation and interview with Resident 1 on 2/24/2025 at 2:45 p.m., observed Resident 1 in his bed. Resident 1 stated he had pain 8/10 to his knees. Resident 1 stated he rubs the Diclofenac gel cream on his knees that was on his bedside table. During an observation, record review, and concurrent interview with Licensed Vocational Nurse 6 (LVN 6) on 2/24/2025 at 3:03 p.m., observed the medication cart in which Resident 1's medications are located. LVN 6 was unable to locate Resident 1's Voltaren in the medication cart. LVN 6 reviewed Resident 1's Physician's orders which indicated there was an order dated 1/29/2025 for Voltaren. During an interview with the Treatment Nurse 1 (TN 1) on 2/24/2025 at 3:30 p.m., TN 1 stated TN 1 searched the treatment cart and Resident 1's Voltaren was not there. TN 1 stated they were unfamiliar with Resident 1's medication because it was not on Resident 1's Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident). During an observation on 2/24/2025 at 3:40 p.m., observed TN 1 rubbing the Voltaren gel on Resident 1's knees. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicated TN 1 applied the Voltaren to Resident 1's knees on 2/24/2025 at 3:47 p.m. During an interview with the Assistant Director of Nursing (ADON) on 2/24/2025 at 3:44 p.m., the ADON stated Resident 1 told them that their family member brought Voltaren to the resident. The ADON stated it is important to keep Voltaren in the medication cart so the licensed nurses can monitor the resident's pain and because other residents could take it. During an interview with the ADON on 2/25/2025 at 9:38 a.m., the ADON stated if Resident 1 was assessed by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the resident's goals) as being able to self-administer the Voltaren then the licensed nurses would complete an assessment indicating Resident 1 could self-administer the Voltaren, and they would also obtain a physician's order to self-administer the medication. The ADON stated there was no assessment indicating it was safe for Resident 1 to self-administer the Voltaren and there was no order for Resident 1 to self-administer the Voltaren. During a concurrent interview with the Director of Nurses (DON) on 2/26/2025 at 4:29 p.m., the DON stated if a resident's IDT assessed a resident as able to self-administer medications, then the licensed nurses will obtain a physician's order, self-administration assessment would be completed, and the medication(s) would be kept locked in the resident's bedside draw with the resident only having the key. During a phone interview with Resident 1's Family Member 1 (FM 1), on 2/27/2025 at 10:57 a.m., FM 1 stated he brought the Voltaren gel for Resident 1 that was on his bedside table. FM 1 stated Resident 1 needed the medication for pain relief. During a review of the facility's policy and procedure titled, Self-Administration of Medications, last reviewed 1/15/2025, indicated the following: As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers: -The medication is appropriate for self-administration; -The resident is able to read and understand medication labels; -The resident can follow directions and tell time to know when to take the medication; -The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; 2. During a review of Resident 1's Fall Risk Evaluation, dated 1/29/2025, the evaluation indicated the resident was at high risk for falls. During a review of Resident 1's Care Plan (CP) for Falls Risk, initiated 2/03/2025, the CP indicated a goal that Resident 1 will be free of significant injury secondary to falls through the review date. One of the interventions, added 2/24/2025, indicated floor/landing pad to be placed next to bed bilaterally (on both sides). During an observation and interview with Resident 1 and Certified Nursing Assistant 3 (CNA 3) on 2/24/2025 at 2:45 p.m., observed Resident 1 in his bed. Resident 1 stated he had a floor mat that was on his right side but is now placed on the left side. CNA 3 stated they use only one landing mat on the floor for Resident 1. During an interview with Licensed Vocational Nurse 6 (LVN 6) on 2/24/2025 at 3:03 p.m., LVN 6 stated it is usually just one landing mat in Resident 1's room for that resident. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/24/2025 at 3:44 p.m., reviewed Resident 1's Post Fall Accident Assessment, dated 12/17/2024. The ADON stated Resident 1 does not currently have an order for any landing mat but will follow up and stated Resident 1 would probably need a landing mat on each side since Resident 1 fell on the left side when they were trying to get from their wheelchair to bed without assistance. The ADON stated for Resident 1 staff would not know which side Resident 1 would fall on which is why two landing mats are needed. During a concurrent interview and record review with the Director of Nursing (DON) on 2/26/2025 at 4:29 p.m., reviewed the facility's policy and procedure titled, Fall Prevention - Potential Interventions, last reviewed 1/15/2025. The policy indicated fall reduction methods included placing a mattress placed on the floor. The DON stated this intervention includes the use of floor/landing mats placed next to residents' beds. The DON stated the licensed nurses access for a need for one or two landing mats for a resident to prevent falls. The DON stated Resident 1 needed two landing mats because they had a fall from wheelchair to the floor on the left side on 12/16/2025. The DON stated Resident 1 might attempt to get out of bed on either side so two landing mats are needed. The DON stated the importance of having the landing mats is to prevent any injuries if the resident has a fall. The DON confirmed that the intervention for bilateral floor/landing pad was added to the Falls Risk Care Plan after being brought to attention by the survey team on 2/24/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents who needed respiratory care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) were provided such care, consistent with professional standards of practice to one out of two sampled residents (Resident 136) by failing to administer oxygen (a colorless, odorless, and tasteless gas, that supports life) to Resident 136 as per the physician's order. These deficient practices had the potential to negatively impact Resident 136's respiratory well-being. Findings: During a review of Resident 136's admission Record, the admission Record indicated that the facility initially admitted Resident 136 on 1/20/2025 with diagnoses including respiratory failure (a condition in which your blood does not have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury) with hypoxia (low levels of oxygen in the body tissues), heart failure (when heart muscle cannot pump enough blood to meet the body's needs), and parkinsonism (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of Resident 136's History and Physical (H&P), dated 1/21/2025, the document indicated that the resident had the capacity to understand and make decisions. During a review of Resident 136's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/26/2025, the MDS indicated that the resident had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS further indicated that Resident 136 needed supervision for eating, maximal assistance for upper body dressing, oral and personal hygiene, and was dependent on assistance of two or more helpers for showering, toileting hygiene, lower body dressing and bed-chair transfer. During a review of Resident 136's Physician Order, dated 1/21/2025, the Physician Order indicated an order for oxygen at two (2) liters/minute (l/min- unit of measurement for oxygen flow) via nasal cannula (a device that gives additional oxygen through the nose) as needed (PRN- when required), for hypoxia (low levels of oxygen in the body tissues) or shortness of breath. The goal is to maintain oxygen saturation (a percentage of oxygen-saturated hemoglobin [a protein in red blood cells that carries oxygen from lungs to the body's tissues and organs] in the blood compared to total hemoglobin) above 90%. During the review of Resident 136's Medication Administration Record (MAR), the vital signs dated 2/25/2025, the MAR indicated that the resident's oxygen saturation was 90%. During a concurrent observation and interview on 2/24/2024 at 9:24 AM in Resident 136's room with Registered Nurse 2 (RN 2), Resident 136 was observed in his bed sleeping with the nasal canula not connected to the resident and instead under Resident 136's gown. The oxygen concentrator was on at two liters of flow. RN 2 stated that oxygen had to be administered to Resident 136 via nasal canula at 2 l/min to keep oxygen saturation over 90%. RN 2 connected the oxygen to Resident 136 via nasal canula at 2 l/min. RN 2 stated that Resident 136 required oxygen because of his hypoxia and the location of nasal canula under the resident's gown may lead to cross contamination (the act of making something unclean or harmful). During an interview on 2/27/2024 at 12:03PM with the Director of Nursing (DON), the DON stated that oxygen should be administered to Resident 136 according to the physician's order to prevent the possibility of worsening of Resident 136's respiratory illness. During a review the facility Policy and Procedure named Oxygen Administration, last reviewed on 1/15/2025, the document indicated to remove any [NAME] blanket, nylon and/or [NAME] clothing, etc , from immediate area where oxygen is to be administered .Place appropriate oxygen device on resident (mask, nasal canula/or nasal catheter). Before administering oxygen, and while the resident is receiving oxygen, assess the following .securely anchor the tubing that it does not rub or irritate the resident's nose, behind the resident's ears.

Based on interview, and record reviews, the facility failed to follow their policy and procedure for pain assessment and management for one of one sampled resident (Resident 38) reviewed under pain by failing to: 1. Conduct pain assessments after Resident 38`s change of conditions (a deviation from a resident`s normal state of health that can be physical, mental, or behavioral) on 12/8/2024 and 2/13/2025. 2. Thoroughly complete Resident 38`s Pain Risk Evaluation form on 12/30/2024. 3. Monitor Resident 38 for presence of pain on 2/7/2025 and 2/23/2025. These deficient practices had the potential to negatively affect Resident 38`s psychosocial well-being and quality of life. Findings: During a review of Resident 38's admission Record (face sheet), the admission record indicated that the facility admitted the resident on 8/27/2024, with diagnoses including secondary malignant neoplasm of bone (a cancerous tumor in bone which expands quickly and can spread to other areas of the body), secondary malignant neoplasm of peritoneum (a thin, smooth membrane that lines the abdominal cavity and covers most of the abdominal organs) and retroperitoneum (an anatomical space located behind the abdominal or peritoneal cavity), and gout (a form of inflammatory arthritis that causes pain and swelling in your joints). During a review of Resident 38's Minimum Data Set (MDS-a resident assessment tool) dated 12/30/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 38 was dependent to staff (helper does all of the effort) for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated that Resident 38 received scheduled and PRN (as needed) pain medications in the last five days. The MDS further indicated that Resident 38 has almost constantly experienced pain or hurting (pain that is present most of the time) over the last five days. During a review of Resident 38`s Order Summary Report (physician orders) dated 11/16/2024, the Order Summary Report indicated to monitor the resident for presence of pain during every shift including verbal/non-verbal pain (expression of pain through physical behaviors and facial expressions, rather than using words) using pain scale of 0-10 (pain rating scale of zero being no pain and 10 being the worst pain possible) 0=no pain, 1-2=least pain, 3-4=mild pain, 5-6=moderate pain, 7-8=severe pain, 9-10=very severe/worst pain. During a review of Resident 38`s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 12/8/2024, the SBAR communication form indicated that the resident had left shoulder pain that was radiating to his arm. The SBAR communication form indicated that although Resident 38 had pain but was able to move his left arm. During a review of Resident 38`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) titled Resident is Receiving Pain Medication, initiated on 12/11/2024, the care plan indicated a goal that the resident will not have an interruption in normal activities due to pain through the review date. The care plan interventions were to monitor for presence of pain during every shift, provide non-pharmacological pain interventions (treatments that reduce pain without using medication) during every shift, administer analgesia medications (a drug that treats pain) as ordered by the physician, and evaluate the effectiveness of pain interventions during every shift and PRN. During a review of Resident 38`s Pain Risk Evaluation form dated 12/30/2024, the pain risk evaluation form indicated that the resident did not verbalize any symptoms of pain. The pain risk evaluation form did not indicate the names of both scheduled and PRN medications used for Resident 38. During a review of Resident 38`s SBAR Communication Form dated 2/13/2025, the SBAR communication form indicated that the resident had new or worsening pain. The SBAR communication form indicated that Resident 38 was experiencing pain in the upper left area of his ribs. During a review of Resident 38's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 2/1/2025-2/26/2025, the MAR indicated no entries for the resident`s pain monitoring on 2/7/2025 and 2/23/2025 during the evening shift. During a concurrent interview and record review on 2/26/2025 at 3:34 p.m., with Registered Nurse 1 (RN1), Resident 38`s SBARs, pain risk evaluations and MAR for February were reviewed. RN1 stated Resident 38 had a change of condition on 12/8/2024 for new onset of pain to his left shoulder. RN 1 stated on 2/13/2025, Resident 38 had a change of condition for pain in the upper left area of his ribs. RN 1 stated licensed staff did not develop and complete pain risk evaluations after Resident 38`s change of conditions on 12/8/2024 and 2/13/2025. RN 1 stated licensed staff are required to complete a pain risk evaluation upon resident`s admission to the facility, quarterly, and whenever there is a significant change in the resident condition. RN 1 stated the potential outcome of not completing a pain risk evaluation is the inability to assess resident`s pain and implement proper interventions to relieve the pain. RN 1 stated licensed staff did not complete Resident 38`s pain risk evaluation thoroughly on 12/30/2024. RN 1 stated the pain risk evaluation form did not indicate the names of both scheduled and PRN medications used for Resident 38. RN1 stated that a residents` assessments for pain must be complete and include all pertinent information regarding the resident. RN 1 stated Resident 38`s MAR for February did not indicate any entries for the resident`s pain monitoring on 2/7/2025 and 2/23/2025 during the evening shift. RN 1 stated licensed nurses did not document that they monitored Resident 38`s pain on 2/7/2025 and 2/23/2025. RN 1 stated staff are required to monitor Resident 38`s pain during every shift as ordered by his physician. RN 1 stated the potential outcome of not monitoring a resident`s pain is worsening of the pain and the inability to implement timely interventions to control the pain. During a review of the facility`s Policy and Procedures (P&P) titled Pain Assessment and Management, last reviewed on 1/15/2025, the P&P indicated that comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Assess the resident at admission, and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition. Monitor the resident`s pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete the Hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) Communication Record with information including post dialysis assessment of the access site (locations on the body where a needle or catheter can be inserted to provide access to the bloodstream for hemodialysis treatment) and post dialysis vital signs for one of one resident (R108) investigated under the dialysis care area. This deficient practice placed the resident at risk for delayed detection of potential complications after dialysis treatment such as blood clot formation and bleeding which could lead to hemorrhage. Findings: During a review of Resident 108's admission Record, the admission record indicated that the resident was admitted on [DATE], with diagnoses including history of falling and end stage renal disease (a severe medical condition where the kidneys have permanently lost their ability to function adequately). During a review of Resident 108`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/14/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was impaired and required assistance from staff for toileting, shower, dressing and personal hygiene. During a review of Resident 108's Order Summary Report dated 03/30/2023, the Order Summary Report indicated an order for dialysis treatment every Tuesday-Thursday-Saturday at 09:30 a.m. for 4 hours. During an interview and record review on 02/26/25 at 11: 15 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 108`s Dialysis Unit/SNF Communication Record dated 01/25/2025 and 01/30/2025. The Dialysis Unit/SNF Communication Record form indicated that post dialysis vital signs must be obtained, and access site assessment will be documented if the following signs and symptoms of dialysis complications are observed, namely: a. Redness b. Swelling c. Drainage d. Prolonged bleeding; The Dialysis Unit/SNF Communication Record on these dates (1/25/25 and 1/30/25), indicated that post dialysis vital signs and access site assessment were not done. The ADON stated that it is important to assess the access site for any complications and obtain the resident's vital signs after a dialysis treatment. The ADON stated that if the resident is not assessed then it can result to undetected complications which could worsen and result to negative outcome such as bleeding and hemorrhage. During a review of the facility policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, last reviewed on 1/15/2025, the policy and procedure indicated that Residents with end-stage renal disease will be cared for according to currently recognized standards of care .including resident receiving dialysis care outside the facility . the nature and clinical management of ESRD (including infection prevention and nutritional needs) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Consultant Pharmacist`s (CP) recommendation for 12/2024 Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to give Ferrous Sulfate (iron supplement) was discussed with the physician and acted upon for one of eight (Resident 48) sampled residents. This deficient practice has placed the resident at an increased risk for untreated anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body) which could result to complications such as fatigue, weakness, and shortness of breath. Findings: During a review of Resident 48's admission Record, the admission Record indicated that the facility originally admitted the resident on 03/29/2020 and readmitted on [DATE], with diagnoses including anemia, muscle weakness and hearing loss. During a review of Resident 48`s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/16/2024, the MDS indicated that Resident 48 had the ability to usually makes self-understood and had the ability to understand others. The MDS indicated that the resident required maximal assistance with toileting hygiene, shower, upper body dressing, putting on and taking off footwear and personal hygiene. During an interview and record review on 02/25/2025 at 8:56 a.m., with the Assistant Director of Nursing (ADON), reviewed the Consultant Pharmacist`s Medication Regimen Review (CPMRR) created between 12/01/2024 and 12/17/2024. The review indicated that the consultant pharmacist recommended to give Ferrous Sulfate (iron supplement) 325 milligram (mg) three times a day to stimulate erythropoiesis (the production of red blood cells). The ADON stated that iron supplement is beneficial for residents` who have diagnoses of anemia. The ADON stated that anemia symptoms can include generalized weakness and makes the resident susceptible to infection. The ADON stated that the Quality Assurance Nurse (QAN)is in-charge of following up with the physician regarding consultant pharmacist`s recommendation. During an interview and record review on 2/25/25 at 4:23 p.m., with the QAN, reviewed the consultant pharmacist`s MRR created between 12/01/2024 and 12/17/2024. The QAN stated that if the consultant pharmacist has a recommendation, she will communicate the recommendation to the physician and if the physician agrees, the medication will be ordered. The QAN stated that the recommendation created between 12/01/2024 to 12/17/2024 was not discussed with the physician as there is no documentation that it was acted upon or if the physician's disagreed with the recommendation. The QAN stated that if the consultant pharmacist's recommendation was not communicated to the physician, Resident 48 could potentially experience weakness and fatigue, and her anemia will not be treated. During a review of the facility`s policy and procedures titled Medication Regimen Reviews, last reviewed on 01/15/2025, indicated that The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .the goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication .

Based on observation, interview, and record review the facility failed to maintain electronic medical administration records (EMAR) in accordance with accepted professional standards and practices by failing to ensure all licensed nurses charted accurately the administration of the medication Gemtesa (medication for overactive bladder [an organ that holds urine]) from 2/11/2025 to 2/19/2025 to one of three sampled residents (Resident 112) reviewed during the unnecessary medication task This deficient practice resulted in inaccurate documentation in Resident 112's medical record. Cross-reference F755 Findings: During a review of Resident 112's admission Record, the admission Record indicated the facility admitted Resident 112 on 6/15/2023 with diagnoses that included, but not limited to Alzheimer's Disease (progressive state of decline in mental abilities), Parkinson's Disease (a progressive neurological [relating to the brain, spinal cord, and nerves] disorder that affects movement, balance, and coordination), major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness), and a history of falling. During a review of Resident 112's Physician's Progress Note, dated 1/7/2025, the Physician's Progress Note indicated Resident 112 had the capacity to understand and make decision and had urinary incontinence (inability to control urine flow) with improvement in bladder spasms (sudden uncontrollable squeezing of the bladder) and urination when on Gemtesa. The progress note indicated the resident to continue using Gemtesa. During a review of Resident 112's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/18/2024, indicated Resident 112 was able to understand others and make herself understood. The MDS indicated Resident 112 needed moderate assistance on staff for bathing, dressing, and toileting. During a review of Resident 112's Physician's Orders, the order indicated Gemtesa oral tablet - give 75 milligrams (mg - a unit of measurement) by mouth one time a day for overactive bladder was discontinued on 2/19/2025. During a review of Resident 112's Bladder Incontinence (inability to control the flow of urine from the bladder) Care Plan (CP) initiated on 6/26/2023 and last revised on 7/8/2024, the CP indicated goals to keep Resident 112 clean, dry and free of odors and to reduce episodes of incontinence through the next review date of 03/18/2025. During a review of Resident 112's Electronic Medical Administration Record (EMAR - online charting system), the EMAR indicated the charting code 3 entered by the Licensed Vocational Nurses (LVN) indicates Hold/Progress Note MD Notification, and a check mark indicates Administered. The EMAR further indicated the following entries for the medication Gemtesa: - On 2/11/2025 at 9:00am a code of 3 was documented by LVN 4. - On 2/12/2025 at 9:00am a check mark was documented by LVN 9. - On 2/13/2025 at 9:00am a check mark was documented by LVN 8. - On 2/14/2025 at 9:00am a check mark was documented by LVN 8. - On 2/15/2025 at 9:00am a check mark was documented by LVN 9. - On 2/16/2025 at 9:00am a check mark was documented by LVN 9. - On 2/17/2025 at 9:00am a code of 3 was documented by LVN 6. - On 2/18/2025 at 9:00am a code of 3 was documented by LVN 4. - On 2/19/2025 at 9:00am a code of 3 was documented by LVN 6. During a review of Resident 112's Progress Notes, the Progress Notes indicated the following documentation for the medication Gemtesa: - On 2/11/2025 LVN 4 entered awaiting refill from RX, medicine NA. - On 2/17/2025 LVN 6 entered medication unavailable. MD notified. - On 2/17/2025 LVN 4 entered medicine NA, awaiting refill from RX. - On 2/17/2025 LVN 6 entered medication unavailable. MD notified. During a concurrent interview and record review on 2/26/2025 at 10:20 am with LVN 8 of Resident 112's EMAR, LVN 8 confirmed she worked on 2/13/2025 to 2/14/2025 and the medication Gemtesa was not available but accidently check marked in the EMAR that Gemtesa was given. LVN 8 indicated it is extremely important to be careful and accurate when charting in the EMAR so other nurses would know the medication was not available. During a concurrent interview and record review on 2/26/2025 at 11:00 am with LVN 9 reviewed Resident 112's EMAR. LVN 9 confirmed she worked on 2/12/2025, 2/15/2025 and 2/16/2025 and the medication Gemtesa was not available on those days but does not remember why Gemtesa was checked off as given. LVN 9 confirmed the check marks were documented in error. LVN 9 stated the EMAR is a legal document and it is very important to be accurate when charting so other nurses know if the resident received the medication or not. During a phone interview on 2/26/2025 at 1:47 pm with LVN 4, LVN 4 stated on 2/11/2025 the bubble pack (a card that packages doses of medication within small, clear, plastic bubbles that is punched out to administer to a resident) for Gemtesa was completely empty and indicated a 3 in the EMAR and wrote that the medication was NA (LVN 4 clarified NA meant not available) and waiting for delivery from RX (LVN 4 clarified RX meant pharmacy). LVN 4 then stated when she worked again on 2/18/2025, the bubble pack was still empty and indicated a 3 in the EMAR again, requested a refill from the pharmacy again and then spoke with Resident 112's family member (FM 2) to inform him that the medication has been unavailable for several days. LVN 4 stated FM 2 stated he was never told in advance that the medication was out and was going to call Resident 4's pharmacy. LVN 4 stated she was unaware why other LVNs indicated they administered Gemtesa on 2/12/2025 -2/16/2025 on the EMAR when the medication was not available on 2/11/2025 and 2/18/2025. LVN 4 further stated the Gemtesa should have been followed up by the other LVNs to minimize the number of days the Resident 112 went without Gemtesa. During an interview on 2/26/2025 at 2:15pm with Registered Nurse (RN) 1, RN 1 stated medicine in bubble packs must be reordered when there are about 7 tablets left to give time for any insurance issues and for the medication to arrive before the current stock runs out. RN 1 further stated if LVN 8 and LVN 9 charted correctly, Resident 112's may have received a replenished supply sooner. During a review of the facility provided Policy and Procedure (P&P) titled, Charting and Documentation, last reviewed 1/15/2025, indicated the documentation in the medical record will be objective, complete and accurate. During a review of the facility's P&P titled, Charting and Documentation, last reviewed 1/15/2024, indicated medications administer is to be documented in the resident medical record. The P&P indicated documentation in the medical record will be objective, complete, and accurate. The P&P indicated entries may only be recorded in the resident's clinical record by licensed personnel. The P&P further indicated documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided. b. The name and title of the individual(s) who provided the care. c. The assessment data and/or any unusual findings obtained during the procedure/treatment. d. How the resident tolerated the procedure/treatment. e. Whether the resident refused the procedure/treatment. f. Notification of family, physician, or other staff, if indicated; and g. The signature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to: 1. Ensure residents are provided with a call light (a device used by a patient to signal his or her need for assistance from a professional staff) that the resident can use and within the resident's reach for two of three (Resident 34 and Resident 395) sampled residents reviewed under the environment task. 2. Ensure that a call light was answered by any staff member walking by the room for 1 of three sampled residents (Resident 134) reviewed in environment task. These deficient practices had the potential to result in the residents unable to call health care workers for assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being. Findings: 1.a. During a review of Resident 34's admission Record, the admission Record indicated the facility admitted Resident 34 on 9/14/2022 with diagnoses including atherosclerotic heart disease (a condition where plaque [fats and other substances], builds up inside the arteries, causing them to narrow and potentially blocking blood flow to the heart), muscle weakness, major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness), and fall on same level from slipping, tripping and stumbling. During a review of Resident 34's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/10/2024, the MDS indicated Resident 34 was able to understand others and make herself understood. The MDS indicated Resident 34 needed substantial assistance from staff for bathing, dressing, and toileting and moderate assistance for mobility while in bed and transfers. The MDS also indicated repeated falls. During a review of Resident 34's Self-Care Performance Deficit (less than what is needed or expected) Care Plan (CP) initiated on 1/2/2024 and last revised on 1/9/2025, the CP indicated an intervention to encourage the use of call light for assistance - ensure call light is within reach, secure to bed for easy access through the next review date of 03/12/2025. During an observation on 2/24/2025 at 9:30 am in Resident 34's room, Resident 34 was asleep, and the call light was under her mattress and not within reach. During a concurrent observation and interview on 2/24/2025 at 9:34 am with a Care Partner (a person employed by the facility to assist CNA's for resident's basic care needs) in Resident 34's room, the Care Partner confirmed Resident 34's call light was under her mattress and not within reach. The Care Partner stated the call light must always be within the resident's reach so they can call for help, especially if there is an emergency. During an interview on 2/27/2025 at 11:24 am with Registered Nurse (RN) 1, RN 1 stated the call light must be within reach so the resident can call for help and to prevent a delay in care. During a review of the facility's policy and procedure titled, Call System, Resident last reviewed on 1/15/2025, the policy indicated the facility will provide a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation. The policy indicated each resident is provided with a means to call staff directly for assistance from the bed, from toileting/bathing facilities and from the floor. 2. During a review of Resident 134's admission Record, the admission Record indicated the facility admitted Resident 134 on 1/18/2025 with diagnoses including history of falling, dysphagia, age related osteoporosis (a disease that causes bones to weaken and become more likely to break), paralysis of vocal cords (a condition that causes the loss of control of the muscles that control the voice) and larynx (the voice box containing vocal cords). During a review of Resident 134's History and Physical (H&P), dated 1/20/2025, the H&P indicated Resident 134 had the capacity to understand and make decisions. During a review of Resident 134's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/10/2024, the MDS indicated Resident 134 was able to understand others and make herself understood. The MDS indicated Resident 134 needed moderate assistance from staff for bathing, dressing, and toileting and a history of falls. During a review of Resident 134's Self-Care Performance Deficit (less than what is needed or expected) Care Plan (CP) initiated on 1/19/2025 and last revised on 1/30/2025, the CP indicated an intervention to encourage the use of call light for assistance - ensure call light is within reach, secure to bed for easy access through the next review date of 04/25/2025. During an observation on 2/24/2025 at 10:05 am in Resident 134's room, Resident 134's was up in her bed with the call light in her hand. The call light was lit in her room and outside of her door to indicate she needed assistance. At 10:07 am, the Director of Nursing (DON) was seen walking by the room without entering or addressing the call light. Moments later, the DON is seen walking by the room again without entering or addressing the call light. During a concurrent observation and interview on 2/24/2025 at 10:08 am outside Resident 134's room with the DON, the DON confirmed the call light was on for Resident 134. The DON stated he was looking for a CNA to assist the resident but that he should have entered immediately to check on the resident first. The DON stated call lights should be answered by any staff member immediately to prevent a delay in care and accidents. During a review of the facility's policy and procedure titled, Call System, Resident last reviewed on 1/15/2025, the policy indicated the facility will provide a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation. The policy indicated calls for assistance are answered as soon as possible, but no later than five minutes. 1.b. During a review of Resident 395's admission Record, the admission Record indicated the facility admitted the resident on 2/6/2025 with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection. The infection-fighting processes turn on the body, causing the organs to work poorly), major depressive disorder (a serious mental illness that can cause a persistent low mood, loss of interest, and other symptoms that affect how a person feels, thinks, and acts), and reduced mobility. During a review of Resident 395's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/12/2025, the MDS indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 395 was unable to walk and was totally dependent on two-person extensive assistance for all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 395 History and Physical (H&P), dated 1/20/2025, the H&P indicated Resident 395 had the capacity to understand and make decisions. During a review of Resident 395's Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) for ADL, the Care Plan indicated that the resident required assist of one-to-two person to start and complete most ALDs task. The care plan tasks indicated to ensure call light is within reach and ensure a call light was available to the resident, and the resident's needs were anticipated and met. During an observation on 2/24/2025 at 10:46 a.m. in Resident 395's room, observed the resident lying in bed, the call light was located under Resident 395's pillow on the left side of the bed. Resident 395 stated she could not reach the call light because of weakness in her hands and arms. Resident 395 stated that usually she called the nurse when she saw staff passing her room. During a concurrent observation and interview on 2/24/2025 at 10:50 a.m. with Licensed Vocational Nurse 3 (LVN 3) in Resident 395's room, LVN 3 concurred that the resident could not reach the call light, when the call light was located under the resident's pillow. The call light was placed in the resident's left hand, and she was asked to push the call light. The resident stated that she could not use her fingers to push the red button, and she usually pushes the red button against her chin and demonstrated how she pushed. When asked by the surveyor if this call light is appropriate for Resident 395's condition, LVN 3 stated the facility has different types of call light devices which can be used in cases when a resident cannot use a regular call light. LVN 3 stated that he will provide Resident 395 with adaptive tap call light (when resident does not need to push just lightly tap). LVN 3 stated if the resident was not able to call for assistance, they would be at risk for delayed care. During an interview on 2/26/2023 at 12:03 p.m., with the Director of Nursing (DON), the DON stated that Resident 395 should be provided with adaptive call button, the resident's care plan should reflect the needs of adaptive device. The DON stated the call light should be placed within reach to the resident to be able to call for assistance in case of emergency and for staff to meet their needs. During a review of the facility's policy and procedure titled, Call System, Resident last reviewed on 1/15/2025, the policy indicated the facility will provide a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation. If resident has a disability that prevents him/ her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 27's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/17/2024, and readmitted on [DATE], with diagnoses including acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 27's MDS dated [DATE], the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was maidly impaired (mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS indicated that Resident 27 was dependent on the staff (helper does all the effort) for showering/bathing and lower body dressing, and moderate- to- maximal assistance for all other of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 27's Physician Orders, the Physician Orders indicated an order dated 2/21/2025 for Zyvox (antibiotic used to treat bacterial infection) oral tablet 600 milligrams (mg- unit of measurement), give 1 tablet by mouth two times a day for diagnosis of Methicillin- Resistant Staphylococcus aureus (MRSA- type of bacteria that is resistant to the antibiotic) in urine for 7 days. During a review of Resident 27's Physician Orders indicated, the Physician Orders indicated an order dated 2/21/2025 for Doxycycline (antibiotic used to treat infection) tablet 100 mg, give 1 tablet by mouth every 12 hours for MRSA in urine for 5 days. During a review of Resident 27's Physician Orders, the Physician Orders indicated an order dated 2/23/2025 for Vancomycin (antibiotic used to treat infection) intravenous solution 500 mg /100 milliliters (ml-unit of measurements), use 1 gram intravenously one time only for urinary tract infection (UTI- an infection in any part of the urinary system) for one day. During a review of Resident 27's Physician Orders, the Physician Orders indicated an order dated 2/24/2025 for Ceftazidime (antibiotic used to treat bacterial infection) intravenous solution 2 gram intravenously every 8 hours for UTI for 5 days. During a concurrent interview and record review on 2/26/ 2025 at 9:57 a.m. with Minimum Data Set Coordinator 2 (MDSC 2), MDSC 2 reviewed Resident 27 's care plans (a document that outlines a patient's health information, conditions, treatments, care services, and goals) for antibiotic use for UTI and stated that she did not find any care plans reflecting that Resident 27 was receiving the following antibiotics: Zyvox, Doxycycline, Vancomycin and Ceftazidime. During an interview and concurrent record review with the Director of Nursing (DON) on 2/27/2024 at 12:03 p.m., the DON stated that the facility missed initiating a care plan addressing Resident 27's antibiotic administration. The DON stated that a care plan on antibiotic administration is important because the care plan should provide specific interventions regarding these medications. During a review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Plans, last reviewed 1/15/2025, the policy and procedure indicated the following: -The IDT, in conjunction with the resident and his/her family develops and implements a comprehensive, person-centered care plan for each resident -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for two of three sampled residents (Resident 345 and Resident 27) by failing to: 1. Develop and implement a comprehensive person-centered care plan addressing Resident 345`s oxygen use. This deficient practice had the potential to result in Resident 345`s inadequate care. 2. Develop and implement a comprehensive person-centered care plan addressing Resident 27`s antibiotic (medications that are used to treat infection by stopping bacteria from reproducing or destroying them) use. This deficient practice had the potential to increase Resident 27 's risk for adverse effects of antibiotics. Findings: 1. During review of Resident 345`s admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 12/1/2023, and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and acute (short term) respiratory failure (when not enough oxygen passes from your lungs to your blood) with hypoxia (a medical condition that occurs when there is an inadequate supply of oxygen to the body's tissues). During a review of Resident 345's Minimum Data Set (MDS-a resident assessment tool) dated 2/18/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 345 required partial/moderate assistance (helper does less than half effort) for upper body dressing, and personal hygiene. The MDS further indicated that Resident 345 was receiving intermittent (on and off) oxygen therapy upon admission and while a resident inside the facility. During a review of Resident 345's Order Summary Report (physician order) dated 2/11/2025, the order summary report indicated to administer oxygen at two (2) liters per minute via nasal canula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for hypoxia/shortness of breath. The order summary report indicated to change the oxygen tubing (including NC, mask, and storage bag) every week and as needed and date the tubing and storage bag. During a review of Resident 345's care plans, the care plans did not indicate a documented evidence of a comprehensive care plan addressing Resident 345`s oxygen use. During a concurrent interview and record review on 2/25/2025 at 2:00 p.m., with Registered Nurse 1 (RN 1), Resident 345`s physician orders and care plans were reviewed. RN 1 stated that Resident 345`s is using oxygen, however, licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s oxygen use. RN 1 stated there should have been a care plan developed with person-centered goals and interventions to monitor Resident 345`s oxygen use. RN 1 stated the potential outcome of not developing a care plan for a resident who uses oxygen is the lack of care and the inability to implement the specific services and monitoring that the resident requires. During an interview on 2/27/2025 at 2:09 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to develop a person-centered care plan based on the residents` needs and identified problems. The DON stated licensed staff did not develop a care plan with goal and interventions for Resident 345`s oxygen use. The DON stated that the potential outcome is providing inadequate care to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/15/2025, the P&P indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan is developed within seven days of completion of the required MDS assessment and no more than 21 days after admission. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident`s problem areas and their causes, and relevant clinical decision making.

Based on interview and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) injection sites to two of two sampled residents (Resident 76 and Resident 111) reviewed under the insulin care area. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat), bruising and pain. Cross reference F760 Findings: a. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 10/20/2023 with diagnoses that included, but not limited to type 2 diabetes mellitus (a disease that occurs when the glucose, also called blood sugar, is too high), neuropathy (damage, disease, or dysfunction of one or more nerves) and major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness). During a review of Resident 76's History and Physical (H&P), dated 10/25/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 76's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/3/2024, the MDS indicated the resident had some impaired cognition, needed maximal assistance from staff for activities such as toileting, dressing, bathing and personal hygiene, and was on a high-risk drug class medication hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood). During a review of Resident 76's Order Summary Report, the report indicated an order dated 9/12/2024, Insulin Glargine subcutaneous (SQ - in the fatty layer of the skin) Solution 100 units per milliliters (unit/ml, a unit of fluid volume) inject 12 units SQ at bedtime. During a review of Resident 76's 2/2025 Medication Administration Record (MAR) reviewed on 2/27/2025 at 10:30am, the MAR indicated the insulin was administered on the following dates and sites: Insulin Glargine SQ 100 unit/ml subcutaneous solution: 2/1/2025 - abdomen - left upper quadrant (LUQ) 2/2/2025 - abdomen - left upper quadrant (LUQ) 2/3/2025 - abdomen - left upper quadrant (LUQ) 2/4/2025 - abdomen - left upper quadrant (LUQ) 2/5/2025 - abdomen - left upper quadrant (LUQ) 2/6/2025 - abdomen - left upper quadrant (LUQ) 2/7/2025 - abdomen - left upper quadrant (LUQ) 2/9/2025 - abdomen - left upper quadrant (LUQ) 2/10/2025 - abdomen - left upper quadrant (LUQ) 2/11/2025 - abdomen - left upper quadrant (LUQ) 2/12/2025 - abdomen - left upper quadrant (LUQ) 2/13/2025 - abdomen - left upper quadrant (LUQ) 2/16/2025 - abdomen - left upper quadrant (LUQ) 2/17/2025 - abdomen - left upper quadrant (LUQ) 2/18/2025 - abdomen - left upper quadrant (LUQ) 2/19/2025 - abdomen - left upper quadrant (LUQ) During a concurrent interview and record review on 02/27/25 at 11:27 am with Registered Nurse 1 (RN 1), reviewed Resident 76's MAR. RN 1 stated there were multiple instances where the injection sites of insulin were not rotated in 2/2025. RN 1 stated the licensed nurses must follow the instructions in the manufacturer's guidelines and rotate sites of insulin administration to prevent damage to the skin tissues of the resident and medication error. During a review of the facility's recent policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 1/15/2025, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 1/15/2025, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided medication insert instructions for Insulin Glargine, undated, the insert indicated to change (rotate) injection sites within the area chosen for each dose to reduce the risk of getting lipodystrophy (pits in the skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. b. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted Resident 111 on 10/11/2024 with diagnoses that included, but not limited to type 2 diabetes mellitus (a disease that occurs when the glucose, also called blood sugar, is too high), and major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness). During a review of Resident 111's History and Physical (H&P), dated 1/9/2025, the H&P indicated the resident did have the capacity to understand and make decisions. During a review of Resident 111's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/27/2024, the MDS indicated the resident had the capacity to make herself understood and understand others, needed moderate assistance from staff for activities such as toileting, dressing, bathing and personal hygiene, and was on a high-risk drug class medication hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood). During a review of Resident 111's Order Summary Report, the report indicated an order dated 11/30/2024 for Humulin R Injection Solution 100 u/ml. Inject as per sliding scale (sliding scale, increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal) before meals and at bedtime. During a review of Resident 111's 12/2024 Medication Administration Record (MAR), the MAR indicated Humulin R Injection Solution 100 unit/ml subcutaneous solution was administered on the following dates and sites: 12/2/2024 -11:30 am - abdomen - left lower quadrant (LLQ) 12/2/2024 - 9:00 pm - abdomen - left lower quadrant (LLQ) 12/3/2024 - 9:00 pm - abdomen - left lower quadrant (LLQ) 12/12/2024 - 11:30 am - abdomen - left lower quadrant (LLQ) 12/12/2024 - 4:30 pm - abdomen - left lower quadrant (LLQ) During a concurrent interview and record review on 02/27/25 at 11:30 am with Registered Nurse 1 (RN 1), reviewed Resident 111's MAR. RN 1 stated there were multiple instances where the injection sites of insulin were not rotated in 12/2024. RN 1 stated the sites of insulin administration should be rotated to prevent damage to the skin tissues of the resident. During a review of the facility's recent policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 1/15/2025, the policy and procedure indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 1/15/2025, the policy and procedure indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided medication insert instructions for Humulin R, undated, the insert indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included neuropathy (disease or dysfunction of one or more nerves, typically causing numbness, weakness, or pain in the hands and feet). During a review of Resident 1's Census List (a list of a resident's admissions, room changes, discharges to the hospital, and re-admissions) indicated Resident 1 was transferred to a General Acute Care Hospital (GACH, or simply hospital) 1/15/2025 and re-admitted to the facility on [DATE]. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for upper and lower body dressing and putting on or taking off footwear. During a review of Resident 1's Physician's Orders, the Physician's Orders indicated the following orders: -Voltaren 1% Gel, apply to affected area topically every eight hours as needed for pain management, dated 10/05/2023. (The order was discontinued when Resident 1 was discharged to the GACH on 1/15/2025). -Voltaren 1% Gel, apply to affected area topically every eight hours as needed for pain management, dated 1/29/2025. During an observation and interview with Resident 1 on 2/24/2025 at 2:45 p.m., observed Resident 1 in their bed. Resident 1 stated he had pain 8/10 to his knees. Resident 1 stated he applies the Voltaren gel cream located on his bedside table on his knees. Resident 1 stated it was brought by Family Member 1 (FM 1). During an observation, record review, and concurrent interview with Licensed Vocational Nurse 6 (LVN 6) on 2/24/2025 at 3:03 p.m., observed the Station Three Medication Cart in which Resident 1's medications are located. LVN 6 was unable to locate Resident 1's Voltaren in the medication cart. LVN 6 reviewed Resident 1's Physician's orders which indicated there was an order dated 1/29/2025 for Voltaren. LVN 6 stated he would ask the Treatment Nurse 1 (TN 1) to see if she had Resident 1's Voltaren in the treatment cart. During an interview with the TN 1 on 2/24/2025 at 3:30 p.m., they said they searched their treatment cart and Resident 1's Voltaren was not there. The TN 1 stated they were unfamiliar Resident 1 received the medication because it was not on Resident 1's Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident). During an observation on 2/24/2025 at 3:40 p.m., observed TN 1 rubbing the Voltaren 1% gel (brought by FM 1, according to the resident) on Resident 1's knees. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicated TN 1 applied Voltaren to Resident 1's knees on 2/24/2025 at 3:47 p.m. During an interview with the Assistant Director of Nursing (ADON) on 2/24/2025 at 3:44 p.m., the ADON stated Resident 1 told them that their family member brought Voltaren to the resident. The ADON stated, when family members of a resident bring medications from home, they are to give the medication to the licensed nurses to keep in the medication cart if the medication is unable to be ordered from the pharmacy. During an interview with the ADON on 2/25/2025 at 9:38 a.m., the ADON stated the pharmacy sent a form for licensed staff to fill out asking if they wanted the medication to be sent as house supply (medication that is shared by other residents such for such commonly used medications such as Tylenol) or billed to the resident. The ADON stated the facility probably did not receive the form because it was not sent back to the pharmacy by the licensed nurses, and thus the medication was not sent to the facility from the pharmacy. During a concurrent interview with the Director of Nurses (DON) on 2/26/2025 at 4:29 p.m., the DON stated it is important for the licensed nurses to follow up with the facility's pharmacy to ensure they are available for the resident. The DON stated Resident 1 could potentially not receive pain relief by not having the medication available. The DON stated the facility did not have a specific policy for the licensed nurses to follow to ensure ordered medications were available for residents. The DON stated is important for licensed nurses to follow up with the facility's pharmacy if they do not see a resident's ordered medication in the medication cart. The DON stated they would send a copy of the in-service that will be conducted for all licensed nurses. During a phone interview with Resident 1's Family Member 1 (FM 1), on 2/27/2025 at 10:57 a.m., FM 1 stated he brought the Voltaren gel for Resident 1 that was on his bedside table. FM 1 stated Resident 1 needed the medication for pain relief. During an observation with Licensed Vocational Nurse 7 (LVN 7) on 2/27/2025 at 1:30 p.m., observed the Station Three Medication Cart. Resident 1's Voltaren gel was inside the medication cart. Voltaren's label indicated the medication was sent to the facility on 2/24/2025 and the date opened was 2/25/2025. During a review of the facility's policy and procedure titled, Medications Brought to the Facility by the Resident/Family, last reviewed 1/15/2025, indicated residents and families must report to the nursing staff any medications that they want to bring, or have brought into the facility. During a review of the facility's in-service, titled, Medication and Treatment Orders, the document indicated the in-service was conducted 9/26/2024. The DON indicated in an email, sent 3/04/2025 indicated the following lesson plan: Steps in ordering medication: 1.) Obtain MD order 2.) Fax order to pharmacy 3.) Follow-up call with pharmacy if they received the fax 4.) Endorse to next shift if medication s/medications are not available. Based on observation, interview, and record review the facility failed to: 1. Replace one open used medication emergency kit ([ekit]-storage container for emergency use medications) within 72 hours of opening the kit on 2/13/2025, in one (1) of two (2) inspected medication rooms (Medication Room Station 2.) 2. Account for one (1) dose of Controlled Medication (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 25 in one (1) of four (4) inspected medication carts (Station 2 Medication Cart 1.) 3. Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication ekit containing CMs for February 2025, in one (1) of four (4) inspected medication carts (Station 1 Medication Cart 2.) As a result, control and accountability of CM and availability of medications did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and the risk that residents in the facility could have accidental exposure to harmful medications and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalization. 4. Provide routine drug Gemtesa (medication for overactive bladder [a organ that holds urine]) from 2/11/2025 to 2/19/2025 to one of three sampled residents reviewed under the unnecessary medication task. This deficient practice resulted in the resident not receiving their prescribed medication. 5. Ensure a resident's pro re nata (prn, medication as needed) pain relief medication was available to a resident after being ordered for a resident for one of 33 random sampled residents (Resident 1). This had the potential for Resident 1 to not receive pain relief. Findings: 1.During an observation on 2/24/2025 at 1:14 p.m., with Registered Nurse (RN) 1, in Medication Room Station 2, there was: -One (1) open medication ekit labeled B002 with a document indicating the ekit was opened on 2/13/2025 at 12:45 p.m. During a concurrent interview, RN 1 stated the medication ekit labeled B002 was opened on 2/13/2025, used and awaiting replacement for a new one from pharmacy. RN 1 stated the mediation ekit should have been replaced with a new one from pharmacy within 24 hours of opening the kit. RN 1 stated the medication ekit was not replaced with a new one within 24 hours and this failure could lead to negative consequence for residents by not having emergency medications readily available during emergency situations causing resident harm and potential hospitalization. 2. During an observation on 2/25/2025 at 11:07 a.m., with Licensed Vocational Nurse (LVN) 4, in Station 2 Medication Cart 1, there was a discrepancy in the count between the Controlled Drug Record accountability log and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following residents: -One dose of pregabalin (a CM used for neuropathy [nerve damage or disease that can cause pain, numbness, tingling, or weakness]) 50 milligram ([mg] - a unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug Record accountability log for Resident 445. The Controlled Drug Record accountability log for pregabalin indicated the medication bubble pack should have contained a total of 48 pregabalin 50 mg tablets, after the last administration of pregabalin 50 mg tablet documented/signed-off on 2/24/2025 at 5 p.m., however the medication bubble pack contained 47 pregabalin 50 mg tablets and no other documentation of subsequent administrations. During a concurrent interview, LVN 4 stated LVN 4 administered pregabalin 50 mg tablet to Resident 445 that morning at 9 a.m. and forgot to sign the Controlled Drug Record accountability logs. LVN 4 stated LVN 4 failed to follow the facility's policy of signing each CM dose on the Controlled Drug Record accountability log after preparing the dose for the resident. LVN 4 stated LVN 4 understood it was important to sign each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 4 stated if documentation was not accurate then it can lead to medication error if overdosed (administering more than the prescribed dose) leading to stoppage of breathing, hospitalization and possibly death for Resident 445. 3 During an observation on 2/25/2025 at 12:23 p.m., with LVN 3, in Station 1 Medication Cart 2 there were: -Two (2) medication ekits containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for February 2025. During a concurrent interview, LVN stated that all CMs, including medication ekits containing CMs should be reconciled at every shift. LVN 3 stated that both ekits containing CMs in Station 1 Medication Cart 2 were not reconciled at every shift in February 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an interview on 2/26/2025 at 11:34 a.m., with the Director of Nursing (DON,) in the presence of Clinical Nurse Consultant 1 (NC 1), the DON stated that open and used medication ekits should be replaced with a new one within 72 hours. The DON stated the medication ekit in Medication Room Station 2 was open and used on 2/13/2025 and not replaced within 72 hours. The DON stated this failure can create potential harm for residents by not having critical medication readily available during emergency situations. During the same interview, the DON stated that medication ekits containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated the two (2) eKits containing CMs in Station 1 Medication Cart 2 were not reconciled at each shift change for February 2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits at each shift change in Station 1 Medication Cart 2. During the same interview, the DON stated that LVN 4 failed to follow facility policy of documenting the preparation of CM immediately on the Controlled Drug Record accountability log for Resident 445. The DON stated not documenting the Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents. During a review of Resident 445's admission Record (a document containing demographic and diagnostic information,) dated 2/25/2025, the admission Record indicated Resident 445 was originally admitted to the facility on [DATE] with a diagnosis including polyneuropathy (a condition where many nerves malfunction in the body.) During a review of Resident 445's Order Summary Report, dated 2/25/2025, the report indicated Resident 445 was prescribed pregabalin 50 mg to give by mouth twice a day for neuropathy, starting 2/18/2025. During a review of Resident 445's (Medication Administration Record ([MAR] - a record of mediations administered to residents), for February 2025, the MAR indicated Resident 445 was prescribed pregabalin 50 mg twice a day for neuropathy to be given at 9 a.m. and 5 p.m., and was administered a dose on 2/25/2025 at 9 a.m. During a review of the policy and procedures (P&P), titled Emergency Medications, last reviewed 1/15/2025, the P&P indicated: The facility shall maintain a supply of medications typically used in emergencies. 2. The emergency medication kit will include medications and biologicals that are essential in providing emergency treatment. 7. Drugs from the emergency kit must be replaced within 72 hours. During a review of the P&P titled Controlled Medication Storage, last reviewed 1/15/2025, the P&P indicated that At each shift change, a physical inventory of all Schedule II ., is conducted by 2 licensed nurses .and is documented on the CS accountability record During a review of the P&P titled Controlled Substances, last reviewed 1/15/2025, the P&P indicated that CM are subject to special handling, storage, disposal, and recordkeeping at the nursing care center, in accordance with federal and state laws and regulations. 1. The DON and the CP establish a system of records . of all CDs .to enable an accurate reconciliation and determine that drug records are in order and that an account of all CDs is maintained and periodically reconciled. 2. When a controlled mediation is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose. 6. At each shift change, a physical inventory of all CMs ., is conducted by 2 licensed clinicians and is documented on an audit record. 4. During a review of Resident 112's admission Record, the admission Record indicated the facility admitted Resident 112 on 6/15/2023 with diagnoses including Alzheimer's Disease (progressive state of decline in mental abilities), Parkinson's Disease (a progressive neurological [relating to the brain, spinal cord, and nerves] disorder that affects movement, balance, and coordination), major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness), and a history of falling. During a review of Resident 112's Physician's Progress Note, dated 1/7/2025, the Physician's Progress Note indicated Resident 112 had the capacity to understand and make decision and had urinary incontinence (inability to control urine flow) with improvement in bladder spasms (sudden uncontrollable squeezing of the bladder) and urination when on Gemtesa. The progress note further indicated the resident will continue using Gemtesa. During a review of Resident 112's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/18/2024, the MDS indicated Resident 112 was able to understand others and make herself understood. The MDS indicated Resident 112 needed moderate assistance on staff for bathing, dressing, and toileting. During a review of Resident 112's Bladder Incontinence (inability to control the flow of urine from the bladder) Care Plan (CP) initiated on 6/26/2023 and last revised on 7/8/2024, the CP indicated goals to keep Resident 112 clean, dry and free of odors and to reduce episodes of incontinence through the next review date of 03/18/2025. During a review of Resident 112's Physician's Orders, the order indicated Gemtesa oral tablet - give 75 milligrams (mg - a unit of measurement) by mouth one time a day for overactive bladder was discontinued on 2/19/2025. During a review of Resident 112's Electronic Medical Administration Record (EMAR - online charting system), the EMAR indicated the charting code 3 entered by the Licensed Vocational Nurses (LVN) indicates Hold/Progress Note MD Notification, and a check mark indicates Administered. The EMAR further indicated the following entries for the medication Gemtesa: - On 2/11/2025 at 9:00am a code of 3 by LVN 4. - On 2/12/2025 at 9:00am a check mark by LVN 9. - On 2/13/2025 at 9:00am a check mark by LVN 8. - On 2/14/2025 at 9:00am a check mark by LVN 8. - On 2/15/2025 at 9:00am a check mark by LVN 9. - On 2/16/2025 at 9:00am a check mark by LVN 9. - On 2/17/2025 at 9:00am a code of 3 by LVN 6. - On 2/18/2025 at 9:00am a code of 3 by LVN 4. - On 2/19/2025 at 9:00am a code of 3 by LVN 6. During a review of Resident 112's Progress Notes for the medication Gemtesa: - On 2/11/2025 LVN 4 documented awaiting refill from RX, medicine NA. - On 2/17/2025 LVN 6 documented medication unavailable. MD notified. - On 2/17/2025 LVN 4 documented medicine NA, awaiting refill from RX. - On 2/17/2025 LVN 6 documented medication unavailable. MD notified. During a concurrent interview and record review on 2/26/2025 at 10:20 am with LVN 8, reviewed Resident 112's EMAR. LVN 8 confirmed she worked on 2/13/2025 to 2/14/2025 and the medication Gemtesa was not available but accidently check marked in the EMAR that Gemtesa was given. LVN 8 indicated it is extremely important to be careful and accurate when charting in the EMAR so other nurses would know the medication was not available. LVN 8 further stated Resident 112 should not have gone several days without Gemtesa because it could have made her incontinence worse. During a concurrent interview and record review on 2/26/2025 at 11:00 am with LVN 9, reviewed Resident 112's EMAR. LVN 9 confirmed she worked on 2/12/2025, 2/15/2025 and 2/16/2025 and the medication Gemtesa was not available on those days but does not remember why Gemtesa was checked off as given. LVN 9 confirmed the check marks were mistakes. LVN 9 stated the EMAR is a legal document and it is very important to be accurate when charting so other nurses know if the resident received the medication or not. During a phone interview on 2/26/2025 at 1:47 pm with LVN 4, LVN 4 stated on 2/11/2025 the bubble pack (a card that packages doses of medication within small, clear, plastic bubbles that is punched out to administer to a resident) for Gemtesa was completely empty and indicated a 3 in the EMAR and wrote that the medication was NA (LVN 4 clarified NA meant not available) and waiting for delivery from RX (LVN 4 clarified RX meant pharmacy). LVN 4 then stated when she worked again on 2/18/2025, the bubble pack was still empty and indicated a 3 in the EMAR again, requested a refill from the pharmacy again and then spoke with Resident 112's family member (FM 2) to inform him that the medication has been unavailable for several days. LVN 4 stated she was unaware why other LVNs indicated they administered Gemtesa on 2/12/2025 -2/16/2025 on the EMAR when the medication was not available on 2/11/2025 and 2/18/2025. LVN 4 further stated the Gemtesa should have been followed up by the other LVNs to minimize the number of days the Resident 112 went without Gemtesa. During an interview on 2/26/2025 at 2:15 pm with Registered Nurse (RN) 1, RN 1 stated medicine in bubble packs must be reordered when there are about 7 tablets left to give time for any insurance issues and for the medication to arrive before the current stock runs out. RN 1 further stated Resident 112's Gemtesa should have never run out without replenishment or replacement because Resident 112's incontinence could worsen and possibly lead to skin breakdown. During a review of the facility provided Policy and Procedure (P&P) titled, Charting and Documentation, last reviewed 1/15/2025, the P&P indicated the documentation in the medical record will be objective, complete and accurate. During a review of the facility provided P&P titled, Medication Administration, last reviewed 1/15/2025, the P&P indicated medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. The P&P further indicted if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document/initial and circle the MAR space provided for that drug and dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) by failing to discontinue an antipsychotic [drug that affects brain activities associated with mental processes and behavior] medication for one (1) of one (1) sampled residents (Resident 76) reviewed for unnecessary medication care area. As a result, Resident 76 continued to receive aripiprazole (an antipsychotic medication used for schizophrenia [a mental disorder involving thought, emotion and behavior,]) between 1/24/2025 and 2/18/2025 without documentation indicating to do so. This deficient practice increased the risk that Residents 76 may have experienced serious adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) of antipsychotic medication therapy, such as tardive dyskinesia (uncontrolled face muscle movements,) akathisia (inability to hold still,) tremors, dizziness, and sedation leading to an overall negative impact on their physical, mental, and psychosocial well-being. Findings: During a review of Resident 76's admission Record (a document containing demographic and diagnostic information) dated 2/26/2025, the record indicated Resident 76 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including schizophrenia and depression. During a review of Resident 76's Order Summary Report, dated 2/25/2025, the report indicated Resident 76 was prescribed aripiprazole 5 milligram ([mg] - unit of measure of mass) to give 0.5 tablet by mouth once a day for schizophrenia as evidenced by yelling and screaming leading to shortness of breath give half tab = 2.5 mg, starting 6/19/2024. During a review of medication order note for Resident 76 by Psychiatric Mental Health Nurse Practitioner (PMHNP), dated 1/24/2025, the order indicated to discontinue Abilify (brand name medication for aripiprazole) 2.5 mg tablet by mouth daily for schizophrenia manifested by striking out. The order also indicated to discontinue Abilify due to stability of psychosis symptoms, patient agrees, gradual dose reductions ([GDR] - an effort to reduce or discontinue a drug) at this time, and supporting therapy provided and case discussed with staff. During a review of Resident 76's Minimum Data Set ([MDS] - a comprehensive resident assessment tool), dated 2/4/2025, the MDS indicated resident was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 76 had no mood and no behavioral symptoms, such as screaming at others. MDS indicated schizophrenia diagnosis. The MDS indicated Resident 76 received antipsychotics on a routine basis. The MDS indicated GDR was attempted on 2/2/2025 and that the GDR was not documented by a physician as clinically (relating to medical science and examination of patients) contraindicated (something that is not recommended or advised because it may be harmful.) During a review of medication order note for Resident 76 by PMHNP, dated 2/7/2025, the note indicated no apparent distress after discontinuing Abilify previous visit. During a review of Resident 76's (Medication Administration Record ([MAR] - a record of mediations administered to residents), for February 2025, the MAR indicated Resident 76 was prescribed aripiprazole 5 mg to give 0.5 tablet by mouth once a day for schizophrenia as evidenced by yelling and screaming leading to shortness of breath give half tab = 2.5 mg, to be given at 9 a.m., and Resident 76 was administered a dose every day at 9 a.m. between 2/1/2025 and 2/18/2025. During a concurrent document review and interview on 2/26/2025 at 10:42 a.m., with the Director of Nursing (DON,) the DON reviewed Resident 76's MDS dated [DATE], PMHNP orders dated 1/24/2025 and 2/7/2025 and February 2025 MAR. The DON stated PMHNP order on 1/24/2025 indicated to discontinue Resident 76's Abilify 2.5 mg order, and PMHNP note on 2/7/2025 indicated PMHNP believed Resident 76 was no longer receiving Abilify. The DON stated Resident 76 did not have any behaviors of screaming documented on the MDS, aligning with PMHNP orders to attempt GDR by discontinuing Abilify. The DON stated the February 2025 MAR indicated aripiprazole 2.5 mg was not discontinued and Resident 76 continued to receive aripiprazole until 2/18/2025 without documentation indicating to do so. The DON stated the facility failed to discontinue aripiprazole as per physician orders and document clinical rationale to continue aripiprazole, placing Resident 76 at risk of receiving unnecessary psychotropic medications which could result in adverse consequences and side effects, negatively impacting the resident's health and well-being. The DON stated the DON will contact PMHNP and obtain orders as applicable. During a review of the facility's policy and procedures (P&P), titled Psychotropic Medication Use, last reviewed 1/15/2025, the P&P indicated: 1. A psychotropic medication is any medication that affects brain activities associated with mental processed and behavior. 2. Drugs in the following categories are considered psychotropic drugs medications and are subject to prescribing, monitoring and review requirements specific to psychotropic medications: a. Antipsychotics 9. Consideration of the use of psychotropic medication is based on comprehensive review of the resident. 11. Residents on psychotropic medications receive GDR, unless clinically contraindicated in an effort to discontinue these medications. During a review of the facility's policy and procedures (P&P), titled Tapering Medications and Gradual Drug Dose Reduction, last reviewed 1/15/2025, the P&P indicated: 1. After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. 2. All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as GDR. 3. Residents who use psychotropic medications shall receive GDR and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 4. The staff and practitioner will consider tapering .when: a. The resident's clinical condition has improved or stabilized. 6. The physician will order appropriate tapering of medications, as indicated.

Based on observation, interview and record review, the facility failed to ensure that medication error rate was less than five percent (%). Six medication errors out of 25 total opportunities contributed to an overall medication error rate of 24% for one of four residents (Resident 95) observed during medication administration. Resident 95 received six medications in a form that was not ordered by Resident 95's physician. The deficient practice of medication administration without the physician's orders increased the risk for Resident 95 to experience medication adverse reactions (unwanted, uncomfortable, or dangerous effects that a medication may have) and potential complications. Findings: During concurrent observation and interview on 2/24/2025 at 9:12 am in medication cart 1, with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed crushing medications in one small bag, poured the crushed medications into a medication cup, then mixed with apple sauce. The medications were as follows: 1.Aspirin (a medication used to prevent a blood clot from forming in a deep vein) 81 milligrams (mg, unit of weight) two chewable tablets 2.Calcium 600 mg plus Vitamin D (a nutrient that helps your body use calcium to build strong bones) 200 mg one tablet two times a day 3.Iron 325 mg one tablet two times a day 4. Docusate Sodium (a medication used treat constipation) 100 mg one tablet one time a day 5.Memantine Hydrochloride (a medication used to treat memory loss) 10 mg one tablet 6.Tylenol (a medication used for pain) two 500 mg two tablets two times a day During a concurrent observation and interview on 2/24/2025 at 9:15 am with LVN 1 in Resident 95's room, LVN 1 was observed administering the prepared crushed medications to Resident 95 followed by water to drink. Resident 95 was observed swishing the water in her mouth right after administration of medication and proceeded to spit the medications onto a spit basin. LVN 1 stated she was not able to determine how much dose and what medications were spit out by Resident 95. LVN 1 stated medications can only be crushed with physician orders indicating to do so. LVN 1 stated when there were no orders to crush medications and the resident can benefit from crushing the medications, LVN 1 stated LVN 1 would contact the physician to get an order. During an interview on 2/25/2025 at 10:35 am, with Resident 95's primary care physician (PCP), the PCP stated Resident 95 does not have difficulty swallowing. PCP stated he was not aware Resident 95 cannot medications as a whole pill. During an interview on 2/26/2025 at 11:34 a.m., with Director of Nursing (DON), DON stated medications are crushed according to physician orders. DON stated LVN 1 failed to follow policy of administering medications according to physician orders and crushed Resident 95's medications without an order indicating to do so. During a review of Resident 95's admission Record (AR) dated 2/24/2025, the AR indicated facility admitted the Resident 95 on 1/25/2025 with diagnoses including but not limited to dementia a progressive state of decline in mental abilities) atherosclerosis (a disease that occurs when plaque builds up in the arteries, making them stiff and narrow) and hypertension (high blood pressure). During a review of Resident 95's Medication Administration Record (MAR) dated 2/1/2025- 2/28/2025, the MAR indicated no medication order to crush medications prior to administration. During a review of Resident 95's Order Summary Report (OSR), dated 2/24/2025, the OSR indicated no orders to crush medications since 1/25/2025 and indicated new order added on 2/24/2025. During a review of the facility's policy and procedure (P&) titled Administering Medications, dated April 2019, the P&P indicated medications are administered in accordance with prescriber orders . During a review of facility's policy and procedure (P&P) titled Crushing Medications, dated 4/2018, the P&P indicated medications shall be crushed only when appropriate consistent with physician orders .the guideline when crushing medications, crushing each medication separately is considered the best practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 37's admission Record (a document containing demographic and diagnostic information) dated 2/25/2025, the admission Record indicated Resident 37 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus 2 (DM2 - a condition that affects how the body processes blood sugar.) During a review of Resident 37's Order Summary Report (a report listing the physician order for the resident) dated 2/25/2025, the report indicated Resident 37 was prescribed insulin Fiasp (rapid-acting insulin) Flextouch (type of injection pen) pen to inject 8 units ([un] - a measure of dosage for insulin) subcutaneous ([SQ] - under the skin) before meals for DM twice a day before breakfast and dinner, starting 9/5/2024. During a review of Resident 19's MAR ([MAR] - a document of the medications administered to a resident that is part of the resident ' s permanent medical record], for February 2025, the MAR indicated Resident 37 was prescribed insulin Fiasp to give 8 un SQ before each meals for DM twice a day before breakfast and dinner, at 6:30 a.m. and 4:30 p.m., and that Resident 37 received one (1) dose of expired insulin Fiasp from LVN 10 on 2/25/2025 at 6:30 a.m. During a review of Resident 43's admission Record dated 2/25/2025, the admission Record indicated Resident 37 was originally admitted to the facility on [DATE] with diagnoses including glaucoma. During a review of Resident 43's Order Summary Report, dated 2/25/2025, the report indicated Resident 43 was prescribed latanoprost 0.005% to instill one (1) drop both eyes at bedtime for glaucoma, starting 12/29/2021. During a review of Resident 43's MAR for February 20245, the MAR indicated Resident 43 was prescribed latanoprost 0.005% to instill one (1) drop both eyes at bedtime for glaucoma, at 9 p.m., and that Resident 43 received the following doses by the following licensed nurses: LVN 11 - one (1) dose on 2/23/2025 at 9 p.m. LVN 12 - one (1) dose on 2/24/2025 at 9 p.m During an observation on 2/25/2025 at 12:08 p.m., in Medication Cart 2 Station 4, in the presence of LVN 5, the following medications were found either stored in a manner contrary to their respective manufacturers' requirements, not labeled with an open date as required by their respective manufacturers' specifications, expired and not discarded, or stored and labeled contrary to facility policies, currently accepted laws and professional principles: a. One open Fiasp Flextouch pen for Resident 37 was found stored at room temperature and labeled with a date indicating use began on 1/28/2025. According to the manufacturer ' s product labeling, opened Fiasp Flextouch pens should be stored at room temperature up to 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began. b. One open latanoprost eye drop bottle for resident 43 was found stored at room temperature and labeled with a date indicating use began on 1/12/2025. According to the manufacturer's product storage and labeling, opened latanoprost bottles may be stored at room temperature up to 77 degrees Fahrenheit and used or discarded within 6 weeks of opening/use. During a concurrent interview, LVN 5 stated the Fiasp Flextouch pen for Resident 37 was opened on 1/28/2025. LVN 5 stated insulins are usually good for 28 days and lose potency (effectiveness) and expire beyond that date. LVN 5 stated the Fiasp pen expired on 2/24/2025 and one (1) expired dose was administered to Resident 37 on 2/25/2025. LVN 5 stated administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 37 by causing high blood sugar levels leading to coma hospitalization, and death. LVN 5 stated the Fiasp Flextouch pen needed to be removed from the medication cart and discarded to ensure expired insulin was not administered to Resident 37. LVN 5 stated the latanoprost eye drop bottle for Resident 43 was opened on 1/12/2025. LVN 5 stated eye drop medications are usually good for 30 days after opening. LVN 5 stated administering expired latanoprost to Resident 43 will not be effective in treating the resident ' s glaucoma and lead to worsening of the glaucoma by increasing the pressure in the eye and causing blindness, and potentially cause eye infections since the dropper of the bottle is no longer sterile beyond the expiration date. LVN 5 stated medications that are expired must be removed from the medication cart to prevent accidental use. LVN 5 stated the latanoprost bottle was expired and needed to be removed from the medication cart and discarded to ensure expired latanoprost was not administered to Resident 43 after the expiration date. During an interview on 2/26/2025 at 11:34 a.m., with the Director of Nursing (DON), in the presence of Clinical Nurse Consultant (NC) 1, DON stated that the facility failed to dispose of expired medications per policy and procedures. The DON stated that open insulin vials and pens are usually good for 28 days and giving expired insulin to residents will not be effective due to decreased potency causing high or low blood sugar levels and leading to potential coma, hospitalization, and death. DON stated that using expired eye medications will not be effective in treating glaucoma due to decreased potency and lead to possible infections due to decreased sterility (free of infections.) During a review of facility ' s policy and procedures (P&P), titled Administering Medications, last reviewed 1/15/2025, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. The expiration/beyond use date on the medication label is checked prior to administering. During a review of review facility ' s P&P titled, Medication Storage and Labeling, last reviewed 1/15/2025, the P&P indicated: Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. During a review of facility ' s P&P, titled Abridged List of Medications with Shortened Expiration Dates, [undated,] the P&P listed the following: Fiasp - Beyond Use Date Notes after accessing insulin for first use - pen 28 days. Latanoprost - Beyond Use Date Notes - 6 weeks (42 days) after opening or moving to room temp. During a review of facility ' s P&P, titled Did you Know the steps to perform an internal expired med inventory audit, [undated,] the P&P listed the following: To avoid incorrect medication expiration dates in your ward stock .due to expired meds. Enact a system to regularly check meds for correct expiration dates and to remove expired drugs. See the abridged list of select meds with unique expirations below: Xalatan (brand name for Latanoprost): 6 week expiration Insulin: Multi-dose vials (MDV)and pens stored in refrigerator until first dispense. In-use MDVs stored in med cart: 28 days room temperature. In-use pens: 28 days room temperature. During a review of the facility ' s P&P titled Adverse consequences and Medication Errors, last reviewed 1/15/2025, the P&P indicated: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician ' s orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medication error include: Failure to follow manufacturer instructions and/or accepted professional standards. A 'significant medication-related error' is defined as: Requiring hospitalization Resulting in death. Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber ' s order, manufacturer ' s specifications, and accepted professional standards) by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a medication that regulates sugar in the blood) injections sites to two of two sampled residents (Residents 76 and 111) reviewed under the insulin care area. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat), bruising and pain. 2. a. Administering one (1) dose of expired insulin (a medication used to regular blood sugar levels) on 2/25/2025 by Licensed Vocational Nurse (LVN) 10 to Resident 37 in one (1) of four (4) observed medications carts (Medication Cart 2 Station 4.) b. Administering two (2) doses of expired latanoprost (a medication used for glaucoma [a condition of increased pressure in the eyeball]) eye drop by LVNs 11 and 12 between 2/23/2024 and 2/24/2025 to Resident 43 in one (1) of four (4) observed medications carts (Medication Cart 2 Station 4.) As a result, Resident 37 received one (1) dose of expired insulin on 2/25/2025 and Resident 43 received two (2) doses of expired latanoprost between 2/23/2025 and 2/24/2025 not in accordance with standards of practice. These deficient practices had the potential to cause Resident 37 to experience serious complications such as hyperglycemia (elevated blood sugar levels) diabetic coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels); and to cause Resident 43 complications like blindness and eye infections, resulting in potential hospitalization and/or death. Findings: 1.a. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 10/20/2023 with diagnoses that included, but not limited to type 2 diabetes mellitus (a disease that occurs when the glucose, also called blood sugar, is too high), neuropathy (damage, disease, or dysfunction of one or more nerves) and major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness). During a review of Resident 76's History and Physical (H&P), dated 10/25/2024, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 76's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/3/2024, the MDS indicated the resident had some impaired cognition, needed maximal assistance from staff for activities such as toileting, dressing, bathing and personal hygiene, and was on a high-risk drug class medication hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood). During a review of Resident 76's Order Summary Report, the report indicated an order dated 9/12/2024, Insulin Glargine subcutaneous (SQ - in the fatty layer of the skin) Solution 100 units per milliliters (unit/ml, a unit of fluid volume) inject 12 units SQ at bedtime. During a review of Resident 76's 2/2025 Medication Administration Record (MAR) reviewed on 2/27/2025 at 10:30am, the MAR indicated insulin was administered on the following dates and sites: Insulin Glargine SQ 100 unit/ml subcutaneous solution: 2/1/2025 - abdomen - left upper quadrant (LUQ) 2/2/2025 - abdomen - left upper quadrant (LUQ) 2/3/2025 - abdomen - left upper quadrant (LUQ) 2/4/2025 - abdomen - left upper quadrant (LUQ) 2/5/2025 - abdomen - left upper quadrant (LUQ) 2/6/2025 - abdomen - left upper quadrant (LUQ) 2/7/2025 - abdomen - left upper quadrant (LUQ) 2/9/2025 - abdomen - left upper quadrant (LUQ) 2/10/2025 - abdomen - left upper quadrant (LUQ) 2/11/2025 - abdomen - left upper quadrant (LUQ) 2/12/2025 - abdomen - left upper quadrant (LUQ) 2/13/2025 - abdomen - left upper quadrant (LUQ) 2/16/2025 - abdomen - left upper quadrant (LUQ) 2/17/2025 - abdomen - left upper quadrant (LUQ) 2/18/2025 - abdomen - left upper quadrant (LUQ) 2/19/2025 - abdomen - left upper quadrant (LUQ) During a concurrent interview and record review on 02/27/25 at 11:27 am with Registered Nurse 1 (RN 1), reviewed MAR of Resident 76 with RN 1. RN 1 stated there were multiple instances where the injection sites of insulin were not rotated in 2/2025. RN 1 stated the sites of insulin administration should be rotated to prevent damage to the skin tissues of the resident. RN 1 stated the failure to follow the physician's order to rotate the insulin administration site is considered a medication error. During a review of the facility's recent policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 1/15/2025, the policy and procedure indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 1/15/2025, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided medication insert instructions for Insulin Glargine, undated, the insert indicated to change (rotate) injection sites within the area chosen for each dose to reduce the risk of getting lipodystrophy (pits in the skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. 1.b. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted Resident 111 on 10/11/2024 with diagnoses that included, but not limited to type 2 diabetes mellitus (a disease that occurs when the glucose, also called blood sugar, is too high), and major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness). During a review of Resident 111's History and Physical (H&P), dated 1/9/2025, indicated the resident did have the capacity to understand and make decisions. During a review of Resident 111's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/27/2024, indicated the resident had the capacity to make herself understood and understand others, needed moderate assistance from staff for activities such as toileting, dressing, bathing and personal hygiene, and was on a high-risk drug class medication hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood). During a review of Resident 111's Order Summary Report, the report indicated an order dated 11/30/2024 for Humulin R Injection Solution 100 u/ml. Inject as per sliding scale (sliding scale, increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal) before meals and at bedtime. During a review of Resident 111's 12/2024 Medication Administration Record (MAR), the MAR indicated Humulin R Injection Solution 100 unit/ml subcutaneous solution insulin was administered on the following dates and sites: 12/2/2024 -11:30 am - abdomen - left lower quadrant (LLQ) 12/2/2024 - 9:00 pm - abdomen - left lower quadrant (LLQ) 12/3/2024 - 9:00 pm - abdomen - left lower quadrant (LLQ) 12/12/2024 - 11:30 am - abdomen - left lower quadrant (LLQ) 12/12/2024 - 4:30 pm - abdomen - left lower quadrant (LLQ) During a concurrent interview and record review on 02/27/25 at 11:30 am with Registered Nurse 1 (RN 1), reviewed Resident 111's MAR. RN 1 stated there were multiple instances where the injection sites of insulin were not rotated in 12/2024. RN 1 stated the sites of insulin administration should be rotated to prevent damage to the skin tissues of the resident. RN 1 also stated the failure to follow the physician's order to rotate the insulin administration site was considered a medication error. During a review of the facility's recent policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 1/15/2025, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 1/15/2025, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided medication insert instructions for Humulin R, undated, the insert indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

Based on observation, interview, and record review the facility failed to: 1. Label one (1) Forteo (a medication used for osteoporosis [a condition in which bones become weak, brittle, making them prone to breakage) pen (an injection device containing the medication) for Resident 295 with an open date in accordance with the manufacturers' requirements in one (1) of two (2) inspected medication rooms (Medication Room Station 2). 2. Label one (1) fluticasone and salmeterol (medication used to treat Chronic Obstructive Pulmonary Disease [COPD]- a disease that blocks air flow and makes breathing difficult]) inhalation powder (form of medication that is inhaled) for Residents 23, and one (1) insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial (glass bottle containing insulin) for Resident 111 with an open date in accordance with the manufacturers' requirements in one (1) of four (4) inspected medication carts (Medication Cart 2 Station 4). 3. Label one (1) insulin Lantus (a long-acting insulin) pen with a pharmacy label, in accordance with medication labeling requirements, in one (1) of two (2) inspected medication rooms (Medication Room Station 1). 4. Remove and discard from use one (1) expired insulin Fiasp (rapid-acting insulin) Flextouch (type of injection pen) pen for Resident 37 and one (1) latanoprost (a medication used for glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 43, in accordance with manufacturers' requirements and facility policies, in one (1) of four (4) inspected medication carts (Medication Cart 2 Station 4). These deficient practices increased the risk that Residents 23, 37, 43, 111, and 295 could have received medications that had become ineffective or toxic due to improper storage or labeling, accidentally used due to improper labeling, possibly leading to health complications resulting in infections, hospitalization or death. Findings: During an observation on 2/24/2025 at 1:14 p.m., in Medication Room Station 2, in the presence of Registered Nurse (RN) 1, the following medications were found either stored in a manner contrary to their respective manufacturers' requirements or not labeled with an open date as required by their respective manufacturers' specifications and facility policy and procedures: 1. One (1) open and used Forteo pen for Resident 295 was found stored in the refrigerator in Medication Room Station 2 and not labeled with a date on which use began. According to the manufacturer label on the pen, the label indicated to Throw away 28 days after first use. According to the manufacturer's product storage and labeling, Forteo pens need to be refrigerated and used or discarded after 28 days of use. During a concurrent interview, RN 1 stated Forteo pen for Resident 295 was not labeled with a date indicating when use began, and the label on the pen indicated to discard after 28 days of use. RN 1 stated when opening multi-dose (providing more than one dose) medications, the date opened should be indicated to know when the pen should be discarded. RN 1 stated Forteo pen can lose its potency (effectiveness) after 28 days and when used in error beyond that date will not be effective in treating Resident 295's osteoporosis and harm the resident by potentially resulting in brittle bones and breakage. During an observation on 2/24/2025 at 1:59 p.m., in Medication Room Station 1, in the presence of Licensed Vocational Nurse (LVN) 3, the following medications were found either stored and labeled in a manner contrary to their respective manufacturers' requirements, contrary to facility policies and currently accepted laws and professional principles: -One unopened insulin Lantus pen was found in the refrigerator and not labeled with a pharmacy label and resident name. According to facility policy and professional standards of practice, all medications including insulin pens must be labeled with a pharmacy label that includes the resident name to prevent accidental use and sharing of medications. According to the manufacturer's product information, Lantus pens must never be shared between patients as sharing poses a risk for transmission (transfer of a disease from one person to another) of blood-borne pathogens (organisms in the blood that can cause infections). During a concurrent interview, LVN 3 stated the Lantus pen was not labeled with a pharmacy label and LVN 3 did not know which resident the pen belonged to. LVN 3 stated per facility policy all medications must have a pharmacy label indicating who the medication belongs to and directions for use, so that they are not accidentally administered to the wrong resident. LVN 3 stated that any medication without a pharmacy label should be immediately returned to pharmacy for proper labeling. During an observation on 2/25/2025 at 12:08 p.m., in Medication Cart 2 Station 4, in the presence of LVN 5, the following medications were found either stored in a manner contrary to their respective manufacturers' requirements, not labeled with an open date as required by their respective manufacturers' specifications, expired and not discarded, or stored and labeled contrary to facility policies, currently accepted laws and professional principles: 1. One (1) open and used fluticasone and salmeterol inhalation powder device stored for Resident 23 was found stored at room temperature without a protective foil pouch and not labeled with a date on which use at room temperature outside the foil pouch began. According to the manufacturer's product storage and labeling, opened fluticasone and salmeterol inhalation powder device can be stored at room temperature between 68 and 77 degrees Fahrenheit and used or discarded one (1) month after removal from the moisture-protective foil pouch. 2. One open Fiasp Flextouch pen for Resident 37 was found stored at room temperature and labeled with a date indicating use began on 1/28/2025. According to the manufacturer's product labeling, opened Fiasp Flextouch pens should be stored at room temperature up to 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began. 3. One open latanoprost eye drop bottle for resident 43 was found stored at room temperature and labeled with a date indicating use began on 1/12/2025. According to the manufacturer's product storage and labeling, opened latanoprost bottles may be stored at room temperature up to 77 degrees Fahrenheit and used or discarded within 6 weeks of opening/use. 4. One (1) unopened Humulin R vial for Residents 111 was found stored at room temperature without a date indicating when storage at room temperature began. According to the label on the prescription bottle the label indicated to discard unused medication after 31 days. According to the manufacturer's product storage and labeling, opened Humulin R insulin vials can be stored at room temperature below 86 degrees Fahrenheit and discarded after 31 During a concurrent interview, LVN 5 stated the fluticasone and salmeterol inhalation powder device for Resident 23 was opened, used and not labeled with a date indicating when use began. LVN 5 stated once a multi-dose medication is opened, it must be labeled with the date opened to know when it expires and when it should be discarded. LVN 5 stated it was unknown when the fluticasone and salmeterol inhalation powder device was opened therefore unknown when it would expire and need to be discarded. LVN 5 stated inhalation powders are usually good for 30 days and lose potency and expire beyond that date, and if not labeled then expired inhalation powder can be used in error. LVN 5 stated administering expired fluticasone and salmeterol to Resident 23 will not help in improving breathing and can cause breathing complications, such as shortness of breath, potentially requiring hospitalization. LVN 5 stated the fluticasone and salmeterol inhalation powder device needed to be discarded and replaced with a new one from pharmacy to ensure expired insulin was not administered to Resident 23. LVN 5 stated the Fiasp Flextouch pen for Resident 37 was opened on 1/28/2025. LVN 5 stated insulins are usually good for 28 days and lose potency and expire beyond that date. LVN 5 stated the Fiasp pen expired on 2/24/2025 and one (1) expired dose was administered to Resident 37 on 2/25/2025. LVN 5 stated the Humulin R vial for Resident 111 was stored at room temperature, not opened and should have either been stored in the refrigerator until opened or labeled with a date when storage at room temperature began. LVN 5 stated it was unknown when the Humulin R vial was stored at room temperature therefore unknown when it would expire and need to be discarded to prevent accidental use. LVN 5 stated administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 37 and 111 by causing high blood sugar levels leading to coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels) hospitalization, and death. LVN 5 stated the Humulin R vial and Fiasp Flextouch pen needed to be removed from the medication cart and discarded to ensure expired insulin was not administered to Resident 37 and 111. LVN 5 stated the latanoprost eye drop bottle for Resident 43 was opened on 1/12/2025. LVN 5 stated eye drop medications are usually good for 30 days after opening. LVN 5 stated administering expired latanoprost to Resident 43 will not be effective in treating the resident's glaucoma and lead to worsening of the glaucoma by increasing the pressure in the eye and causing blindness and lead to blindness, and potentially cause eye infections since the dropper of the bottle is no longer sterile beyond the expiration date. LVN 5 stated medications that are expired must be removed from the medication cart to prevent accidental use. LVN 5 stated the latanoprost bottle was expired and needed to be removed from the medication cart and discarded to ensure expired latanoprost was not administered to Resident 43 after the expiration date. During an interview on 2/26/2025 at 11:34 a.m., with the Director of Nursing (DON), in the presence of Clinical Nurse Consultant (NC) 1, DON stated that the facility failed to store and label the above medications properly and dispose of unlabeled and expired medications per policy and procedures. DON stated that opened medications, such as insulins, eye drops, and breathing treatments, should be dated with an open date label to know when they should be disposed of, otherwise they are considered expired. DON stated that open insulin vials and pens are usually good for 28 days and giving expired insulin to residents will not be effective due to decreased potency causing high or low blood sugar levels and leading to potential coma, hospitalization, and death. DON stated that insulin pens without pharmacy label should be immediately returned to pharmacy for re-labeling and unlabeled insulin pens are a safety concern because it can accidentally be used for the wrong resident. The DON stated that giving expired breathing medication to residents will be ineffective due to decreased potency and make breathing more difficult, possibly leading to stoppage of breathing. DON stated that using expired eye medications will not be effective in treating glaucoma due to decreased potency and lead to possible infections due to decreased sterility (free of infections.) During a review of facility's policy and procedures (P&P), titled Administering Medications, last reviewed 1/15/2025, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 13. Insulin pens are clearly labeled with the resident's name or other identifying information. During a review of review facility's P&P titled, Medication Storage and Labeling, last reviewed 1/15/2025, the P&P indicated: 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: a. Medication name b. Prescribed dose c. Strength d. Expiration date e. Resident's name f. Route of administration g. Appropriate instructions and precautions 5. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. During a review of facility's P&P, titled Abridged List of Medications with Shortened Expiration Dates, [undated,] the P&P listed the following: Fluticasone/Salmeterol - Beyond Use Date Notes - 30 days after removal from foil pouch. Fiasp - Beyond Use Date Notes after accessing insulin for first use - pen 28 days. Humulin R - Beyond Use Date Notes after accessing insulin for first use - 31 days. Latanoprost - Beyond Use Date Notes - 6 weeks (42 days) after opening or moving to room temp. During a review of facility's P&P, titled Did you Know the steps to perform an internal expired med inventory audit, [undated,] the P&P listed the following: To avoid incorrect medication expiration dates in your ward stock .due to expired meds. Enact a system to regularly check meds for correct expiration dates and to remove expired drugs. Perform this internal inventory inspection at least monthly to avoid enforcement action via F-tag 761. See the abridged list of select meds with unique expirations below: oXalatan (brand name for Latanoprost): 6 week expiration oInsulin: Multi-dose vials (MDV)and pens stored in refrigerator until first dispense. In-use MDVs stored in med cart: 28 days room temperature. In-use pens: 28 days room temperature The State Operations Manual mentions drug expiration 8 separate times To cite deficient practice at F761 .investigation will generally show that the facility failed to ensure that all drugs .are labeled in accordance with professional standards, including expiration dates. Areas to check should include Medication carts, Med rooms, refrigerator Record an open date on all opened meds (liquids, topicals, insulin vials, insulin pens, eye drops, etc.)

Based on observation, interview, and record review, the facility failed to ensure food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) provide a record of food temperatures when the Assistant Dietary Supervisor (ADS) failed to document the temperature all foods on the tray line. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 143 medically compromised residents who received food from the kitchen. Findings: During a kitchen tray line observation on 2/26/2025 at approximately 11:25 a.m., observed ADS checking the temperatures of the food on the tray line. The ADS took the following food temperatures: 1. soup - 175? F degrees Fahrenheit (? F, a unit of measure for temperature) 2. beef - 175? F 3. vegetable - 170? F 4. starch (rice) - 170? F 5. gravy - 166? F 6. chicken - 196? F 7. pureed (cooked food that has been ground, pressed, blended to the consistency of a creamy paste) beef - 173? F 8. pureed vegetable - 170? F 9. pureed rice - 170? F 10. diced (cut into small portions with a knife) beef - 160? F 11. salad - 36? F 12. milk - 36? F 13. Juice - 39? F 14. yogurt - 39? F 15. fish - 162? F 16. cottage cheese - 39? F 17. beans - 163? F 18. mashed potatoes - 173? F 19. diced chicken - 175? F The ADS took the following temperatures but did not record them: 1. fish 2. cottage cheese, 3. diced chicken, 4. beans, 5. mashed potatoes During a concurrent interview and record review with the ADS on 2/26/25 at 2:33 p.m., reviewed the kitchen Food Temperature Log with surveyor notes. The ADS verified that the fish, cottage cheese, diced chicken, beans, and mashed potatoes were taken but not recorded. The ADS stated they should be added to the Food Temperature Log to ensure that the food temperatures are not at dangerous levels with the potential for a food borne illness. During a concurrent interview and record review with the Dietary Supervisor (DS) on 2/26/2025 at 3:40 p.m., reviewed the kitchen Food Temperature Log. The DS stated all foods on the tray table should be documented on the Food Temperature Log. The DS stated the purpose of the Food Temperature Log is to have a record of food temperatures to ensure food is served within the regulation range. The DS stated documenting all food temperatures ensures that all foods served are safe and would not cause a food borne illness. During an interview with the Director of Nursing (DON) on 2/27/2025 at 8:35 a.m., they stated the purpose of the kitchen Food Temperature Log is to ensure food served from the facility's kitchen is at the right temperature. The DON stated food served too hot could potentially burn a resident's mouth, if too cold would not be palatable (pleasant to taste). The DON stated temperatures should be documented to ensure food served by the kitchen to residents is safe and does not place them at risk for a food borne illness. During a review of the facility's policy and procedure titled, Food Temperatures, last reviewed 1/15/2025, indicated the temperatures will be taken and properly recorded prior to service of each meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure a leftover blueberry muffin from the previous day was removed from the resident`s bedside for one of one (Resident 96) sampled resident. This deficient practice had the potential to result in contamination of the blueberry muffin which could lead to foodborne illness (also called food poisoning, illness caused by eating contaminated food) if the blue berry muffin is ingested (consumed). 2. Follow their Oxygen Administration, policy and procedure by failing to label an oxygen tubing with the date and time of when it was last changed for one of two sampled residents (Resident 345) reviewed under oxygen. This deficient practice had the potential to place Resident 345 at increased risk of infection and cause complications associated with oxygen therapy. 3. Implement policy on Handwashing - Hand Hygiene (a simple and essential hygiene practice that helps prevent the spread of germs and infections) when Treatment Nurse 2 (TN 2) failed to use alcohol-based hand rub (ABHR- antimicrobial solution containing at least 70% alcohol used to reduce the number of microorganisms on hands) after removing Personal Protective Equipment (PPE - gloves) during wound care for one of two (2) sampled residents (Resident 32) investigated for tube feeding. These deficient practices had the potential to increase the risk of spreading infection to other residents. This failure had the potential to increase the risk of spreading infection. 4. Maintain and prevent infection protocols when Licensed Vocational Nurse (LVN) 2 did not perform hand washing before preparation and administration of medication for one of one resident (Resident 31. This failure had the potential to increase the risk of spreading infection. Findings: 1. During a review of Resident 96's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities) and metabolic encephalopathy (a change in how your brain works due to an underlying condition). During a review of Resident 96`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/19/2024, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS also indicated that the resident required moderate assistance with shower and supervision with oral hygiene, toileting hygiene, shower, upper and lower body dressing and personal hygiene. During a concurrent observation and interview with Resident 96 on 02/24/2025 at 10:49 a.m., observed a blueberry muffin on the bedside table, uncovered and exposed to air. Resident 96 stated that the blueberry muffin was served during breakfast from the previous day. During an interview and record review on 02/24/25 at 11:23 a.m., with the Dietary Supervisor (DS), reviewed the menu for the week 2/23/2025 to 3/1/2025 (Cycle 18) which indicated that a blueberry muffin was served during breakfast on 2/23/2025. The DS stated that the facility does not allow residents to store left over food from their meal trays. The DS stated that yesterday (2/23/2025), blueberry muffin was served to Resident 96. The DS stated that leftover food had to be discarded after two hours as it is no longer safe for the resident to consume beyond that time and may cause foodborne illnesses. During a follow up observation on 02/24/2025 at 11:30 a.m., with the DS, in Resident 96's room, observed a blueberry muffin on the bedside table uncovered and exposed to air. The DS stated that the blueberry muffin was from the breakfast menu from the previous day. During a review of the facility`s policy and procedures titled Food Receiving and Storage, last reviewed on 1/15/2025, the policy and procedures indicated that .food shall be received and stored in a manner that complies with safe food handling practices .(Danger Zone- means temperatures above 41 degree Fahrenheit and below 135 degrees Fahrenheit that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness). Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours may cause a foodborne illness outbreak if consumed . 5. During a concurrent observation and interview on 2/24/2025 at 10:05 am, at medication cart one in Nursing Station 2 with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed pulling out medication from the cart drawer and popped out pills from blister pack (unit-dose packaging of medications) into a medication cup. LVN 2 did not perform hand washing or hygiene before handling medication. LVN 2 stated ten medications were prepared to be administered to Resident 31. During an interview on 2/27/2025 at 2:23 pm with LVN 2, LVN 2 stated he did not wash or sanitize his hands before medication preparation and administration. LVN 2 stated handwashing and sanitizing were important to prevent spread of infection. LVN 3 stated hands are carriers of germs, and it was possible to spread infection if standard precaution was not practiced. During an interview on 2/27/2025 at 3:38 pm with Infection Preventionist (IP), the IP stated the standard infection prevention policies and procedures applies to all staff working at the facility. The IP stated the facility also follows the standard precautions recommendation of Center for Disease Control (CDC) when providing care. During a review of facility's policy and procedure (P&P), titled Administering Medications, dated 4/2019, the P&P indicated the staff follows facility's established infection and control procedures .hand washing is a procedure for medication administration. During a review of facility's P&P, titled Handwashing-Hand Hygiene, dated 7/2023, the P&P indicated hand hygiene practice is the facility's practice to prevent the spread of infection .the use of alcohol-based hand rub (ABHR) or soap and water before preparing and handling medications. 2. During review of Resident 345`s admission Record, the admission record indicated that the facility originally admitted the resident on 12/1/2023, and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and acute (short term) respiratory failure (when not enough oxygen passes from your lungs to your blood) with hypoxia (a medical condition that occurs when there is an inadequate supply of oxygen to the body's tissues). During a review of Resident 345's Minimum Data Set (MDS-a resident assessment tool) dated 2/18/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 345 required partial/moderate assistance (helper does less than half effort) for upper body dressing, and personal hygiene. The MDS further indicated that resident 345 was receiving intermittent (on and off) oxygen therapy upon admission and while a resident inside the facility. During a review of Resident 345's Order Summary Report (physician order) dated 2/11/2025, the order summary report indicated to administer oxygen at two (2) liters per minute via nasal canula (NC- (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for hypoxia/shortness of breath. The order summary report indicated to change the oxygen tubing (including NC, and/or mask, and storage bag) every week and as needed and date the tubing and storage bag. During an observation on 2/24/2025 at 10:15 a.m. inside Resident 345`s room, the resident was observed sitting on her bed. Resident 345 was receiving oxygen at two (2) liters per minute via NC. However, the oxygen tubing did not have a label including the date and time of when it was last changed. During a concurrent observation and interview on 2/24/2025 at 10:20 a.m., with Certified Nursing Assistant 2 (CNA 2) inside Resident 345's room, CNA 2 stated that Resident 345`s oxygen tubing did not have a label with the date and time of when it was last changed. During an interview on 2/24/2025 at 10:30 a.m., with Licensed Vocational Nurse 2 (LVN2), LVN 2 stated Resident 345`s oxygen tubing did not have a label with the date and time of when it was last changed. LVN2 stated that the facility staff is required to change the oxygen tubing once a week and label with the date and time of when it was changed. LVN2 stated the potential outcome of not changing patient`s oxygen tubing once per week as ordered by the physician is placing the resident at risk for infection. During an interview on 2/27/2025, at 2:15 p.m., with the Director of Nursing (DON), the DON stated that the facility staff is required to change the oxygen tubing once per week as ordered by the physician and label the tubing with the date and time it was changed. The DON stated Resident 345`s oxygen tubing did not have the date and time of when it was last changed, and the potential outcome is the increased risk of infection for Resident 345. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, last reviewed on 1/15/2025, the P&P indicated that the purpose of this procedure if to provide guidelines for safe oxygen administration. Review the resident`s care plan to assess for any special needs of the residents. Oxygen tubing and humidifier (if in use) will be changed and labeled every seven days and as needed. 4. During a review of Resident 32's admission Record, the Administration Record indicated that the facility initially admitted Resident 32 on 1/3/2025 and readmitted the resident on 1/19/2025 with diagnoses including pneumonitis (lungs tissue inflammation, swelling, and irritation), respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), multiple fracture of ribs. During a review of Resident 32's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning).The MDS further indicated that Resident 32 required maximal assistance from staff with oral and personal hygiene and was dependent on two or more helpers for other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 32 History and Physical (H&P), dated 1/20/2025, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Order Summary Report dated 2/25/2025, the Order Summary Report indicated physician order for cleanse tube stoma site (the surgically created opening in the abdomen where a feeding tube is inserted) with normal saline (a sterile, clear solution containing 0.9% sodium chloride [NaCl]in water) and cover with dry clean dressing daily dated 1/20/2025. During concurrent observation and interview on 2/26/1025 at 9:24 a.m., in Resident 32 room with Treatment Nurse 2 (TN 2), Resident 32 observed in their chair. Observed TN 2 washed her hands, donned (putted on and use PPE [ gloves, gown] properly to minimize the risk of exposure) gown and gloves, removed old dressing, discarded old dressing, doffed (took off PPE [ gloves, gown] in the way that avoid self-contamination) gloves, washed her hands and donned new gloves. TN 2 cleaned the tube stoma site with normal saline and doffed the gloves and without sanitizing her hands with ABHR, TN 2 donned new gloves and proceeded to cover tube stoma site with dry clean dressing. TN 2 stated that she needs to wash her hands before and after providing treatment and after removing old dressing. TN 2 stated she was not aware that she needs to sanitize her hands each time she took off the gloves. During an interview on 2/27/2025 at 11:35 a.m., with the Infection Preventionist (IP), the IP stated when staff is providing wound care for residents, the practice is to sanitize the hands with ABHR each time the nurse removes gloves. The IP stated TN 2 should have sanitized her hand after removing used gloves and before putting new gloves on. The IP stated this deficient practice may increase risk of spreading infection in the facility. During an interview on 2/27/2025 at 12:03 p.m., with the Director of Nursing (DON), the DON stated according to the facility policy Handwashing -Hand Hygiene all staff should follow the hand hygiene procedure and sanitize their hands with ABHR each time they removed the gloves. The DON stated this was important to prevent the spread of infection. During a review of the facility policy named Handwashing -Hand Hygiene, last reviewed on 1/15/2025, the policy indicated: This facility considers hand hygiene the primary means to prevent the spread of infection . Use an alcohol-based hand rub containing at least 70% alcohol; or alternatively, soap and water for following situations: . after removing gloves.

Based on interview and record review, the facility failed to develop a person-centered care plan (a document designed to facilitate communication among members of the care team that the summarizes a resident ' s health conditions, specific care needs, and current treatments) for one of three sampled residents (Resident 1) to address Resident 1 ' s gastrointestinal atony (inability of the stomach to contract normally, causing a delay in the movement of food out of the stomach). This deficient practice had the potential to result in a delay or lack of delivery of care and services and placed Resident 1 at risk for hospitalization. Findings: During a review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 10/9/2023 and readmitted Resident 1 on 12/23/2023 with diagnoses that included pneumonia (an infection of the lungs) and cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/22/2023, indicated that Resident 1 ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 was dependent on staff with toileting hygiene, shower, and bathing; lower body dressing, bed mobility and transfer; and required maximum assistance with eating and personal hygiene. During a review of Resident 1's Physician ' s Order dated 12/14/2023, an order was noted that indicated to obtain a stat (immediately) Kidney, Ureter, and Bladder (KUB) X-radiation (the process of taking pictures or images of the inside of the body) to assess the abdominal area for Resident 1 ' s stomach pain. During a review of Resident 1's KUB X-ray Interpretation Report dated 12/14/2023, the report indicated that Resident 1 was affected with ileus (a temporary condition where the intestine can't push food and waste out of the body). During a review of Resident 1's Progress Notes dated 12/14/2023, timed at 7:53 p.m., indicated Resident 1 ' s physician was notified of the KUB report and stated that Resident 1 needed to mobilize (move) more. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 7/18/2024 at 4:40 p.m., the ADON reviewed Resident 1's Physician Order for KUB X-ray dated 12/14/2023, the KUB X-ray interpretation report dated 12/14/2023, and Resident 1 ' s care plans from 12/14/2023 to 7/18/2024. The ADON stated that the facility did not develop a comprehensive care plan for Resident 1's condition of ileus. During a review of the facility policy and procedures titled Care Plans, Comprehensive Person-Centered, revised 03/2022, last reviewed on 7/17/2024, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Reflects currently recognized standards of practice for problem areas and condition Assessment of residents are ongoing and care plans are revised as information about the resident and the residents ' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report the initial report of the physical abuse allegation was made within two (2) hours of the incident for one of five sampled residents (Resident 1). This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by the State Survey Agency (SSA). Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 2/8/2021 and re-admitted Resident 1 on 9/28/2023 with diagnoses that included left hand tenosynovitis (inflammation of the protective sleeve of tissue surrounding the tendons [tough cord of strong, flexible tissue that attaches muscle to the bone]), cardiomyopathy (disease of the heart muscle that makes it harder to pump blood to the rest of the body), and atrial fibrillation (irregular heartbeat). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/16/2024 indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 1 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident's health) Evaluation Form dated 6/10/2024, timed at 11:32 a.m. indicated that on 6/8/2024 (unspecified time) Resident 1 reported to the Social Service Director (SSD) and Director of Nursing (DON) that Resident 2 run over her (Resident 2) wheelchair at him (Resident 1) twice. A review of Resident 1's care plan (untitled) dated 6/10/2024, indicated that Resident 1 was at risk for decline in psychosocial well-being related to being run over by a wheelchair of another Resident (Resident 2). The goal was for Resident 1 to not have indications of psychosocial wellbeing problem. A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 3/31/2023 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with a resident's daily life and activities), and hypertension (high blood pressure). A review of Resident 2's MDS dated [DATE] indicated Resident 2 had severely impaired cognition and required moderate assistance from staff with upper body dressing, and personal hygiene. The MDS indicated Resident 2 required maximum assistance from staff with toileting hygiene, shower, and lower body dressing. A review of Resident 2's COC Evaluation Form dated 6/10/2024, timed at 11:44 a.m., indicated that Resident 1 accused Resident 2 of running her (Resident 2) wheelchair against him (Resident 1). A review of Resident 2's care plan (untitled) dated 6/10/2024, indicated that Resident 2 was at risk for decline in psychosocial well-being related to allegation of physical abuse. The goal was for Resident 2 to not have indications of psychosocial wellbeing problem. During an interview on 6/20/2024 at 11:00 a.m. with Resident 1, Resident 1 stated that on 6/8/2024 at around 7:03 p.m., Resident 1 was in the hallways when Resident 2 started to wheel towards him and run her (Resident 2) wheelchair against him (Resident 1). Resident 1 further stated he then moved away and reported the incident to Licensed Vocational Nurse 1 (LVN 1). During an interview on 6/20/2024 at 1:40 p.m. with LVN 1, LVN 1 stated that on 6/8/2024 (unable to recall specific time) Resident 1 informed her that Resident 2 attempted to run him over with her wheelchair. When asked if LVN 1 reported the incident to the Administrator (ADM) or DON, LVN 1 stated she did not. LVN 1 stated on 6/8/2024 (unable to recall specific time) LVN 1 was in the middle of the hallway. LVN 1 stated she did not witness any incident between Resident 1 and Resident 2. LVN 1 further stated Resident 1 stated it was an attempt only that is why she did not report to the ADM or DON immediately. During an interview on 6/20/2024 at 4:20 p.m. with the SSD, the SSD stated any abuse allegations should have been reported within two hours per the facility's abuse policy. The SSD further stated even if it was an attempt and not an actual abuse, LVN 1 should have reported immediately to ensure Resident 1's safety. During an interview on 6/20/2024 at 4:45 p.m. with the ADM, the ADM stated the allegation was not reported to the SSA until 6/10/2024. The ADM stated that the abuse allegation should have been reported within two hours, whether it was an attempt or actual incident of abuse to ensure resident's safety and protection. A review of the facility's policy and procedure (P&P) titled, Abuse (willful infliction of injury with resulting physical harm, pain or mental anguish), Neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), Exploitation (the act of using someone or something unfairly for own advantage) or Misappropriation (wrongful use) - Reporting and Investigating last revised on 9/2022, last reviewed on 7/19/2023, indicated All reports of resident abuse (including injuries of unknown source) . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by the facility management. Findings of all investigations are documented and reported.

Based on interview and record review, the facility staff failed to notify the physician immediately of a change in condition (when there is a sudden change in a resident's health) for one of six sampled residents (Resident 1) when Resident 1 had an episode of elevated blood pressure (pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) result of 193/93 on 3/28/2024. This deficient practice had the potential to cause a delay of obtaining appropriate medical treatment and interventions for the resident which could have resulted in a negative impact to his overall physical well-being. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/13/2024 with diagnoses that included cerebral infarction (stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), atrial fibrillation (irregular heartbeat), and hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/19/2024, indicated that Resident 1's cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was moderately impaired. The MDS further indicated Resident 1 required moderate assistance from staff with toileting and dressing. A review of Resident 1's Physician's Order dated 2/14/2024 indicated to administer Cardizem LA (a medication used to treat hypertension [high blood pressure] extended release tablet 180 milligram (mg-unit of measure) one tablet my mouth one time a day for hypertension, hold if systolic blood pressure (first number, indicates how much pressure your blood is exerting against your artery walls when the heart contracts) is less than (<) 110. A review of Resident 1's Medication Administration Record (MAR - a report detailing the medications administered to a resident) for 3/2024 indicated on 3/28/2024 at 9:00 a.m. Resident 1's BP was 193/93 and received Cardizem LA 180 mg one tablet my mouth. During a concurrent interview and record review on 4/18/2024 at 1:30 p.m. with the Director of Nursing (DON), Resident 1's MAR for 3/2024 and Resident 1's progress notes from 3/28/2024 to 3/29/2024 were reviewed. The DON stated there was no documented evidence found Resident 1's physician was notified of Resident 1's elevated BP reading of 193/93. The DON further stated there was no documented evidence a Change of Condition Form was completed on 3/28/2024. The DON stated the licensed nurse should have notified Resident 1's physician on 3/28/2024 upon identifying Resident 1's elevated BP of 193/93. The DON stated a Change of Condition Form should have also been completed by the licensed nurse to address Resident 1's elevated BP because unreported changes in resident's condition can lead to serious outcome such as stroke if the high blood pressure remains untreated and unmanaged. A review of the facility's policy and procedure titled Change in a Resident's Condition or Status last reviewed on 7/19/2023, indicated it is the facility's policy to promptly notify the resident, his or her attending physician and the resident representative of changes in the resident's medical condition and/or status.

Based on interview and record review, the facility staff failed to re-check and monitor a change in condition (when there is a sudden change in a resident's health) for one of six sampled residents (Resident 1) when Resident 1 had an episode of elevated blood pressure (pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) result of 193/93 on 3/28/2024. This deficient practice placed Resident 1 at risk for further episodes of elevated blood pressure due to not receiving appropriate medical treatment and intervention immediately (with no delay). Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/13/2024 with diagnoses that included cerebral infarction (stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), atrial fibrillation (irregular heartbeat), and hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/19/2024, indicated that Resident 1's cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was moderately impaired. The MDS further indicated Resident 1 required moderate assistance from staff with toileting and dressing. A review of Resident 1's Physician's Order dated 2/14/2024 indicated to administer Cardizem LA (a medication used to treat hypertension [high blood pressure] extended release tablet 180 milligram (mg-unit of measure) one tablet my mouth one time a day for hypertension, hold if systolic blood pressure (first number, indicates how much pressure your blood is exerting against your artery walls when the heart contracts) is less than (<) 110. A review of Resident 1's Medication Administration Record (MAR - a report detailing the medications administered to a resident) for 3/2024 indicated on 3/28/2024 at 9:00 a.m. Resident 1's BP was 193/93 and received Cardizem LA 180 mg one tablet my mouth. During a concurrent interview and record review on 4/18/2024 at 1:30 p.m. with the Director of Nursing (DON), Resident 1's MAR for 3/2024 and Resident 1's progress notes from 3/28/2024 to 3/29/2024 were reviewed. The DON stated there was no documented evidence found indicating Resident 1's BP was re-checked and monitored 30 minutes to an after hour administering Cardizem LA to determine if the medication was effective and BP is getting better. The DON stated it is important to address Resident 1's elevated BP of 193/93, monitor changes or fluctuations in the resident's BP and document in the clinical record because unreported changes in resident's condition can lead to serious outcome such as stroke if the high blood pressure remains untreated and unmanaged. A review of the facility's policy and procedure titled Hypertension - Clinical Protocol last reviewed on 7/19/2023, indicated the staff and physician will identify individuals with poorly controlled hypertension. It is desirable to monitor and to report trends or patterns in blood pressure over a period of time. Isolated blood pressure elevations may warrant additional monitoring. In addition, the nurse shall assess and document the vital signs (measurements of the body's most basic functions including blood pressure, heart rate, breathing rate and temperature).

Based on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of verbal and financial abuse within two hours for one of three sampled residents (Resident 136). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: A review of Resident 136's Face Sheet (admission Record) indicated the facility admitted the resident on 1/22/2024, with diagnoses including obstructive hydrocephalus (abnormal fluid buildup in the brain that may lead to brain damage), essential hypertension (elevated blood pressure), and unspecified moderate dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbances. A review of Resident 136's Minimum Data Set (MDS- an assessment and care screening tool) dated 1/28/2024 indicated Resident 136 usually had the ability to make herself understood and usually had the ability to understand others. A review of Resident 136's History and Physical, dated 1/24/2024, indicated the resident had the ability to make her needs known but could not make medical decisions. A review of the facility Fax Confirmation Sheet, dated 2/22/2024 at 3:55 p.m., indicated the facility reported an allegation of abuse for Resident 136 on 2/22/2024 at 3:49 p.m. to the SSA. During a concurrent record review and interview on 3/5/2024 at 8:05 a.m. with the Administrator (ADM), reviewed the facility fax confirmation sheet dated 2/22/2024 at 3:55 p.m. The ADM stated on 2/21/2024 at approximately 6 p.m., Resident 136's Family Member (FM 3) reported allegations of verbal and financial abuse by other family members to the resident. The ADM stated he reported the allegations of abuse the following day on 2/22/2024 at approximately 3:30 p.m. to the SSA. During an interview on 3/8/2024 at 9:15 a.m. with the Social Service Director (SSD), SSD stated the allegation of abuse towards Resident 136 was not reported within two hours of the facility being first made aware of the allegation . The SSD stated she did not know why the allegation was not reported within two hours. SSD stated that the ADM was the facility abuse coordinator. During an interview and record review on 3/8/2024 at 9:35 a.m. with the ADM, reviewed the facility policy titled, Abuse Prohibition and Prevention Program last reviewed 7/19/2023. The ADM stated the policy indicated, The facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The ADM stated the facility policy indicated to report all allegations of abuse within two hours. The ADM stated that the allegation of abuse towards 136 was not reported within two hours of the facility first being made aware of the allegation. The ADM stated the facility policy was not followed because the allegation of abuse should have been reported within two hours. A review of the facility policy and procedure titled, Abuse Prohibition and Prevention Program last reviewed 7/19/2023 indicated the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for one of two sampled residents (Resident 31) by failing to develop a comprehensive care plan for Resident 31's seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain) precaution. This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received. Findings: A review of Resident 31's admission Record indicated the facility originally admitted the resident on 4/13/2022 and readmitted on [DATE] with diagnoses including type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). A review of Resident 31's Minimum Data Set (MDS-standardized assessment and screening tool) dated 1/8/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely intact The MDS further indicated that Resident 31 was totally dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing and lower body dressing. A review of Resident 31's Change on Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated 8/19/2023, indicated that Resident 31 had a seizure that lasted two minutes. The COC dated 8/19/2023 also indicated that Resident 31 was sent to the general acute care hospital (GACH or simply hospital) for further evaluation. During a concurrent interview and record review on 3/7/2024 at 11:54 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 31's COC and Care Plans dated 8/19/2023 to 3/7/2024. The ADON verified by stating that there was no care plan for seizure precaution developed for Resident 31. The ADON stated that after Resident 31's seizure episode and brief hospital stay, the facility should have initiated a care plan for seizure precaution when the resident was readmitted . The ADON stated that a care plan is a road map on how to care for the patient and what are the goals and objectives. The ADON stated that seizure episodes can lead to accidents and without a care plan, the staff caring for the resident would not be able to implement interventions and prevent potential injuries. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 7/19/2023, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .when possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming is provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 45) investigated under activities of daily living (ADL- activities related to personal care). This deficient practice had the potential to result in a negative impact on the resident's self- esteem due to an unkempt appearance. Findings: A review of Resident 45's admission Record indicated the facility originally admitted the resident on 12/23/2019 and readmitted on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function), type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). A review of Resident 45's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/24/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and required extensive assistance for bed mobility, transfer, dressing, personal hygiene, and bathing. During a concurrent observation and interview on 3/4/2024 at 11:18 a.m., observed Resident 45 with long fingernails and with black substances under the tip of the fingernails. When asked if staff have trimmed his fingernails, Resident 45 stated it had been several months since they had trimmed his fingernails. Resident 45 stated that he cannot do it himself because he cannot see very well. During a concurrent observation and interview on 3/8/2024 at 2:27 p.m., with the Assistant Director of Nursing (ADON), observed Resident 45 in bed. The ADON confirmed the observation by stating that Resident 45's fingernails were long and had black substances under the tip of the fingernails. The ADON stated that the resident could injure himself if he accidentally scratched any part of his body and cause a skin tear which can led to infection. A review of the facility's policy and procedure titled, Activities of Daily Livings (ADLs), Supporting, last reviewed 7/19/2023, indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure an inhaler (handheld device that delivers medication directly to your lungs) of albuterol budesonide (medication used to prevent and treat difficulty breathing) was not left at the bedside dresser for one of six sampled residents (Resident 81). 2. Ensure that facility staff monitored a resident's bed alarm (a device that alerts staff when a patient stands up or attempts to leave their bed) for placement and functionality for one (Resident 65) of four sampled residents. These deficient practices had the potential to place the resident at increased risk of sustaining a fall with injuries, and placed residents at risk for theft and loss of medication and increased risk for drug overdose and or medication errors. Findings: 1. A review of Resident 81's admission Record indicated the facility admitted the resident on 2/8/2021 and readmitted the resident on 9/28/2023, with diagnosis of ischemic cardiomyopathy an issue with damaged heart muscle that can't pump blood well). A review of Resident 81's History and Physical Examination (H&P), dated 3/4/2024, indicated the resident had the capacity to make decisions. A review of Resident 81's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 2/14/2024, indicated the resident had the ability to make self-understood and understand others. During a concurrent observation and interview on 3/4/2024 at 11:15 a.m. with Care Partner 1 (CP 1), observed Resident 1's room. During the observation, noted on top of the drawer next to Resident 1's bed was an inhaler of Albuterol Budesonide. CP 1 validated the observation by stating that there was an inhaler on top of Resident 1's drawer. CP 1 stated that it is not safe to leave medications at bedside because the resident might overdose. CP 1 further stated that medications should be given with the supervision of a licensed nurse. During a concurrent interview and record review with Licensed Vocational Nurse 6 (LVN 6) on 3/4/2024, at 1:00 p.m., Resident 81's physician orders from 9/28/2023 to 3/4/2024 were reviewed. LVN 6 stated that there were no active physician orders for Resident 81 to receive albuterol budesonide. LVN 6 further stated that they were aware that Resident 81 had an inhaler at the bedside. LVN 6 stated that it is not safe to leave medications at the resident's bedside. During an interview on 3/7/2024, at 9:30 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that it is not safe to store the medications at tje bedside because another resident can take it. During an interview on 3/8/2024, at 9:15 a.m. with the Director of Nursing (DON), DON stated that it is important to store the medication in a lock box for safety of the resident and other residents. A review of the facility's policy and procedure titled, Self-administration of Medications, last reviewed on 7/19/2023 indicated that self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. 2. A review of Resident 65's admission Record indicated the facility admitted the resident on 5/24/2023 with diagnoses including fracture (broken bone) of the femur (thigh bone), unspecified fall, and Parkinson's disease (a progressive brain condition that affects the nervous system). A review of Resident 65's MDS dated [DATE], indicated the resident had moderately impaired cognition (a term for the mental processes that take place in the brain) and required maximum assistance for most activities of daily living (ADLs-the basic skills needed to care for oneself independently). A review of Resident 65's care plan (a written document that summarizes a resident's health, care needs, and current treatments) for an unwitnessed fall, initiated on 3/6/2024, indicated the goal that the resident will minimize fall reoccurrence daily. The intervention indicated to continue bed and chair alarm and ensure it's functioning and in place. During a concurrent interview and record review on 3/7/2024 at 10:10 a.m. with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 65's physician's orders from 9/28/2023 to 3/7/2024. LVN 5 stated after reviewing Resident 65's physician orders that the resident did not have a physician's order for a bed alarm. LVN 5 stated that the facility placed a ed alarm on Resident 65 after the resident sustained a fall on 6/21/2024. When asked if staff had been monitoring for the placement and functionality of the bed alarm, LVN 5 stated there was no monitoring. On 3/8/2024 at 1:56 p.m., during an interview, the DON stated that Resident 65 has had seven falls in the past nine months. The DON stated staff should have been monitoring if the bed alarm was in place and working. The DON stated it is important to monitor the bed alarm because, if it is not working, then staff would not be alerted if the resident had a fall. The DON stated there can be potential harm to the resident if the resident sustained a fracture from a fall. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, last reviewed on 7/19/2023, indicated that the use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on interview and record review, the facility failed to complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of two sampled residents (Resident 118) investigated addressing the dialysis care area. This deficient practice placed Resident 118 at risk for complications of dialysis such as redness at the catheter site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions). Findings: A review of Resident 118's admission Record indicated the facility admitted the resident on 8/9/2023 and readmitted the resident on 2/2/2024, with diagnoses of end stage renal disease (a condition in which the kidneys no longer function normally) and dependence in renal dialysis. A review of Resident 118's History and Physical (H&P - a formal assessment of a patient and their problem), dated 2/24/2024, indicated the resident does have the capacity to understand and make decisions. A review of Resident 118's Order Summary Report, dated 2/24/2024, indicated the resident's hemodialysis schedule was on Monday, Wednesday, and Friday at 9:30 a.m. A review of Resident 118's Care Plan titled, Chronic Renal Failure/End Stage Renal Failure, dated 2/23/2024, indicated vital signs every shift and upon return from dialysis obtain blood pressure. A review of Resident 118's Nurse's Dialysis Communication Record dated 3/4/2024, indicated the post-dialysis assessment was blank and there was no documentation for post-hemodialysis monitoring for an assessment of the access site and vital signs. During a concurrent interview and record review on 3/4/2024 at 3:45 p.m., with Licensed Vocational Nurse (LVN 7), reviewed Resident 118's Nurse's Dialysis Communication record dated 3/4/2024. LVN 7 confirmed by stating that the post-dialysis assessment on 3/4/2024 was blank and was not done. LVN 7 stated that it was important to assess the vital signs, level of cognition, assess the access site, do a skin assessment, and monitor for bleeding. LVN 7 stated this could lead to altered level of consciousness (state of reduced alertness or inability to arouse due to low awareness of the environment) and bleeding if the post-dialysis assessment was not done for the resident after treatment. During an interview on 3/7/2024 at 9:30 a.m., with Registered Nurse 1 (RN 1), RN 1 stated if the post-dialysis assessment was blank, it means it was not done. RN 1 stated it was important to monitor the access site and to monitor for bleeding, infection, and mental status of the resident. RN 1 stated changes could happen after dialysis treatment that might lead to hospitalization if staff did not monitor the resident after treatment. During an interview on 3/8/2024 at 9:15 a.m., with the Director of Nursing (DON), the DON stated post-dialysis assessment must be done after every dialysis treatment because if not, it can cause a negative outcome like hypotension (low blood pressure), bleeding, and altered level of consciousness. A review of the facility's policy and procedure titled, Hemodialysis Access Care last reviewed on 7/19/2023, indicated: The general medical nurse should document in the resident's medical record every shift as follows: a. Location of catheter. b. Condition of dressing (interventions if needed). c. If dialysis was done during shift. d. Any part of report from dialysis nurse post-dialysis being given. e. Observations post-dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to monitor a resident's lipid panel (a measure of cholesterol [a waxy, fat-like substance found in the blood] and other fats in the blood) who was on a hyperlipidemic medication (medication used to lower cholesterol) for one of five residents (Resident 12) investigated for unnecessary medications. This had the potential to place a resident at risk for having high cholesterol levels that are not controlled which can result in blocked arteries (blood vessels that transport blood away from the heart). Findings: A review of Resident 12's admission Record indicated the facility admitted the resident on 3/18/2018 and re-admitted on [DATE] with diagnoses that included hyperlipidemia (high cholesterol). A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/21/2024, indicated Resident 12 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 12 required maximum assistance (helper does most of the effort) with eating and dressing. A review of Resident 12's Physician's Orders indicated the following: - Atorvastatin calcium (medication used to lower cholesterol) 20 milligrams (mg, a unit of measure), give one tablet by mouth at bedtime for hyperlipidemia, ordered 2/19/2022 and discontinued 10/18/2022. - Atorvastatin calcium 20 mg, give one tablet by mouth at bedtime for hyperlipidemia, ordered 10/19/2022 and discontinued 8/20/2023. - Atorvastatin calcium 20 mg, give one tablet by mouth at bedtime for hyperlipidemia, ordered 8/21/2023. A review of Resident 12's Care Plan titled, Potential for Coronary Artery Disease (heart disease), initiated on 9/18/2023, indicated a goal that the resident will be free from signs and symptoms of complications of cardiac problems through the review date. The care plan indicated to give medications to control medications as ordered by the physician. During a concurrent interview and record review on 3/7/2024 at 11:04 a.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Resident 12's laboratory records from 8/21/2023 to 3/7/2024. LVN 3 stated there were no lipid blood laboratory values obtained for Resident 12. When asked if there should be a baseline lipid panel, LVN 3 stated she was not sure and would check with the Director of Nursing (DON). During an interview on 3/8/2024 at 8:33 a.m., with the DON, the DON stated Resident 12 had been prescribed and had been taking the medication, atorvastatin since 2/19/2022. The DON stated he spoke to Resident 12's physician who said they would order a lipid panel to be drawn when the next labs were to be obtained. The DON stated the facility did not have a policy that addressed drawing of laboratory values for residents on cholesterol lowering medication but that there should at least be a baseline laboratory value and then checked six months to one year after that, depending on what a resident's physician decides or what their pharmacy consultant recommends. The DON stated it was important to have a lipid panel to know if a resident has high cholesterol and needs the medication. During an interview on 3/8/2024 at 4:30 p.m., with the Medical Records Director (MRD), the MRD stated there were no lipid panel laboratory values drawn for Resident 12 at any time while in the facility since 2/19/2022 or when she was in the general acute care hospital (GACH or simply hospital) before admission to the facility. A review of the facility's policy and procedure titled, Laboratory Monitoring Considerations, reviewed 7/19/2023, indicated the decision to order laboratory tests is best done, in light of, a resident's overall condition and prognosis. The policy and procedure indicated before ordering laboratory tests it is appropriate for the health care practitioner to determine where the tests would potentially change the resident's diagnosis, management, outcome or quality of life. The policy and procedure indicated antihyperlipidemic medications recommendation was to draw a lipid panel every six months or yearly as clinically warranted. The policy and procedure indicated to draw a liver function test baseline test if hepatic (liver) symptoms (symptoms to indicate the liver could be negatively affected) occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from significant medication error by failing to administer two doses of ceftriaxone sodium (an antibiotic [treats bacterial infections]) as ordered by the physician for one of one sampled resident (Resident 31) investigated under Unnecessary Medications. This deficient practice placed the resident at risk for developing an antibiotic resistance to the bacteria and causing reinfection. Findings: A review of Resident 31's admission Record indicated the facility originally admitted the resident on 4/13/2022 and readmitted on [DATE] with diagnoses including type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). A review of Resident 31's Minimum Data Set (MDS-standardized assessment and screening tool) dated 1/8/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely intact The MDS further indicated that Resident 31was totally dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing and lower body dressing. A review of Resident 31's Change on Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated 11/20/2023, indicated that Resident 31 presented with elevated white blood cells (protect you against illness and disease) count (cause for a high white blood cell count is response to an infection) and noted with lethargy (involves diminished energy, mental capacity, and motivation) and paleness. A review of Resident 31's physician's orders dated 11/20/2023, indicated an order for ceftriaxone sodium injection solution reconstituted one gram intravenously (into or within a vein) at bedtime for urinary tract infection (an infection in any part of the urinary tract [the system of organs that makes urine]) for four days. During a concurrent interview and record review on 3/7/2024 at 10:21 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 31's COC dated 11/20/2023, Resident 31's physician's order for ceftriaxone dated 11/20/2023, and Resident 31's Medication Administration Record (MAR, used to document medications taken by each individual) dated 11/2023. The review indicated that the order for ceftriaxone was transcribed in the MAR for ceftriaxone with a start date of 11/20/2023. The ADON stated that ceftriaxone was not administered on 11/20/2023 and 11/22/2023. The ADON stated that if the antibiotic is not administered completely, there is a potential that the infection will not be resolved, and the resident could develop a resistance to that particular antibiotic which will then require higher doses or a more potent antibiotic for the reinfection. A review of the facility's policy and procedure titled, Antimicrobial Stewardship Policy, last reviewed on 7/19/2023, indicated, The World Health Organization (specialized agency of the United [NAME] responsible for international public health) has reported that antimicrobial resistance is one of the major threats to human health, especially because some bacteria have developed resistance to all known classes of antibiotics.

Based on observation, interview, and record review, the facility failed to provide residents with a nourishing, palatable, well-balanced diet to meet the daily nutritional needs by failing to ensure fortified (foods with nutrients added to them to increase the nutritional value) mashed potatoes were included on the lunch tray per the dietary order and as indicted on the lunch meal ticket for one of eight sampled residents (Resident 26) investigated under the Dining Task. This deficient practice had the potential to result in unwanted resident weight loss. Findings: A review of Resident 26's admission Record indicated the facility admitted the resident on 3/31/2023 with diagnoses including chronic obstructive pulmonary disease (COPD, progressive lung disease, hyperlipidemia (elevated cholesterol [a waxy substance found in the blood that may increase the risk of heart problems]), and weakness. A review of Resident 26's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/28/2023, indicated Resident 26 had the ability to make herself understood and had the ability to understand others. A review of Resident 26's dietary order dated 4/15/2023, indicated regular diet, soft and bite-sized texture, thin liquid consistency, fortified. A review of Resident 26's lunch meal ticket dated 3/4/2024, indicated to include fortified mashed potatoes. During a concurrent observation, interview, and record review on 3/4/2024 at 12:04 p.m., with Resident 26 and Certified Nursing Assistant 1 (CNA 1), reviewed Resident 26's lunch meal ticket dated 3/4/2024. Observed CNA 1 place Resident 26's lunch tray on the bedside table. Resident 26 asked CNA 1 what was included for lunch and CNA 1 replied turkey and vegetables. Resident 26 replied no thanks, and CNA 1 asked if Resident 26 wanted something different from the kitchen. Resident 26 replied no, and CNA 1 exited the resident's room. Surveyor requested to view the meal ticket with Resident 26. Observed the meal ticket indicated the meal included fortified mashed potatoes. Resident 26 stated she did not see fortified mashed potatoes on the tray, but she likes them and would eat them if they were served. During a concurrent observation and interview on 3/4/2024 at 12:10 p.m., with Certified Nursing Assistant 2 (CNA 2), reviewed Resident 26's lunch meal ticket dated 3/4/2024. CNA 2 observed Resident 26's lunch meal tray and lunch meal ticket and confirmed by stating that Resident 26 was not served fortified mashed potatoes, but it was listed on the meal ticket. CNA 2 stated when meal trays are served to residents, they are checked to see that the ticket matches the meal served. During a concurrent interview and record review on 3/4/2024 at 12:19 p.m., with CNA 1, reviewed Resident 26's lunch meal ticket dated 3/4/2024. CNA 1 stated Licensed Vocational Nurse 2 (LVN 2) reviewed Resident 26's lunch meal ticket and tray to ensure the tray matched with the ticket. CNA 1 stated she also reviewed Resident 26's meal ticket and did not notice anything was missing. During a concurrent interview and record review on 3/4/2024 at 1 p.m., with LVN 2, reviewed Resident 26's lunch meal ticket dated 3/4/2024. LVN 2 stated she reviewed Resident 26's lunch meal ticket and tray to check for accuracy. LVN 2 stated maybe she reviewed the ticket and tray too quickly and did not notice the fortified mashed potatoes were missing. LVN 2 stated every resident needs a healthy balanced diet and fortified foods provide extra nutrients. During an interview on 3/4/2024 at 3:44 p.m., with the Dietary Supervisor (DS), the DS stated fortified foods provide additional calories to residents and everything listed on the meal ticket should be included on the resident's tray. The DS stated the kitchen staff probably was confused and did not include the fortified mashed potatoes on the resident's tray. During an interview on 3/7/2024 at 3:20 p.m., with the Director of Nursing (DON), the DON stated fortified foods have added nutrients that do not occur naturally in the food. The DON stated residents on fortified diets need the added nutrients to improve their nutrition and prevent unwanted weight loss and maintain their general health. The DON stated health maintenance is important because residents have comorbidities (two or more diseases present at the same time and is associated with worse health outcomes) and are at risk for decline and serving the appropriate diet potentially prevents resident decline and possible hospitalization. A review of the facility's policy and procedure titled, Menus, last reviewed 7/19/2023, indicated menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). A review of the facility's policy and procedure titled, Enhanced/Fortified Food Program for Generational Healthcare, Adopted from Every Bite Counts, last reviewed 7/19/2023, indicated when a resident's oral intake is not adequate to meet the nutritional need, promoting real food first before supplementation is the best way for a majority of residents. Providing enhanced/ fortified food or calorie dense foods provides concentrated sources of calories and protein from residents that require additional nutrition without increasing food volume. The purpose of the program is to prevent complications associated with undesirable weight loss. The Registered Dietician (RD) / Interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) identifies residents at nutritional risk. The RD/IDT will recommend physician order for Fortified/Enhanced program. The basic Fortified food program will provide 650 calories and 30 grams (gm, a unit of measurement) protein. Staff serving the Fortified/enhanced food need to be aware of the fortified/enhanced item added to each meal. A review of the facility's policy and procedure titled, Accuracy and Quality of Tray Line Service, last reviewed 7/19/2023, indicated all meals will be checked for accuracy by the food and nutrition services staff and by the service staff prior to serving the meal to the individual. Staff will refer to the meal identification card/ticket for food dislikes, allergies and other details and substitute appropriately for those items. Each meal tray will be checked for accuracy of following the therapeutic diet extension.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the proper storage, preparation, and distribution of food in accordance with professional standards for food service safety for 142 of 146 residents by failing to: 1. Ensure food items were labeled and dated. 2. Ensure food items were not stored and readily available to be served past the discard date. 3. Ensure temperatures were being monitored for two reach-in refrigerators. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). Findings: During an initial observation tour of the kitchen on 3/4/2024 at 8:05 a.m., and interview with the Dietary Supervisor (DS), the DS stated the facility labels and dates all food items with the date delivered or prepared to ensure older items are used first and no expired foods are served to residents. Observed the following in the facility's kitchen with the DS: a. In the dry storage area, observed one loaf of white bread dated 2/22/2024. The DS stated a loaf of white bread is discarded after 5 days and the bread labeled 2/22/2024 was past the five days and should have been removed but it was not. The DS stated the importance of not serving bread after five days it to ensure the quality of the bread that is served to residents. b. In the walk-in refrigerator, observed the following: - One undated bin containing seven (7) avocados and two (2) broccoli heads. The DS stated all food bins should be labeled with the date and different food types should be kept separately, and stated the avocados and broccoli heads were not labeled or individually bagged. - One bin of tuna labeled to discard on 2/29/2024. The DS stated the label indicated to discard the tuna on 2/29/2024 but it was not discarded. The DS stated the tuna should not be in the refrigerator available to serve to residents. - One large bin with no label indicating the contents or date, and three (3) small bowls not labeled with the contents. The DS stated the unlabeled contents of the bowls and bin was egg salad and should have been labeled in order for kitchen staff to know the contents. The DS stated unlabeled containers could lead to confusion over the contents and all items should be labeled with the date in order to ensure expired food is not served to residents. c. Two reach-in refrigerators located in the meal preparation area. The DS stated there was no documentation of temperature monitoring for the reach-in refrigerators. The DS stated all refrigerators should be maintained below 41 degrees Fahrenheit (F- unit of temperature). The DS stated the facility maintains a log for the walk-in refrigerator, but not for the two reach-in refrigerators. The DS stated the importance of maintaining a log for all refrigerators was to ensure the correct temperature was maintained for food safety. During a concurrent interview and record review on 3/4/2024 at 4:26 p.m., with the DS, reviewed the facility's policy and procedure titled, Policy and Procedure [NAME], and Policy and Procedure [NAME] Food Storage, dated 2023. The DS stated the facility's policy and procedure to document temperatures of the reach-in refrigerators was not followed because there was no documentation that it was done. During a concurrent interview and record review on 3/7/2024 at 3:20 p.m., with the Director of Nursing (DON), reviewed the facility's policy and procedures procedure titled, Policy and Procedure [NAME], and Policy and Procedure [NAME] Food Storage, dated 2023. The DON stated the facility labels food with the contents and date to ensure fresh, nutritious food is served to residents. The DON stated the importance of labeling all food contents is to ensure residents are not served foods they may be allergic to. The DON stated the importance of documenting the temperatures of all refrigerators is to ensure the temperatures are maintained and the food stored in them is safe to be eaten. The DON stated if the temperatures were not documented then it was not done. The DON stated the facility cares for fragile people and they do not want to aggravate or add anything else to the residents' ill health. The DON stated serving spoiled food can lead to infections that impair or prolong the healing process. A review of the facility-provided document titled, Policy and Procedure [NAME], dated 2023, indicated to take each refrigerator/freezer units' internal temperature and document. If temperatures are not acceptable (refrigerators should be 41 degrees F or less and freezers should be 0 degrees F or less), call immediately for repair. Assess the safety of foods in the unit and discard any questionable foods. A review of the facility-provided document titled, Policy and Procedure [NAME] Food Storage, dated 2023, indicated sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. Old stock is always used first (first-in, first out method). Food should be dated as it is placed on the shelves. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat food should be consumed, sold or discarded. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. All refrigerator units should be kept clean and in good working order. Refrigerator thermometers should be checked at least two times each day. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or discarded. A review of the facility-provided untitled and undated document indicated shelf life of bread depends on a variety of factors, such as the best by date, preparation method and how it is stored. Always label bags with open date and check expiration date before opening bag. Room temperature white loaves of bread stored at room temperature for five days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an interview on 3/7/2024 at 8:41 a.m., with the Maintenance Director (MD), the MD stated he never conducted any water testing for Legionella for this facility since 2015. The MD stated he only tests the water if there is any suspicion. The MD stated the cost for water testing is very expensive. The MD stated he only tests water temperatures for four random resident's rooms of his choice in each station and the required areas that have pre-listed in the building maintenance daily logs. The MD stated there is no other monitoring logs for water management program beside the building maintenance daily logs for the hot water temperature monitoring. During an interview on 3/7/2024 at 9:37 a.m., with the Infection Preventionist (IP), the IP stated I know there is a water management test for legionella policy in the infection control. what I heard is if there is no problem, we don' t need to test it. IP stated MD knows how to take care of it and maintenance department responsible for water management of the infection control program. During an interview on 3/7/2024 at 9:47 a.m., with the Administrator (ADM), the ADM stated the facility will only test the water if there is a suspicion. The ADM stated he did not see any Legionella water test since he started working in the facility since 3/2023. During a concurrent interview and record review on 3/8/2024 at 8:40 a.m., with the ADM and the MD, the MD stated he did not understand what is building water systems and flow diagrams. The ADM stated they could not find any flow diagrams and text description of the facility's building water systems and devices in his water management binder. The ADM stated the MD and him are the team members of the water management team. The ADM stated if the water was not tested, they would not know if the water had legionella or other bacteria and they were not able to monitor for water safety and if sanitary. The ADM stated it was important to test the water for safe and sanitary water to prevent residents from contracting Legionella Disease or other waterborne illness. A review of the facility's policy and procedure titled, Legionella, Legionnaires Disease, last reviewed 7/19/2023, indicated the facility establishes and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment including procedures to reduce the risk of Legionella Disease. l. Establish a water management program team. 2. Describe the building water systems using text and flow diagrams. 3. Identify areas where Legionella could grow and spread. 4. Decide where control measures should be applied and how to monitor them. 5. Establish ways to intervene when control limits are not met. 6. Ensure the program is running as designed and is effective. 7. Document and communicate all the activities. 1.c. A review of Resident 454's admission Record indicated the facility admitted the resident on 3/2/2024, with diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm). A review of Resident 454's History and Physical (H&P - a formal assessment of a patient and their problem), dated 3/4/2024, indicated the resident had the capacity to make decisions. A review of Resident 454's Order Summary Report, dated 3/4/2024, indicated a physician's order for oxygen at two to five LPM via nasal cannula as needed for shortness of breath. During observation on 3/4/2024 at 11:20 a.m., observed Resident 454 sitting in their wheelchair with a nasal cannula that was observed with no date or time noted. During a concurrent observation and interview on 3/4/2024 at 11:20 a.m., with Certified Nursing Assistant (CNA 6), observed Resident 454's nasal cannula. CNA 6 confirmed by stating that there was no date labeled on Resident 454's nasal cannula. CNA 6 stated that charge nurses were in charge in labeling it and it was important to label it know when it will be changed again. During an interview on 3/7/2024 at 7:57 a.m., with the DSD, the DSD stated nasal cannulas must be dated to ensure it is current and to know when it will be changed. The DSD stated this might cause an infection to the resident if it was not changed and monitored. During an interview on 3/7/2024 at 3:20 p.m., with the DON, the DON stated oxygen tubing and humidifiers are to be changed weekly to prevent respiratory infections. The DON stated although the oxygen policy does not specifically indicate to label and date the oxygen tubing and humidifier, it is to be conducted by the licensed nurses. The DON stated he teaches the licensed nurses to label and date the oxygen tubing and humidifier bottle to ensure they are changed every seven days. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed 7/19/2023 indicated the purpose is to provide guidelines for safe oxygen administration. A review of the facility's policy and procedure titled, Infection Control, last reviewed 7/19/2023, indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the facility. 2. A review of Resident 446's admission Record indicated the facility admitted the resident on 2/7/2024 with diagnosis of dysphagia (difficulty swallowing). A review of Resident 446's History and Physical Examination (H&P - a formal assessment of a patient and their problem), dated 3/8/2024, indicated the resident had the capacity to understand his medical condition. A review of Resident 446's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/13/2024, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 446's physician's orders indicated an order for enteral (also known as tube feeding) feed every shift, ordered on 2/7/2024. During a concurrent observation and interview on 3/4/2024 at 10:30 a.m., with Registered Nurse (RN 3), RN 3 confirmed by stating there was no date labeled on Resident 446's g-tube syringe. RN 3 stated it was important to label the syringe to know when to replace it and for infection control purposes. A review of the facility's policy and procedure titled, Infection Control, last reviewed 7/19/2023, indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the facility. Based on observation, interview, and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure nebulizer (a device used for the inhalation [breathing in] of medication) face masks (a piece of soft plastic designed to fit over the mouth that delivers medication by inhalation via a long hollow tube) and tubing, nasal cannulas (NC, a device used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory health), and humidification bottles (water is combined with the normal flow of oxygen, reducing sensations of dryness in the upper airways) were labeled and dated within the last seven days or as needed as ordered by the physician for three of four sampled residents (Resident 22, 8, 454) investigated for Respiratory Care. 2. Based on observation, interview, and record review, the facility failed to label the syringe used to administer medication via gastrostomy tube (G-tube, a plastic tube inserted into a resident's stomach to administer nutrition and medications) for one of one sampled resident (Resident 446). This deficient practice had the potential for the resident to develop resident infection. 3. Ensure a resident's NC oxygen tubing was not touching the floor for one of three sampled residents (Resident 31) investigated for infection control. These deficient practices had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infections and respiratory distress. 4. Ensure the Legionella (a type of bacteria spread through small droplets of water that can cause legionellosis [Legionnaires' Disease, a serious and potentially deadly lung infection]) Water Management Program policy and procedure was fully implemented including a flow diagram of the water system, identify areas where legionella could grow and spread, determining the location where control measures should be applied and how to monitor them, and documenting and communicating all the activities the water management team, investigated during the Infection Control task. This deficient practice had the potential to result in widespread infection in the facility. Findings: 1.a. A review of Resident 22's admission Record indicated the facility admitted the resident on 8/30/2023 and readmitted the resident on 10/4/2023, with diagnoses including calculus of kidney (hard, pebble like pieces of material that form in the kidneys [organ that removes waste and water in the urine]) chronic obstructive pulmonary disease (COPD, progressive lung disease), and pulmonary fibrosis (a disease that causes scar tissue in the lungs that may result in shortness of breath). A review of Resident 22's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/4/2023 indicated Resident 22 sometimes had the ability to make herself understood and sometimes had the ability to understand others. A review of Resident 22's physician's order indicated the following: - Oxygen: at two liters per minute (LPM, a unit of measurement) via nasal cannula as needed for wheezing (whistling sound you make when your airway is partially blocked)/shortness of breath (difficulty breathing). Goal is to maintain oxygen saturations (measurement of oxygen in the blood) above 90% (normal reference range 92-100%), dated 10/4/2023 and discontinued on 3/4/2024. - Oxygen: Change oxygen tubing to include NC and/or mask, tubing and storage bag every week and/or as needed, dated 10/4/2023 and discontinued on 3/4/2024. - Oxygen: Change humidifier bottles every seven days and/or as needed, dated 10/4/2023 and discontinued on 3/4/2024. - Oxygen: Change nebulizer mask, tubing and storage bag every week and/or as needed, dated 10/4/2023 and discontinued on 3/4/2024. During a concurrent observation and interview on 3/4/2024 at 12:26 p.m., with Family Member 1 (FM 1), observed Resident 22 lying in bed with an oxygen concentrator (device used to deliver supplemental oxygen to a resident) at bedside with a prefilled humidifier bottle, labeled 11/10/2023, connected to an unlabeled NC. Observed a bag hanging from the concentrator containing an unlabeled nebulizer face mask connected by tubing to a nebulizer. FM 1 stated Resident 22 receives breathing treatments. During a concurrent observation and interview on 3/4/2024 at 12:44 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated all oxygen tubing used for treatments are labeled with the date. LVN 2 stated the night shift changes the tubing and humidification bottles once a week and as needed. LVN 2 observed and confirmed by stating Resident 22's nebulizer mask and tubing and NC were not labeled with the date. LVN 2 stated the date on the humidification bottle indicated it had not been changed since 11/10/2023, but the resident was not currently receiving oxygen. LVN 2 stated tubing and humidification bottles should be changed weekly and labeled with the date it was changed in order to ensure they were changed timely, and protocols were followed. LVN 2 stated it is an infection control issue when humidification bottles, oxygen tubing, and nebulizer tubing are not changed weekly, and it can lead to respiratory infections which jeopardize resident's health. During an interview on 3/7/2024 at 7:57 a.m., with the Director of Staff Development (DSD), the DSD stated licensed nurses monitor equipment, oxygen tubing, and humidification bottles and they are changed weekly and labeled with the date changed. The DSD stated the importance of labeling is to ensure the tubing and bottles are current. The DSD stated by labeling the equipment, they know when it was last changed. During a concurrent interview and record review on 3/7/2024 at 3:20 p.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Administering Medications through a small Volume (handheld) Nebulizer, and Oxygen Administration, last reviewed 7/19/2023. The DON stated the policy did not specifically indicate to label the tubing and bottles, but there is an order to change them weekly and it is the practice of the facility to label the date, so they do not miss changing them. The DON stated it was an infection control issue because sometimes tubing can become dirty and lead to upper respiratory infections. The DON stated a humidification bottle with a date of 11/10/2023 should have been removed and not left on the concentrator because it could have been used resulting in the same infection control issues. A review of the facility's policy and procedure titled, Administering Medications through a small Volume (handheld) Nebulizer, last reviewed 7/19/2023 indicated the purpose of the procedure was to administer aerosolized particles of medications safely and aseptically into the resident's airway. Change the equipment and tubing every seven days. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed 7/19/2023, indicated the purpose is to provide guidelines for safe oxygen administration. A review of the facility's policy and procedure titled, Infection Control, last reviewed 7/19/2023, indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the facility. 3. A review of Resident 31's admission Record indicated the facility originally admitted the resident on 4/13/2022 and readmitted on [DATE] with diagnoses including type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). A review of Resident 31's MDS dated [DATE], indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely intact The MDS further indicated that Resident 31was totally dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing and lower body dressing. A review of Resident 31's physician's orders dated 8/24/2023, indicated an order to administer oxygen at 2 LPM via nasal cannula as needed to maintain oxygen saturation above 90% every shift. During a concurrent observation and interview on 03/04/24 at 3:51 p.m., with the DON, observed Resident 31 sleeping on her bed with the oxygen nasal cannula detached from the oxygen concentrator and the end part of the nasal cannula tubing on the floor. The DON stated that if the tubing is on the floor, it becomes contaminated and may potentially introduce infection to the resident. The DON stated nursing staff must ensure the oxygen tubing will not be touching the floor. A review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. 1.b. A review of Resident 8's admission Record indicated the facility admitted the resident on 6/4/2011 and re-admitted on [DATE] with diagnoses that included acute (sudden) and chronic respiratory failure with hypoxia (a long-term condition in which the respiratory system is unable to adequately exchange oxygen to the body), acute and chronic respiratory failure with hypercapnia (respiratory failure with a buildup of carbon dioxide [waste product that your body gets rid of when you exhale] in the blood, and dependence on supplemental oxygen. A review of Resident 8's MDS dated [DATE], indicated Resident 8 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 8 required maximal assistance (helper does more than half the effort) with oral hygiene, toileting, and supervision with eating. A review of Resident 8's physician's orders indicated the following: - Oxygen: at 2 LPM via nasal cannula every shift for acute and chronic respiratory failure with hypoxia and hypercapnia, dated 6/23/2023. - Oxygen: Change humidifier bottles every seven days and/or as needed, dated 6/16/2023. - Change oxygen tubing and storage bag every week and/or as needed; date tubing and bag every day shift every Friday, dated 6/16/2023. - Oxygen: goal to maintain oxygen saturation above 90%, dated 6/16/2023. A review of Resident 8's Care Plan for Oxygen, initiated 8/15/2023, indicated Resident 8 was admitted on oxygen therapy. The care plan indicated a goal that Resident 8 will not exhibit signs of respiratory distress. The care plan indicated an intervention to administer oxygen as ordered by the physician. During an observation on 3/4/2024 at 4:43 p.m., observed Resident 8 in bed wearing a nasal cannula. Resident 8's nasal cannula tubing and humidifier bottle were not labeled with a date or time. During a concurrent observation and interview on 3/4/2024 at 4:45 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 8's nasal cannula tubing and humidifier bottle in her room. LVN 1 verified by stating that the nasal cannula tubing and humidifier bottle were not labeled with a date when applied. LVN 1 stated the nasal cannula tubing and humidifier bottle should have been labeled when first placed to ensure it would not be there for longer than was allowed. LVN 1 stated this was important for infection control reasons. During an interview on 3/7/2024 at 7:57 a.m., with the DSD, the DSD stated the licensed nurses change the nasal cannula tubing because oxygen is a medication, and the licensed nurses also monitor the equipment. The DSD stated the process to label and date the nasal cannula tubing and humidifier bottle is to ensure the equipment is current and not there longer than a week. The DSD stated by labeling the equipment the licensed nurses know they changed it. The DSD stated the reason in labeling was to prevent the possibility of acquiring a respiratory infection for the residents. During an interview on 3/7/2024 at 3:20 p.m., with the DON, the DON stated oxygen tubing and humidifiers are to be changed weekly to prevent respiratory infections. The DON stated although the oxygen policy does not specifically indicate to label and date the oxygen tubing and humidifier, it is to be conducted by the licensed nurses. The DON stated he teaches the licensed nurses to label and date the oxygen tubing and humidifier bottle to ensure they are changed every seven days. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed 7/19/2023, indicated the purpose is to provide guidelines for safe oxygen administration. A review of the facility's policy and procedure titled, Infection Control, last reviewed 7/19/2023, indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report an alleged allegation of abuse on 8/27/2023 within two hours of being made aware of the allegation to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect other residents from further abuse. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included functional quadriplegia (inability to move due to another medical condition) and type 2 diabetes ( a disease that occurs when your body is unable to regulate the amount of sugar in the blood resulting in high levels of sugar in the blood) without complications. A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/1/2023, indicated That Resident 1 had the ability to understand others and be understood by others. The MDS also indicated that Resident 1 ' s cognitive skills (the mental processes involved in gaining knowledge and comprehension) for daily living decision making was intake. During an interview on 9/19/2023 at 11:52 p.m., Family Member 1 (FM 1) stated that on 8/27/2023, FM 1 electronically mailed (e-mailed) the Administrator (ADM), the Director of Nurses (DON), and the Social Services Director (SSD) regarding an allegation of verbal and physical abuse reported to FM 1 by Resident 1. During an interview on 9/19/2023 at 1:24 p.m., the SSD stated that she was made aware of an abuse allegation involving Resident 1 on 8/27/2023 by FM 1. When asked how SSD was made aware of the allegation of abuse, SSD stated that SSD received an email from FM 1 on 8/27/2023. SSD stated that the email was also sent to the ADM and the DON. During an interview on 9/28/2023 at 12:44 p.m., the ADM stated that an e-mail regarding an allegation of abuse by Resident 1 was sent to the facility on 8/27/2023 by FM 1. The ADM stated that he saw the email on 8/28/2023. The ADM stated that on 8/28/2023, after reading the e-mail sent by FM 1, the ADM spoke to Resident 1 who denied the abuse allegation. The ADM stated that on 9/5/2023, Resident 1 stated that she felt abused, and that is when the ADM reported the allegation of abuse to the SSA. The ADM further stated that he should have reported the allegation of abuse as soon as he read the e-mail on 8/28/2023. ADM stated that because the e-mail received on 8/28/2023 was not directly from Resident 1, ADM wanted to speak first speak with Resident 1 to ask if it was really abuse. A review of the facility ' s policy and procedure titled, Abuse Investigate/Prevent/Report Alleged Violation, reviewed on 7/19/2023, indicated that it is the facility ' s procedure to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than two (2) hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that three of three sampled residents (Resident 2, Resident 3, and Resident 4) were provided the necessary treatment and services to promote healing of pressure ulcer (PU - injury to skin and underlying tissue resulting from prolonged pressure on the skin) when staff placed multiple layers of linen over the residents' low air loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts). This deficient practice placed the residents at increased risk for worsening and further development of pressure ulcers and delayed wound healing. Findings: a. A review of Resident 2's admission Record indicated the facility admitted the resident on 7/2/2023 with diagnoses including both lower legs fracture (broken bone) and hypertensive heart disease (heart problems that occur because of high blood pressure) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/8/2023 indicated, Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) status was severely impaired. The MDS further indicated Resident 2 required total assistance from staff for transfer and toilet use and extensive assistance from staff for bed mobility, dressing, eating and personal hygiene. A review of Resident 2's Physician's Order Summary Report dated 7/20/2023, indicated the use of LALM for wound treatment and to check the setting and functionality every shift. A review of Resident 2's Weekly Pressure Ulcer Report dated 7/24/2023 indicated Resident 2 had pressure ulcer on sacrococcyx (tail bone). On 7/31/2023, at 3:39 p.m., during an observation and concurrent interview with Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) in Resident 2's room, Resident 2 was observed lying on top of a total of seven layers of linen between the resident and the LALM; from the top of LAL mattress towards the resident skin, a fitted sheet, a bed sheet folded twice (totaling to four layers), one thick washable linen barrier pad and Resident 2 was wearing a breathable brief. CNA 1 stated that Resident 2 was laying on seven layers of linen. CNA 1 stated no more than two layers of linen should have been placed. LVN 1 instructed CNA 1 to remove all the extra linens and leave two layers of linen instead. LVN 1 stated use of multiple layers of linen could lead to a delay in wound healing. b. A review of Resident 3's admission Record indicated the facility admitted the resident on 2/18/2022 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 3's MDS dated on 5/10/2023 indicated Resident 3's cognitive status was severely impaired, and Resident 3 needed extensive assistance from staff for bed mobility, transfer, dressing, and personal hygiene. A review of Resident 3's Physician's Order Summary Report dated 2/21/2022, indicated the use of LAL mattress for right buttock wound treatment every shift. A review of Resident 3's Wound Progress Note dated 7/26/2023 indicated Resident 3 had pressure ulcer on sacrococcyx. On 7/31/2023, at 4:05 p.m., during an observation and concurrent interview with the Assistant Director of Nursing (ADON) and CNA 2 in Resident 3's room, Resident 3 was observed lying on top of a total of seven layers of linen between the resident and the LALM; from the top of LAL mattress towards the resident skin, a fitted sheet, a bed sheet folded twice (totaling to four layers), one thick washable linen barrier pad and Resident 3 was wearing a breathable brief. CNA 2 stated that Resident 3 was laying on seven layers of linen. CNA 2 stated that the facility had provided in-services to staff about not using more than two layers of linen with the LAL mattress. The ADON instructed CNA 2 to remove all the extra linens and stated there should be no more than two layers of linen used. The ADON stated there would be no benefit to the residents if staff placed multiple layers of linen and thick reusable linen pads with the LAL mattress. c. A review of Resident 4's admission Record indicated the facility admitted the resident on 7/22/2022 and readmitted on [DATE] with diagnoses including acute kidney failure (a sudden episode of kidney damage that happens within a few hours or a few days and suddenly become unable to filter waste products from your blood) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 4's MDS dated on 4/21/2023 indicated Resident 4's cognitive status was moderately impaired (decisions poor and cues or supervision required). The MDS further indicated Resident 4 required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 4's Physician's Order Summary Report dated 7/7/2023, indicated the use of LAL mattress for wound treatment and to check the setting and functionality every shift. A review of Resident 4's Weekly Skin Alteration Report dated 7/25/2023 indicated Resident 4 had blister (painful skin condition where fluid fills a space between layers of skin) on left hip that developed on 7/6/2023 and resolved on 7/25/2023. On 7/31/2023, at 4:15 p.m., during an observation and concurrent interview with the ADON and CNA 2 in Resident 4's room, Resident 4 was observed lying on top of a total of seven layers of linen between the resident and the LALM; from the top of LAL mattress towards the resident skin, a fitted sheet, a bed sheet folded twice (totaling to four layers), one thick washable linen barrier pad and Resident 4 was wearing a breathable brief. CNA 2 stated that Resident 2 was laying on seven layers of linen. CNA 2 stated no more than two layers of linen should have been placed. The ADON stated Resident 4 continues to use the LALM to prevent skin breakdown and development of new pressure ulcers. The ADON stated, the staff should not use more than two layers of linen with the LALM use, otherwise, it would defeat the purpose of LALM use. On 7/31/2023, at 4:50 p.m., during an interview with Director of Nursing (DON), the DON stated that staff have been instructed not to place more than two layers of linen for residents using LAL mattresses as this could delay the wound healing process. A review of the facility's policy and procedure titled Low Air Loss Mattress reviewed 7/19/2023 indicates, Low air loss mattress has been an integral tool for wound care management as a facility protocol to enhance wound healing and treatment of pressure ulcer Multiple layer approach: one sheet over the mattress, one breathable pad, resident on top of the breathable pad and one sheet to cover patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure Restorative Nursing Assistant 1 (RNA 1) performed hand hygiene (HH - cleaning hands by washing with soap and water or using an alcohol-based hand sanitizer) before and after providing meal assistance for three of three sampled residents (Resident 4, 5, and 6) during lunch in the dining room. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria from one person, object, or place to another) and spread of infections to staff and residents. Findings: a. A review of Resident 4's admission Record indicated the facility admitted the resident on 11/20/2019 with diagnoses including Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a general term for the impaired ability to remember, think, or make decision that interferes with doing everyday activities), and history of Coronavirus disease (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/24/2023 indicated, Resident 4 ' s cognitive (mental action or process of acquiring knowledge and understanding) status was severely impaired, and Resident 4 needed total assistance from staff for eating. b. A review of Resident 5's admission Record indicated the facility admitted the resident on 8/16/2022 with diagnoses including liver cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) and history of COVID-19. A review of Resident 5's MDS dated [DATE] indicated, Resident 5 ' s cognitive status was moderately impaired, and Resident 5 needed limited assistance from staff for eating. c. A review of Resident 6's admission Record indicated the facility admitted the resident on 10/20/2020 with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden and uncontrolled body movements]) and history of COVID-19. A review of Resident 6's MDS dated [DATE] indicated, Resident 6 ' s cognitive status was severely impaired, and Resident 6 needed extensive assistance from staff for eating. On 6/28/2023, at 12:05 p.m., during a concurrent observation and interview with the Assistant Director of Nursing (ADON) in the dining room, RNA 1 was observed providing Resident 4 with meal assistance, then RNA 1 stood up and went to the table where Resident 5 and Resident 6 were sitting. Without performing HH, RNA 1 assisted Resident 5 to hold the spoon correctly then helped Resident 6 arrange the dish while touching Resident 6 ' s hand and right shoulder. RNA 1 again failed to perform HH when she returned to continue assisting Resident 4 with her meal. ADON stated that RNA 1 should have performed HH after assisting one resident and before assisting another resident. The ADON approached RNA 1 and instructed to perform HH when RNA 1 was about to assist Resident 4 with her meal. On 6/28/2023, at 1:13 p.m., during an interview with RNA 1, RNA 1 stated that she did not perform HH when she assisted three residents with their meals. RNA 1 stated she should always perform hand hygiene after assisting one resident and before assisting another resident. On 6/28/2023, at 1:30 p.m., during an interview with the Infection Preventionist (IP), the IP stated that all staff should perform HH after assisting one resident and before moving to the next resident, the HH procedures were the most important to prevent cross contaminations. A review of the facility ' s policy and procedures (P&P) titled, Infection Prevention and Control Program, dated 8/1/2021 indicated, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. A review of the facility ' s revised August 2019 P&P titled, Handwashing/Hand Hygiene indicated, This facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: Before and after direct contact with residents; Before and after assisting a resident with meals.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was informed of her Coronavirus Disease 2019 (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms) test result. This deficient practice had violated the resident ' s right to be informed of her test result. Findings: A review of Resident 1 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 11/23/2022 with diagnoses including left femur (hip) fracture (broken bone). A review of Resident 1 ' s History and Physical dated 11/24/2022 indicated, resident had history of atrial fibrillation (irregular heart rate), anxiety disorder (a group of mental illnesses that cause constant fear and worry) and osteoarthritis (tissue at the end of the bone wears down). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/30/2022, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. A review of Resident 1 ' s Notice of Room Transfer indicated the resident was moved from Room A to Room B and family was notified on 11/29/2022 and again was moved from Room B to Room C on 12/1/2022. During an interview on 12/2/2022 at 3:58 a.m., with Resident 1, Resident 1 stated facility tested her for COVID-19, but she was not informed of her test result. During an interview on 12/4/2022 at 3:05 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated every time they move resident to yellow zone they notify the physician, family, supervisor, Assistant Director of Nursing (ADON) and Director of Nursing (DON). Social Service also notify the resident and family if there is a need for room change and they document the reason of the transfer. During an interview on 12/4/2022 at 3:36 p.m., with the Social Service Director (SSD), SSD stated they do not notify the resident of the COVID-19 test result but notified Resident 1 ' s family of the need to make room changes on 11/29/2022 and 12/1/2022. During an interview on 12/4/2022 at 3:30 p.m., with the Director of Nursing (DON), DON stated they notify the family if the resident was exposed to COVID-19. DON stated they tested everybody in the facility including staff and residents and if not informed that means they are negative. DON stated they have 55 total positive residents, and they are trying to keep up and prioritizing those who tested positive first. A review of facility ' s policy and procedure titled, Change in Resident ' s Condition, dated 7/1/2020, indicated, It is the policy of this facility that the resident, his or her Attending Physician, and representative shall be notified of changes in the residents medical/mental condition and /or status. 2. A significant change of condition is a major decline or improvement in the resident status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical intervention b. Impacts more than one area of the resident ' s health status. c. Requires interdisciplinary review and/or revision of care plan. 4. Unless other wise instructed by the resident, a nurse will notify the resident representative when. c. there is a need to change the resident ' s room assignment.

Based on interview and record review, the facility failed to revise care plans for two of six sampled residents (Resident 1 and Resident 3) after residents were transferred to yellow zone (area for residents with possible exposure to Coronavirus Disease 2019 [COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms]). This deficient practice had the potential to negatively affect the provision of care and services for Resident 1 and Resident 3. Findings: a. A review of Resident 1 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 11/23/2022 with diagnoses including left femur (hip) fracture (broken bone). A review of Resident 1 ' s History and Physical dated 11/24/2022 indicated, resident had history of atrial fibrillation (irregular heart rate), anxiety disorder (a group of mental illnesses that cause constant fear and worry) and osteoarthritis (tissue at the end of the bone wears down). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/30/2022, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. A review of Resident 1 ' s Notice of Room Transfer indicated the resident was moved from Room A to Room B and family was notified on 11/29/2022 and again was moved from Room B to Room C on 12/1/2022. A review of Resident 1 ' s Care Plan on at risk for Coronavirus Disease 2019 (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms) was initiated on 11/24/2022. During a concurrent interview and record review on 12/4/2022 at 1:54 p.m., with Infection Preventionist 2 (IP 2), facility ' s line list (guide for outbreak management that list the information about resident ' s test date for COVID-19 and exposure are log in) was reviewed. IP 2 stated Resident 1 was in Room B on 11/29/2022 until 11/30/22. IP 2 stated Resident 1 ' s roommate on 11/30/2022 tested positive for COVID-19 causing her to be transferred again to Room C. IP 2 stated on 12/1/2022 Resident 1 ' s roommate tested positive for COVID-19 also. IP 2 admitted Resident 1 ' s care plan was not updated and that they should have, to address residents needs after she was expose to a positive COVID-19 resident. b. A review of Resident 3 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 10/20/2022 with diagnoses including dysphagia (difficulty in swallowing), history of fall and epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body). A review of Resident 3 ' s History and Physical dated 6/12/2022 indicated, resident could make decisions. A review of Resident 3 ' s care plan on at risk for COVID-19 was initiated on 10/20/2022. During an interview on 12/3/2022 at 12:37 a.m., with Registered Nurse 1 (RN 1), RN 1 stated they have no care plan for residents who were exposed to COVID-19. RN 1 stated their care plan is just at risk for COVID-19 and updates it as needed. RN 1 admitted they should have a new care plan if residents were exposed to a positive resident to address their needs. During an interview on 12/3/2022 at 1:01 p.m., with the Director of Nursing (DON), DON stated they did not update the care plan in the yellow zone because it ' s impossible to do it with the range of cases they have. DON stated they currently have 53 positive residents in red zone and 52 in yellow zone. A review of facility ' s Mitigation Plan dated 12/2/2022 indicated, Meet with IDT and create a plan in place to monitor for risks (depression, worsening behavior, development of pressure ulcers, etc.) related to limited /restricted social dining and activities and have interventions for prevention as well as treatment.

Based on observation, interview and record review, the facility failed to implement infection control practices by: 1. Failing to ensure two of 10 facility staff (Certified Nursing Assistant 3 [CNA 3] and Restorative Nursing Assistant 2 [RNA 2]) performed hand hygiene (washing of hands) prior to entering Resident 8 and Resident 9's room who were on respiratory isolation precaution (used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing) due to possible Coronavirus Disease 2019 [COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms]) exposure. 2. Failing to ensure that facility staff did not leave the personal belongings (clothes, hanging frames and wheelchair) of one of 53 COVID-19 positive residents (Resident 7) in a room with a resident (Resident 1) who was negative for COVID-19. 3. Failing to ensure facility staff provided guidance to one of four facility visitors (Visitor 1) observed wearing PPE incorrectly. Visitor 1 was observed wearing an N95 respirator (a mask that filters at least 95 percent [%-unit of measure] of particles [small parts of matter]) sideways. 4. Failing to ensure three of five staff (Laundry Aid 1 [LA 1], Dietary Aid 1 [DA1], [NAME] 1) performed the facility's self-screening process for COVID-19 symptoms before starting to work. These deficient practices had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with COVID-19. Findings: 1. During an observation on 12/3/2022 at 9:40 a.m., in Resident 8 and Resident 9's room that was on respiratory isolation precaution, observed CNA 3 and RNA 2, entering the room. CNA 3 and RNA 2 were observed putting on gloves without first performing hand hygiene. During an interview on 12/3/2022 at 10:46 a.m. with CNA 3, CNA 3 stated she forgot to perform hand hygiene before putting on the gloves when she entered a respiratory isolation precaution room. CNA 3 stated it is important to do hand hygiene to prevent the spread of COVID 19 to other residents and staff. During an interview on 12/3/2022 at 11:00 a.m., with RNA 2, RNA 2 stated they should always do hand hygiene before donning new gloves, and after removing the gloves to prevent the spread of infection. During an interview with the DON on 12/3/2022 at 1:01 p.m., DON stated hand hygiene should be done before and after wearing gloves to prevent the increase of COVID-19 cases in the facility. 2. A review of Resident 1' s admission Record (Face Sheet) indicated the facility admitted the resident on 11/23/2022 with diagnoses including left femur (hip) fracture (broken bone). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/30/2022, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. During an interview on 12/2/2022 at 3:58 p.m., with Resident 1, Resident 1 stated that nurses enter her room without wearing PPE. Resident 1 further stated that her roommate, Resident 7, had tested positive for COVID-19. Resident 1 stated that Resident 7's belongings remained inside her room despite the resident being transferred to the facility's red zone (area designated for COVID-19 positive residents) approximately two days ago. During an observation on 12/3/2022 at 8:45 a.m. of Resident 1's room, observed clothes, hanging frames and wheelchair belonging to Resident 7 next to Resident 1's bed. During a concurrent observation and interview on 12/3/2022 at 12:30 p.m., with Licensed Vocational Nurse 3 (LVN 3) Resident 1's room was observed. LVN 3 observed Resident 7's clothes, hanging frames and wheelchair inside Resident 1's room. LVN 3 stated the belongings of Resident 7 should be transferred with the resident when the resident was moved to red zone. LVN 3 stated that belongings of COVID-19 positive residents should not remain with residents who are negative of COVID-19 to help prevent the spread and expose other residents to COVID-19. During an interview on 12/4/2022 at 3:30 pm with the DON, the DON stated that the belongings of COVID-19 positive residents should be transferred with the resident when they are moved to the facility's red zone to help prevent the spread of COVID-19 in the facility. 3. During an observation on 12/3/2022 at 9:30 a.m., observed Visitor 1 coming out of Resident 12's room who is under respiratory isolation precaution, wearing an N95 respirator sideways. Visitor 1 was then observed walking in the hallway speaking with LVN 2 before going back inside Resident 12's room without wearing a protective gown, with their N95 mask still on sideways. During a concurrent observation and interview on 12/3/2022 at 9:31 a.m., with LVN 3, Visitor 1 was observed walking in the hallway with N95 sideways. LVN 3 informed Visitor 1 that her N95 was on sideways. LVN 2 came and assisted Visitor 1 in wearing her N95 correctly. LVN 3 stated Visitor 1 should be informed on how to wear an N95 to prevent the spread of COVID-19 to residents, staff, and visitors. During a follow up interview on 12/3/2022 at 12:30 p.m., with LVN 3, LVN 3 stated that facility staff should have informed Visitor 1 that she was wearing her N95 incorrectly. LVN 3 stated that it is important to wear the N95 correctly to prevent the spread of COVID-19 to residents, staff, and visitors. During an interview with the DON on 12/3/2022 at 1:01 p.m., the DON stated that the receptionist should educate visitors on wearing the required PPE correctly for resident and staff protection from spreading COVID-19. 4. During an interview on 12/4/2022 at 3:02 p.m., DA 1, stated that he did not screen himself or fill out the COVID 19 screening form prior to entering the facility on 12/4/2022. During a concurrent interview and record review on 12/4/2022 at 3:10 p.m. with [NAME] 1 and Screener 1, the facility's COVID-19 screening form for 12/4/2022 was reviewed. Screener 1 stated that she was not able to find documented evidence that [NAME] 1 completed a COVID-19 screening form for 12/4/2022. Screener 1 stated [NAME] 1 should have filled out a screening form for COVID-19. During an interview on 12/5/2022, at 12:05 p.m. with LA 1, LA 1 stated that she was unable to find the COVID-19 screening form when she arrived at the facility. LA 1 stated that because she was unable to find a COVID-19 screening form, she was unable to document the required COVID-19 screening form. LA 1 stated that on occasion, when she was unable to locate a screening tool for COVID-19, she would then not fill out the form. During an interview on 12/5/2022, at 1:05 p.m. with Infection Preventionist 2 (IP 2), IP 2 stated that all staff should be screened for COVID-19 by the Receptionist before starting their shift, or if the Receptionist is out, staff should then perform self-screening when they arrive the facility to make sure that they are ready to work without COVID-19 symptoms. Staff is also expected to fill out the screening tools. IP 2 stated that if there were no screening tools done, it meant staff did not do their screening process before starting their shift. During an interview and concurrent record review on 12/5/2022 at 2:23 p.m., the facility's screening logs from 11/25/2022 to 11/29/2022 and from 12/2/2022 to 12/4/2022 were reviewed with the Business Office Manager (BOM). BOM stated that upon review of the facility's COVID-19 screening tools log from 11/25/2022 to 11/29/2022 and from 12/2/2022 to 12/4/2022, there was a total of eight days where LA 1 did not document a COVID-19 screening tool. During an interview on 12/5/2022, at 3:40 p.m. with the DON, DON stated all facility staff should be screened by the Receptionist when they arrive to the facility. DON stated that if the Receptionist is unavailable, staff should perform their own self-screening process and fill out the screening tools before their shift starts. DON stated that it is important to screen for COVID-19 to ensure they are free of COVID-19 symptoms and can work in the facility. A review of facility's policy and procedure titled, Infection Prevention and Control Program dated 4/19/2022, indicated that important facets (aspect) of infection prevention include: iii. educating staff and ensuring that they adhere to proper technique and procedures; vi. implementing appropriate isolation precautions when necessary and vii. following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure necessary care was provided for one of three sampled residents, (Resident 1), who was receiving Hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill). The facility did not collaborate with the Hospice staff in the care planning process. This deficient practice resulted on Resident 1 ' s family not to be prepared for Resident 1 ' s death Findings: A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on [DATE] with diagnoses included dysphagia (swallowing difficulty), diabetes (uncontrolled elevated blood sugar), and history of fall. A review of Resident 1 ' s History and Physical exam, dated [DATE], indicated the resident was able to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care-screening tool) dated [DATE], indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required extensive assistance with moving in bed, transferring to bed to chair, dressing, toilet use and personal hygiene. Resident 1 was frequently incontinent (unable to control) bowel and bladder functions. A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to admit the resident to Hospice services. A review of Resident 1 ' s Care Plan developed for the resident end stage of life, dated [DATE], included in the intervention to coordinate care with hospice and other end of life services. A review of Resident 1 ' s Discharge Summary form indicated Resident 1 expired on [DATE]. On [DATE] at 4:45 p.m., during an interview, Family Member 1 (FM 1) stated she was not informed that Resident 1 ' s health had declined (health worsen in condition) before she passed away. FM 1 stated she was not provided with emotional support or other services to prepare for her loved one passing. On [DATE] at 11:12 a.m., during an interview, the Assistant Director of Nursing (ADON) stated there were no Interdisciplinary Team (IDT - a health care team to ensure that various aspects of residents' healthcare needs are integrated, aligned, addressed, and met in a time-efficient manner) meeting conducted after Resident 1 was admitted to hospice on [DATE]. The ADON stated there should be an IDT meeting to discuss Resident 1 ' s care plan with the Hospice staff, resident, and family. The ADON stated resident died on [DATE]. The ADON further stated the facility does not have a policy and procedure for post mortem care (care given once death has occurred). On [DATE] at 4:34 p.m., during an interview, Social Service 1 (SS 1) stated IDT meetings were done quarterly and as needed. SS1 could not provide evidence the hospice and facility staff met with the resident and FM 1 in preparation of the grieving process due Resident 1's imminent death. A review of facility ' s policy and procedure titled, Palliative Care dated 6/2018, indicated, The interdisciplinary team provides services to the resident and family that are consistent with the palliative plan of care. The interdisciplinary team utilizes evidence- based care to manage pain and physical symptoms in residents. The interdisciplinary team assesses and manages psychological and psychiatric aspects of palliative care to maximize the quality of life and coping skills of the resident and family. Communication with the resident and family is respectful of religious and spiritual beliefs, practices, and rituals. A review of facility ' s policy and procedure, titled, Hospice Services, dated 6/2018, indicated, the facility is responsibility to furnish 24- hour room and board care, meet the residents personal care and nursing needs in coordination with the hospice representative. Facility personnel will provide necessary services in accordance with the hospice plan of care. The facility designates an interdisciplinary team member to arrange for the provision of hospice acre including working with hospice representative to coordinate care to the resident provided by the facility staff and hospice staff. A review of facility ' s contract with hospice titled, Business Associate Agreement, signed on [DATE], indicated, Hospice and facility shall jointly coordinate and participate in periodic review and modification of each Patients Plan of Care at intervals specified in the Plan of Care, taking into account any changes in the Patients conditions.

Based on interview and record review, the facility failed to ensure nonpharmacological interventions (any sort of intervention not directly involving a medication) were included in a resident's care plan (contains all of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders, and a plan for evaluation) for use of psychotropic medication (any drug that affects behavior, mood, thoughts, or perception), for one out of five residents (Resident 257) investigated for unnecessary medications. This deficient practice had the potential to place the resident at risk for unnecessary side effects from psychotropic medications. Findings: A review of the admission record indicated Resident 257 was admitted to the facility, on 8/01/2021 with diagnoses including unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbance. During a concurrent interview and record review, on 8/05/2021 at 10:59 a.m., the Minimum Data Set Nurse 2 (MDSN 2) stated the physician ordered Seroquel (antipsychotic medication) 25 milligrams (mg) by mouth at bedtime for psychosis delusions as evidenced by verbalizing theft accusations of personal items. A review of the care plan for use of psychotropic medication for psychosis (conditions that affect the mind, where there has been some loss of contact with reality) as evidenced by delusions and verbalizing theft, initiated on 8/02/2021, indicated a goal that the resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. There was no documented evidence of nonpharmacological interventions included in Resident 257's care plan. MDSN 2 stated there were no nonpharmacological interventions (any sort of intervention not directly involving a medication) included in the resident's care plan for use of psychotropic medication. MDSN 2 stated they should have included nonpharmacological interventions in the care plan. During an interview, on 8/06/2021 at 11:45 a.m., the Director of Nursing (DON) stated care plans should be comprehensive and person-centered. The DON stated the resident's care plan for use of psychotropic medication should have included nonpharmacological interventions. A review of the facility's policy titled, Comprehensive Care Plans, dated 7/01/2020, indicated it is the policy of the facility that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and update the care plan for two of two sampled residents (Resident 8 and Resident 62) investigated under the care area of Care Plan Timing and Revision. This deficient practice had the potential to affect the provision of necessary care and services for the residents. Findings: a. A review of the admission record indicated Resident 8 was admitted to the facility, on 2/22/2015 and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), end stage renal disease (ESRD [longstanding disease of the kidneys leading to renal failure]), and dependence on renal dialysis ( dialysis keeps your body in balance by removing waste, salt and extra water). A review of the Minimum Data Set (MDS- an assessment and screening tool), dated 2/01/2021, indicated Resident 8's cognitive skills (cognition refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS indicated Resident 8 was totally dependent on staff for transfers, toilet use, personal hygiene, and bathing. During a review of the readmission Evaluation- Progress Note, dated 7/27/2021, indicated Resident 8 was readmitted with right upper chest perma cath (a tube placed through a vein into or near your right heart and used for dialysis). During a concurrent interview and record review, on 8/06/2021, at 8:30 a.m., the Assistant Director of Nursing (ADON) stated that Resident 8 was on hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) every Tuesday, Thursday, and Saturday at 12 p.m. A review of Resident 8`s Care Plan with revision date of 7/28/2021 for high risk for complications and requiring on-going dialysis due to ESRD, indicated for staff to check and change dressing daily on the AV shunt ( An AV fistula is a surgically placed shunt; surgically created vein used to remove and return blood during hemodialysis) to left upper arm. According to the ADON, since the hemodialysis access site was through a perma cath and not the AV Fistula, the care plan should have been updated and revised to reflect the current status of the resident. b. A review of the admission record indicated Resident 62 was readmitted to the facility, on 1/04/2020, with diagnosis including essential hypertensive (high blood pressure) heart disease and a chronic obstructive pulmonary disease (COPD - lung disease). During an observation, on 8/04/2021 at 8:05 a.m., Resident 62 was observed sleeping and received oxygen at four liters per minute (4 L/m) via nasal cannula (device used to administer oxygen through the nose). A review of the physician's order, dated 4/28/2021, indicated Resident 62 was to receive oxygen at four liters per minute via nasal cannula continuously and may titrate oxygen to five liters per minute to keep oxygen saturation above 89 % to patient's comfort. A review of the care plan, dated 4/15/2020, indicated Resident 62 had oxygen therapy related to COPD. The care plan's interventions were for staff to administer oxygen via nasal cannula at two liters per minute (2 L/m) PRN (as needed) as ordered. During a concurrent record review and interview, on 8/04/2021, at 2:55p.m., the Licensed Vocational Nurse 6 (LVN 6) stated that Resident 62's care plan should have been updated to reflect her receiving oxygen at four liters per minute continuously, not PRN (as needed). A review of the facility`s policy titled Comprehensive Care Plans, indicated that it is the policy of the facility that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident. Further, the policy and procedure indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the resident`s condition changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality by failing to document orthostatic (upright posture) blood pressure per physician orders for Resident 19. This deficient practice placed the resident at risk for not receiving necessary interventions to help maintain the resident's blood pressure and prevent cardiac side effects from the use of Seroquel (antipsychotic medication used to manage abnormal condition of the mind described as involving a loss of contact with reality). Findings: A review of the admission Record indicated Resident 19 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including cerebral infarction (stroke), hemiplegia and hemiparesis (mild loss of strength or paralysis of one side of the body), type 2 diabetes mellitus (abnormal blood sugar regulation), hyperlipidemia (high cholesterol), unspecified psychosis (condition of distorted reality), and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 05/21/2021, indicated Resident 19's cognition was intact (able to understand and be understood). The MDS indicated Resident 19 required extensive assistance with one person physical assist with eating, personal hygiene, dressing toilet use, bed mobility and transfer; and required total dependence of locomotion on and off unit (how resident moves between locations in his room and adjacent corridor on same floor). A review of care plan, initiated 5/19/2021, indicated Resident 19 had hypotension (low blood pressure) related to diabetes and thyroid disease. The care plan indicated goals for resident to be free of signs, symptoms, and complications of hypotension, maintain blood pressure within acceptable range as determined by MD. The care plan indicated approaches to goals including staff to educate to change positions slowly, give medications as ordered, monitor side effects and effectiveness, monitor vital signs and notify MD of significant abnormalities. A review of Resident 19's physician orders, dated 06/01/2021, indicated to monitor blood pressure every week on Sunday lying, sitting, standing, if able, due to use of quetiapine (antipsychotic medication). Call MD (medical doctor) if there is a drop of 20 mm Hg (millimeters of mercury) in SBP (systolic blood pressure - measures the force of heart exerted on walls of arteries) or 10 mmHg drop in DBP (diastolic blood pressure - measures force of heart exerted on arteries between beats). Every day shift every Sunday for use of quetiapine, lying, sitting, standing BP if able. During a review of Resident 19's Medication Administration Record (MAR) monitoring, on 8/6/2021 at 12:18 pm, indicated the order to monitor BP (blood pressure) every week on Sunday lying, sitting, standing if able, for Sundays, dated 6/2021 until 8/2021, the same blood pressure result for each position. During concurrent interview and record review, on 8/6/2021 at 12:20 p.m. the Licensed Vocational Nurse (LVN 2) stated taking orthostatic blood pressure (checking blood pressure reading from lying to standing positions) depended on the resident. LVN 6 stated Resident 19 preferred taking her blood pressure lying down. During concurrent interview and record review, on 8/6/2021 at 12:30 p.m. LVN 3 stated that most of the time blood pressures were done with the resident lying down, and it was usually the Certified Nurse Assistants (CNA) who checked the blood pressure. LVN 3 stated the patient should be sitting and lying for orthostatic blood pressure, but they could refuse standing. If they refuse, then the nurse would document the refusals on the MAR. During concurrent interview and record review on 8/6/2021 at 12:41 pm with CNA 1, CNA1 stated that checking blood pressure laying then sitting, will be different; if a resident cannot stand, then they will just sit in bed. During concurrent interview and record review, on 8/6/2021 at 12:45 p.m., LVN 4 stated that LVNs took orthostatic blood pressure with the resident lying down first, then sitting, then standing if able. If a resident was not able to stand, then the nurse would document NA or non-applicable. LVN 4 stated the blood pressures for each position depended on the resident but usually were not the same results as indicated on the MAR. During concurrent interview and record review, on 8/6/2021 at 12:50 p.m., LVN 5 stated Resident 19 was only able to lay down for blood pressure checks, unable to sit or stand. LVN 5 stated he would chart not able to if he cannot sit or stand depending on a resident. During concurrent interview and record review, on 8/6/2021 at 1:01 p.m., the Director of Nursing (DON) stated the nurses should chart if refused, and in some cases the blood pressures could be the same but not all the time. DON stated nurses have to identify how to get blood pressure and which position. The DON stated the nurses should write if the resident was not able and if a resident could only do certain positions. DON stated the nurses should tell doctor if the resident cannot stand.

Based on observation, interview, and record review, the facility failed to administer up to four liters of oxygen therapy as ordered by the physician, for one of three sampled residents (Resident 62). This deficient practice had the potential to cause oxygen toxicity (lung damage that happens from breathing in too much extra supplemental oxygen). Findings: A review of the admission record indicated Resident 62 was readmitted to the facility, on 1/04/2020, with diagnosis including essential hypertensive (high blood pressure), heart disease, and chronic obstructive pulmonary disease (COPD-lung disease). A review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 6/23/2021, indicated Resident 62 usually made self-understood and understand others sometimes. Resident 62 required extensive assistance in bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. During an initial tour, on 8/03/2021, at 9:40 a.m., Resident 62 was observed lying in bed with oxygen at six liters per minute via nasal cannula (device used to deliver oxygen through the nose. During a concurrent observation and interview, on 8/03/2021, at 9:44 a.m., the Licensed Vocational Nurse 6 (LVN 6) stated residents with COPD should get oxygen not more than three liters per minute. LVN 6 could not answer when asked why Resident 62 was getting oxygen at six liters per minute. LVN 6 was observed to lower the oxygen level to four liters per minute. A review of the physician's order, dated 4/28/2021, indicated for Resident 62 to receive oxygen at four liters per minute via nasal cannula continuously and may titrate oxygen to five liters per minute to keep oxygen saturation above 89 % for patient's comfort. A review of Resident 62's care plan, dated 4/15/2020, titled Resident has oxygen therapy related to COPD, indicated staff's interventions to administer oxygen via nasal cannula at two liters per minute (2 L/m) PRN (as need) as ordered. A review of the facility's policy, revised 7/2016, titled, Oxygen Administration, indicated it is the policy of this facility that oxygen therapy be administered upon a physician order or in the event of an emergency by a licensed nurse or respiratory therapist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR - accountability record of medications that are considered to have a strong potential for abuse) coincided with the number of doses in the bubble pack (a blister pack, medication package with compartments of single doses) for two of two residents (Resident 17 and Resident 11). 2. Ensure the licensed nurse documented the administration of controlled medications on the CDR and the Medication Administration Record (MAR) for two of two residents (Resident 17 and Resident 11). These deficient practices resulted in inaccurate reconciliation of the controlled medications (hydrocodone/acetaminophen [Norco] and hydromorphone medications used to treat moderate to severe pain) and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes) of controlled medications for Resident 17 and Resident 11. Findings: a. A review of Resident 17's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs), difficulty in walking, and peripheral vascular disease (PVD-a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Resident 17's Minimum Data Set (MDS- an assessment and care screening tool) dated 05/14/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated the resident received opioid (class of drugs used to reduce pain medications) during the look-back period (time frame for observation). A review of Resident 17's Order Summary Report indicated a physician order for Norco (hydrocodone/acetaminophen - an opioid medication used to treat moderate to severe pain) tablet 10-325 milligrams (mg - unit of measurement) by mouth every six hours as needed for moderate to severe pain. During an observation (inspection) of Medication Cart 2 in Station 3 on 08/05/2021 at 3:45 p.m., Licensed Vocational Nurse 6 (LVN 6) conducted a medication count of Resident 17's Norco medication bubble pack (a blister pack, medication package with compartments of single doses) with the surveyor. The medication count on the bubble pack did not match the count on the Controlled Drug Record (CDR - accountability record of medications that are considered to have a strong potential for abuse). The bubble pack had four Norco 10-325 mg tablets. The CDR indicated there were five Norco 10-325 mg tablets in the bubble pack. During a concurrent interview and record review on 08/05/2021 at 4:06 p.m., with LVN 6, Resident 17's Medication Administration Record (MAR) was reviewed. The MAR indicated Resident 17 last received Norco on 08/05/2021 at 3:00 a.m. LVN 6 stated she administered Norco to Resident 17 on 08/05/2021 at 12:00 p.m. but she did not document the administration on the CDR and the MAR. LVN 6 stated she should have documented removal of the narcotic medication on the CDR and she should have signed the MAR after she gave the medication to the resident. During an interview with the Director of Nursing (DON) on 08/06/2021 at 9:03 a.m., the DON stated the licensed nurse should sign on the accountability record after a narcotic medication is removed from the cart. The licensed nurse will then sign on the MAR after the medication was administered to the resident. A review of the facility policy and procedures titled, Controlled Medications, dated 08/2014, indicated when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1. Date and time of administration. 2. Amount administered. 3. Signature of nurse administering the dose on the accountability record at the time the medication is removed from the supply. 4. Initials of the nurse administering the dose on the MAR after the medication is administered. b. A review of Resident 11's admission Record (face sheet) indicated the resident was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including spinal stenosis (narrowing of the spinal canal), hypertension and gout (a form arthritis characterized by severe pain, redness, and tenderness in joints). A review of Resident 11's Minimum Data Set (MDS- as assessment and care screening tool) dated 05/05/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated the resident opioid medications (class of drugs used to reduce pain medications) during the look-back period (time frame for observation). A review of Resident 11's Order Summary Report indicated a physician order for hydromorphone hydrochloride (an opioid medication used to treat moderate to severe pain) tablet 2 milligrams (mg - unit of measurement) by mouth every six hours as needed for breakthrough pain (a sudden increase in pain that may occur in patients who already have chronic pain). During an inspection of the medication cart in Station 3 on 08/05/2021 at 3:45 p.m., Licensed Vocational Nurse 6 (LVN 6) conducted a medication count of Resident 11's hydromorphone medication bubble pack (a blister pack, medication package with compartments of single doses) with the surveyor. The medication count on the bubble pack did not match the count on the Controlled Drug Record (CDR - accountability record of medications that are considered to have a strong potential for abuse). The bubble pack had 25 hydromorphone 2 mg tablets. The CDR indicated there were 26 hydromorphone 2 mg tablets in the bubble pack. During a concurrent interview and record review, on 08/05/2021 at 4:06 p.m., with LVN 6, Resident 11's Medication Administration Record (MAR) was reviewed. The MAR indicated Resident 11 last received hydromorphone on 08/03/2021 at 7:30 a.m. LVN 6 stated she administered hydromorphone to Resident 11 on 08/05/2021 at 2:50 p.m. but she did not document the administration on the CDR and the MAR. LVN 6 stated she should have documented removal of the narcotic medication on the CDR and she should have signed the MAR after she gave the medication to the resident. During an interview with the Director of Nursing (DON) on 08/06/2021 at 9:03 a.m., the DON stated the licensed nurse should sign on the accountability record after a narcotic medication is removed from the cart. The licensed nurse will then sign on the MAR after the medication was administered to the resident. A review of the facility policy and procedures titled, Controlled Medications, dated 08/2014, indicated when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1. Date and time of administration. 2. Amount administered. 3. Signature of nurse administering the dose on the accountability record at the time the medication is removed from the supply. 4. Initials of the nurse administering the dose on the MAR after the medication is administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to clarify a physician order for a controlled medication, Norco (an opioid [controlled medication that can treat pain, with high risk for addiction and dependence]) to ensure there was no duplication of orders for one (Resident 87) of two sampled residents reviewed under the care area of pain. This deficient practice placed Resident 87 at risk for unnecessary medications that can potentially adversely affect the resident's health condition. Findings: A review of Resident 87's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including pathological fracture (broken bone that was cause by a disease rather than an injury) of the right femur (thigh bone) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 07/11/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated the resident received opioid (controlled medication that can treat pain, with high risk for addiction and dependence) medications during the 7-day look-back period (time frame for observation). A review of Resident 87's Order Summary Report as of 08/05/2021, indicated the following physician's orders for Norco (hydrocodone-acetaminophen): 1. Norco tablet 10-325 milligrams (mg - unit of measurement). Give 1 tablet by mouth every four hours as needed (PRN) for moderate to severe pain. The order was on 08/04/2021. 2. Norco tablet 10-325 mg. Give 1 tablet by mouth every four hours as needed (PRN) for moderate to severe pain. The order was on 07/05/2021. During a concurrent interview and record on 08/05/2021 at 9:22 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 87's physician orders and Medication Administration Record (MAR) were reviewed. LVN 1 confirmed that they were two active orders of Norco tablet 10-325 mg. Give 1 tablet by mouth every four hours as needed for moderate to severe pain. LVN 1 stated Resident 87 went to his oncology appointment on 08/04/2021 and the oncologist prescribed the resident with the same PRN Norco medication. LVN 1 stated the nurse who received the new order should have clarified with the physician that the resident has already an existing PRN order for Norco to ensure there are no duplicate orders. A review of the facility policy and procedures titled, Medication Administration-General Guidelines, dated 10/2017, indicated if a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to administration of the medication of if necessary, contacts the prescriber for clarification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 19's admission Record (face sheet) indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including cerebral infarction (stroke), hemiplegia and hemiparesis (mild loss of strength or paralysis of one side of the body), unspecified psychosis (condition that affects the mind described as having some loss of contact with reality), and dysphagia (difficulty or discomfort in swallowing). A review of Resident 19's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 05/21/2021, indicated the resident's cognition was intact (able to understand and be understood). The MDS indicated the resident required extensive assistance of one-person physical assist with eating, personal hygiene, dressing toilet use, bed mobility and transfer; and required total dependence of locomotion on and off unit (how resident moves between locations in his room and adjacent corridor on same floor). A review of Resident 19's physician orders indicated an order initiated 05/30/2021 for quetiapine fumarate (antipsychotic medication used to manage abnormal condition of the mind described as involving a loss of contact with reality) tablet 25 milligrams (mg - unit of measurement), give 0.5 tablet by mouth every 24 hours as needed (PRN) for psychosis manifested by screaming/yelling in the morning. A review of Resident 19's Medication Administration Record (MAR) for the month of June 2021 indicated an administration of quetiapine on 06/18/2021 at 4:04 p.m., past the expected limit of 14 days for PRN psychotropic medications. The month of July 2021 and the first week of August 2021 did not show any administration of quetiapine. A review of Resident's 19 Care Plan, initiated 05/26/2021, indicated the resident uses psychotropic medications quetiapine due to behavior management: yelling, screaming. The care plan had a goal including to administer psychotropic medications as ordered by physician, reduce the use of antipsychotic medication through the review date, remain free of psychotropic drug related complications, and review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. A review of the pharmacy Medication Regimen Review (MRR) dated 07/28/2021, indicated a notice from the pharmacist that quetiapine PRN was only ordered 14 days at a time. During a concurrent interview and record review on 08/05/2021 at 2:21 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated antipsychotic PRN orders should only last for 14 days. Seroquel (quetiapine) ordered since 05/30/2021 and continued, should not be active. During a concurrent interview and record review with the Director of Nursing (DON), on 08/05/2021 at 4:49 p.m., the DON stated antipsychotics PRN should only last 14 days, the doctors should only order for 14 days, then the psychiatrist will see the resident and extend order if needed for another 14 days. The DON was not able to find MRR for the month of June 2021 if there was prior notice from pharmacy. A review of facility policy and procedures titled Psychotropic Medication Use, dated 10/2017, indicated antipsychotic PRN orders are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. If attending physician or prescribing practitioner wishes to write a new order for the prn antipsychotic, the attending physician or prescribing practitioner must first evaluate the resident to determine if new order for the PRN antipsychotic is appropriate. Based on interview and record review, the facility failed to ensure the residents' as needed (PRN) psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) orders were limited to 14 days for three (Residents 261, 19, and 87) out of five sampled residents investigated for unnecessary medications by: 1. Failing to ensure Resident 261's as needed (PRN) physician orders for psychotropic medications, Ambien (medication to treat insomnia [a sleep disorder in which a person has trouble falling and/or staying asleep]) and lorazepam (medication to treat anxiety) were limited to 14 days. 2. Failing to ensure Resident 87's as needed (PRN) physician orders for psychotropic medications, lorazepam and zolpidem tartrate (medication to treat insomnia [a sleep disorder in which a person has trouble falling and/or staying asleep]) are limited to 14 days unless the physician has directly assessed the resident's current condition and progress and has written a new PRN order for the resident. 3. Failing to ensure to indicate a duration or to limit a PRN order for the psychotropic medication quetiapine fumarate (antipsychotic medication used to manage abnormal condition of the mind described as involving a loss of contact with reality) to 14 days for Resident 19. This deficient practice had the potential to place the residents at risk of adverse side effects (any unexpected or dangerous reaction to a drug) associated with the use of psychotropic medications. Findings: a. A review of Resident 261's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (the feeling of excessive, unrealistic worry and tension with little or no reason) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 261's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 07/27/2021, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 08/05/2021 at 3:49 p.m., during a concurrent interview and record review, Minimum Data Set Nurse 2 (MDSN 2) stated the resident had a physician's order for Ambien (hypnotic medication - a class of drugs used to induce and/or maintain sleep) 10 milligrams (mg - unit of measurement) at bedtime by mouth as needed (PRN) for inability to sleep, ordered on 07/21/2021. MDSN 2 stated the resident also had a physician's order for lorazepam (antianxiety medication) 0.5 mg by mouth every 12 hours as needed for anxiety manifested by verbalization of nervousness, ordered on 07/21/2021. MDSN 2 stated neither medication had a stop date (the date that a resident's medication order is to be stopped). On 08/06/2021 at 11:45 a.m., during an interview, the Director of Nursing (DON) stated that psychotropic medications (any drug that affects behavior, mood, thoughts, or perception) that are given on an as needed basis should be reassessed and reevaluated after 14 days. A review of the facility's policy and procedures titled, Psychotropic Medication Use, effective 10/2017, indicated PRN orders for psychotropic drugs are limited to 14 days. For psychotropic PRN medication, excluding antipsychotics, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the residents' medical record and indicated the duration for the PRN order. b. A review of Resident 87's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including pathological fracture (broken bone that was cause by a disease rather than an injury) of the right femur (thigh bone) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 07/11/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated the resident antianxiety and hypnotic (sleep-inducing medication) medications during the 7-day look-back period (time frame for observation). A review of Resident 87's Order Summary Report as of 08/05/2021, indicated the following physician's orders: 1. Lorazepam tablet 1 milligram (mg - unit of measurement), give one tablet by mouth every four hours as needed (PRN) for anxiety manifested by restlessness leading to shortness of breath (SOB), with order date of 07/05/2021. 2. Zolpidem tartrate tablet 5 mg, give 1 tablet by mouth as needed (PRN) for sleep at bedtime with order date of 07/05/2021. A review of the Medication Administration Record (MAR) from 07/05/2021-07/31/2021 and from 08/01/2021-08/05/2021, indicated Resident 87 did not receive PRN lorazepam. A review of the MAR from 0705/2021-07/31/2021, indicated Resident 87 received PRN zolpidem tartrate 5 mg tablet three times. A review of the MAR from 08/01/2021-08/05/201, indicated Resident 87 did not receive PRN zolpidem tartrate. During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1), on 08/04/2021 at 9:53 a.m., Resident 87's physician orders and MAR were reviewed. LVN 1 stated there was no specific duration for use of lorazepam PRN. LVN 1 stated the order have not exceeded 14 days. During a concurrent interview and record review with Minimum Data Set Nurse 1 (MDSN 1), on 08/05/2021 at 1:06 p.m., Resident 87's physician orders, physician progress notes, and MAR were reviewed with MDSN 1. MDSN 1 stated there was no documented evidence of a rationale (underlying reason) from the physician indicating the need for continuing the order for PRN lorazepam and PRN zolpidem tartrate beyond 14 days. A review of the facility policy and procedures titled, Psychotropic Medication Use, dated 10/20217, indicated residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic drugs are limited to 14 days; if the attending physician believes that is appropriate for PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the therapeutic diet prescribed by the physician in accordance with the residents' preferences by: 1. Failing to provide a heart healthy/kosher (fit or proper as it relates to Jewish dietary law) diet to Resident 17 and by serving parsley on a meal tray when it was indicated on the meal ticket that the resident disliked parsley. 2. Failing to follow the physician's order for Resident 103's diet of consistent carbohydrates/no added salt (NAS) diet, minced and moist texture, and regular fluids consistency. These deficient practices had the potential for inadequate calories in residents who did not receive the correct amount of food items of their choices and preferences. Findings: a. A review of Resident 17's admission Sheet (face sheet) indicated the resident was admitted on [DATE] with diagnosis that included pneumonia (an infection that inflames the air sacs in one or both lungs), unspecified organism. A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 05/14/2021, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated Resident 17 had the ability to make self-understood and had has the ability to understand others. A review of the Order Summary Report (physician's orders), dated 02/08/2021, indicated Resident 17's diet order was heart healthy (low fat, low cholesterol, 2-3 grams [unit of measurement] sodium) diet, regular texture, regular fluids consistency, small portion at dinner, no bread on the side per resident request, vegetarian/kosher, egg & dairy ok, double protein. During a concurrent observation and interview on 08/03/2021, at 10 a.m., Resident 17 stated he was given a can of raw salted nuts and chicken soup. Resident 17 stated his diet was heart healthy, vegetarian, and kosher (fit or proper as it relates to Jewish dietary law). During an interview on 08/04/2021, at 9:05 a.m., with Registered Dietician 2 (RD 2), RD 2 stated that she got the can of nuts in the supermarket but did not check if it was is salted or not. RD 2 stated they made a mistake when they added parsley as a garnish to the tray served to Resident 17 when the meal ticket clearly stated the resident disliked parsley. RD 2 also acknowledged serving blue berry pie which was not on the meal ticket tray of Resident 17. A review of the facility's Therapeutic Diet policy and procedures, dated 11/2017, indicated the facility ensures residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his/her goals and preferences. b. A review of Resident 103's admission Sheet (face sheet) indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included displaced intertrochanteric fracture (broken bones) of right femur (thigh bone), subsequent encounter for closed fracture with routine healing. A review of Resident 103's History and Physical dated 08/03/2021 indicated the resident was diagnosed with sepsis (is a life-threatening condition that arises when body's response to infection causes injury to its own tissues and organs), urinary tract infection (UTI- infection in any part of your urinary system) and diabetic ketoacidosis (DKA - is a potentially life-threatening complication of high blood sugar levels). A review of Resident 103's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 07/09/2021, indicated the resident sometimes was able to make self-understood and sometimes had the ability to understand others. The MDS also indicated the resident had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. During a concurrent observation and interview on 08/03/2021, at 12:52 p.m., with Restorative Nursing Assistant 1 (RNA 1) while assisting Resident 103 with eating/feeding, RNA 1 stated that the diet of Resident 103 was pureed, consistent carbohydrate, no added salt, thin liquids, pureed meat. Resident 103 was served with glass of thickened cranberry juice on a glass with straw and box of milk carton, no thickener on the tray. During an interview on 08/03/2021 at 1:00 p.m., with Certified Nurse Assistant 3 (CNA 3) and Certified Nurse Assistant 4 (CNA 4), both stated that the milk on the carton box was is not thickened yet. A review of Resident 103's Order Summary Report (physician's orders), dated 04/13/2021, indicated a diet order of consistent carbohydrates/no added salt (NAS) diet, minced and moist texture, regular fluids consistency. The diet served to the resident was different from the physician's order. A review of the facility's Therapeutic Diet policy and procedures, dated 11/2017, indicated the facility ensures residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his/her goals and preferences.

Based on interview and record review, the facility staff failed to maintain accurate Medication Administration Record (MAR) for one out of three sampled residents (Resident 62). This deficient practice had a potential for creating confusion to staff and placed the resident at risk for not receiving appropriate care. Findings: A review of the admission record indicated Resident 62 was readmitted to the facility, on 1/04/2020, with diagnosis including essential hypertensive (high blood pressure) heart disease and cerebral infarction (stroke). During a concurrent record review and interview, on 8/04/2021, at 2:45 p.m., at a concurrent record review and interview, Licensed Vocational Nurse (LVN 1) stated that she made an error when she documented on Resident 62's MAR for Amlodipine (blood pressure medication). LVN 6 stated she was supposed to mark the medication as held because her blood pressure was below 110 mm Hg (millimeters of mercury). A review of the Resident 62's MAR, dated 7/13/2021, indicated Resident 62's blood pressure at 9 a.m., was 108/59 mm Hg. The record indicated LVN 1 administered the medication to lower blood pressure. LVN 1 stated that she made an error when she documented in the MAR.to charting on MAR. LVN 1 stated she was supposed to mark it as held it because her blood pressure was below 110 mm Hg. A review of Resident 62's Physician Orders, indicated to administer Amlodipine Besylate Tablet 5 milligram (mg) one tablet by mouth one time a day for high blood pressure, hold if systolic blood pressure (SBP: the pressure in your arteries when your heart beats) is lower than 110 mm Hg or heart rate is lower than 60 beats per minute. A review of the facility's undated policy titled Preparation and General Guidelines for Medication Administration, indicated if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, 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 Pro Re Nata (PRN: as need) documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner, for seven out of seven sampled residents (Residents 33, 82, 307. 55, 5, 261, and 263) investigated for accommodation of needs. This deficient practice had the potential to negatively impact the psychosocial well-being of the residents and result in delayed provision of services. Findings: a. A review of the admission record indicated Resident 33 was admitted to the facility, on 5/24/2021 and readmitted [DATE], with diagnoses including chronic congestive heart failure (CHF-heart weakness causing build-up of fluid), acute respiratory failure with hypoxia (condition of not enough oxygen), chronic obstructive pulmonary disease (COPD-lung disease), chronic kidney disease, osteoarthritis (condition causing breakdown of bones and cartilage), gastrointestinal hemorrhage (stomach bleedning). A review of the Minimum Data Set (MDS-a standardized assessment and screening tool), dated 8/01/2019, indicated Resident 33's cognition was intact (able to understand and be understood). The MDS indicated Resident 33 required extensive assistance with one to two people physical assistance with personal hygiene, dressing, bed mobility, toilet use and locomotion on and off unit (how resident moves between locations in his room and adjacent corridor on same floor), and supervision with eating. A review of the physician orders, dated 7/29/2021, indicated Resident 33 was to receive Lasix (medication used to eliminate excess fluid in the body) tablet 20 mg (milligrams-unit of measurement) give one tablet by mouth one time a day for CHF. During interview, on 8/3/2021 at 9:35 a.m., Resident 33 stated that she had to wait over an hour and wetted herself. Resident 33 stated that it was difficult to wait for call light. During interview, on 8/6/2021 at 9:39 a.m., the Administrator (ADM) stated he was made aware the day before by maintenance about the call lights and it was difficult to change the call light system. b. A review of the admission record indicated Resident 82 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses including CHF, acute kidney failure, chronic embolism and thrombosis (blood clots) of deep vein of lower legs, asthma, type 2 diabetes mellitus (abnormal sugar regulation), optic neuritis (inflammatory disease), urinary tract infection (bladder infection). A review of the MDS, dated [DATE], indicated Resident 82's cognition was intact (able to understand and be understood). The MDS indicated Resident 82 required extensive assistance with one to two people physical assistance with eating, personal hygiene, dressing, bed mobility, toilet use and total dependence for locomotion on and off unit (how resident moves between locations in his room and adjacent corridor on same floor). The MDS also indicated Resident 82 had frequent urinary incontinence and bowel incontinence. A review of the physician orders, dated 7/28/2021, indicated Resident 82 was capable of understanding rights, responsibilities, and informed consent. During interview, on 8/3/2021 at 2:39 p.m., Resident 82 stated that using call light was worse during the day, and she usually called her family member to call the facility for someone to help her. Resident 82 stated that if she used the call light in the bathroom, the light override the bedroom call light. Resident 82 stated that staff would be unaware of the call light because the staff did not turn the bathroom light off at times. During concurrent interview and observation, on 8/4/2021 at 11:08 a.m., Licensed Vocational Nurse (LVN 1) was observed pulling the shared bathroom call light. After the bathroom light was pulled, it did not light out in hallway. In addition, the bedside call light did not light up in the hallway but was observed in the wall inside. When the bathroom call light was observed turned off, the hallway light turned on. LVN 1 stated she was not sure why that happened and she would call maintenance to fix it. During concurrent interview and observation, on 8/4/2021, at 11:14 a.m., the Maintenance Supervisor (MS) stated the bathroom and room lights were interconnected in system. When MS pulled the bathroom light harder, the light did not light out in the hallway. MS stated he should change the switch to make sure it worked properly. During interview, on 8/6/2021 at 9:39 a.m., the ADM stated he was made aware the day before by maintenance and it was difficult to change the actual call light system. c. A review of the admission record indicated Resident 307 was admitted to the facility on [DATE] with diagnoses including fracture (break in the bone) of neck of left femur (hip), anemia (lack of oxygen in the blood), repeated falls, paraplegia (paralyzed from waist down), acute respiratory failure, COPD, hypertension (high blood pressure), osteoarthritis, peptic ulcer (break in the inner lining of the stomach). During interview, on 8/3/2021 at 10:10 a.m., Resident 307 stated mostly during mornings and change of shift, call light response took a long time. Resident 307 stated she had to get up by herself to see if someone could help her. Resident 307 stated she had to sometimes wait two hours in between. During interview, on 8/4/2021 at 8:13 a.m., Resident 307 stated she asked for coffee and something else for breakfast and the staff took a long time yesterday. During interview, on 8/6/2021 at 9:39 a.m., the ADM stated he was made aware the day before by maintenance and it was hard to change the actual call light system. The ADM stated he would talk to each resident, social services, and maintenance. d. A review of the admission record indicated Resident 55 was admitted to the facility, on 3/14/2021 with diagnoses that included history of falling, abnormalities of gait and mobility, and colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) status. A review of the MDS, dated [DATE], indicated Resident 55 was moderately impaired in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 55's care plan titled High risk for falls related to impaired mobility and history of falling, initiated on 3/14/2021, indicated for staff to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan also indicated the resident needed prompt response to all requests for assistance. During an interview, on 08/03/2021 at 9:57 a.m., Resident 55 stated staff took about 30 minutes to answer her call light. Resident 55 stated she usually called for assistance when her colostomy bag needed to be changed. Resident 55 stated it took a long time for staff to answer her call light both during the day and night shifts. During the Resident Council Meeting (an independent group of long-term care facility residents who typically meet at a minimum of once a month to discuss concerns and suggestions in the facility and to plan activities that are important to them), on 08/04/2021 at 11:15 a.m., six out of ten residents (Residents 306, 87, 409, 11, 410, and 90) agreed they had to wait a long time for their call light to be answered. A review of the Resident Council Minutes dated 5/06/2021, indicated there was a complaint that call lights were not being answered timely. e. A review of the admission record indicated Resident 5 was admitted to the facility, on 10/13/2014 and readmitted on [DATE], with diagnoses including post-polio syndrome (a disorder of the nerves and muscles) and history of urinary tract infection. A review of the MDS, dated [DATE], indicated Resident 5 was moderately impaired in cognition and required extensive assistance from staff for bed mobility, dressing, and personal hygiene. The MDS indicated Resident 5 was totally dependent on staff for toilet use. A review of Resident 5's care plan for risk for falls related to post-polio syndrome, dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), use of psychotropic medication (used to treat mental health disorders), and antihypertensive medication (used to treat high blood pressure), initiated on 02/11/2020, indicated for staff to be sure the resident's call light was within reach and to encourage the resident to use it for assistance if needed. The care plan also indicated the resident needed prompt response to all requests for assistance. During an interview, on 8/03/2021 at 9:38 a.m., Resident 5 stated it took a couple of hours for staff to answer his call light during all shifts. f. A review of the admission record indicated Resident 261 was admitted to the facility, on 7/20/2021 with diagnoses that included generalized muscle weakness, difficulty in walking, and urinary tract infection. A review of the MDS, dated [DATE], indicated Resident 261 was cognitively intact and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 261's care plan for potential for falls related to weakness, initiated on 7/20/2021, indicated for staff to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan also indicated the resident needed prompt response to all requests for assistance. During an interview, on 8/03/2021 at 9:01 a.m., Resident 261 stated it took staff 30 minutes to answer her call light at night. The resident stated she usually put her call light on because she needed assistance to be cleaned. g. A review of the admission record indicated Resident 263 was admitted to the facility, on 7/23/2021 with diagnoses including abnormalities of gait and mobility and spinal stenosis (a narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine). A review of the MDS, dated [DATE], indicated Resident 263 was cognitively intact. A review of Resident 263's care plan for at risk for falls related to bilateral knee pain, initiated on 7/24/2021, indicated for staff to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan also indicated the resident needed prompt response to all requests for assistance. During an interview, on 8/03/2021 at 8:51 a.m., Resident 263 stated it took an hour or more for staff to answer his call light. Resident 263 stated he usually put his call light on when he needed to use the bathroom. Resident 263 stated he had soiled himself while waiting for his call light to be answered. During an interview, on 8/06/2021 at 11:17 a.m., the Director of Staff Development (DSD) stated call lights should be answered as soon as possible. During an interview, on 08/06/2021 at 11:45 a.m., the Director of Nursing (DON) stated the facility's policy indicated that no one should pass a call light when it was on and call lights should be answered immediately. A review of the facility's policy titled, Call Lights, effective on 07/2016, indicated it is the policy of the facility to answer call lights in a timely manner. The facility has a No Pass call light philosophy, empowering all staff to answer resident call lights regardless of patient care assignments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 105's admission Record (face sheet) indicated the resident was admitted on [DATE] with diagnosis that included diabetes mellitus (DM - high blood sugar). A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 07/10/2021, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS also indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). A review of Resident 105's Order Summary Report dated 04/15/2021, indicated a physician's order to administer linagliptin (medication to control high blood sugar) tablet 5 milligrams (mg - unit of measurement), one tablet by mouth in the morning for diabetes mellitus (DM). During a concurrent interview and record review on 08/04/2021 at 10:02 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that she did not give the linagliptin tablet 5 mg by mouth in the morning for Resident 105 because they were are giving the medicine at 9:00 p.m. and per patient request. A review of the facility's Medication Administration- General Guidelines policy and procedures, dated 10/2017, indicated medications are administered in accordance with written orders of the attending physician. Based on interview and record review, the facility failed to ensure residents were free from potential significant medication errors for three out of three sampled residents (Residents 359, 105, and 62) reviewed by: 1. Failing to ensure that blood pressure medications were administered within the parameters (limit or boundary) ordered by the physician for Resident 359. This deficient practice placed the resident at risk of inadequate blood pressure management, which can cause hypotension (low blood pressure). 2. Failing to follow the physician's order for antidiabetic (used to manage high blood sugar) medication scheduled to be given in the morning instead of 9:00 p.m. for Resident 105. This deficient practice had the potential to cause complications of hypoglycemia (low blood sugar level) or hyperglycemia (high blood sugar level). 3. Failing to ensure Resident 62 did not receive medications for the high blood pressure when the blood pressure was lower than a parameter according to the physician's order. This deficient practice had a potential for lowering resident's blood pressure, worse chest pain, or a heart attack. Findings: a. A review of the admission Record (face sheet) indicated Resident 359 was admitted to the facility on [DATE], with diagnoses that included diastolic heart failure (a condition where the lower left chamber of the heart [left ventricle] is not able to fill properly with blood reducing the amount of blood pumped out to the body), hypertension (HTN - high blood pressure), and diabetes mellitus (DM - abnormally high levels of the sugar in the blood). A review of the History and Physical (H & P) dated 07/20/2021 indicated Resident 359 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool) dated 07/26/2021 indicated Resident 359 had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident needed extensive assistance with bed mobility, dressing, toileting, and personal hygiene. A review of Resident 359's Order Summary Report dated 07/19/2021, indicated a physician's order to administer atenolol tablet 25 milligrams (mg - unit of measurement) give 0.5 tablet by mouth two times a day for HTN. Hold (do not administer) if systolic blood pressure (SBP - measures the pressure the blood is exerting against the artery walls when the heart beats) is less than 130 (<130) or heart rate is less than 60 (<60). A review of Resident 359's Medication Administration Record (MAR) from 07/20/2021-07/31/2021, indicated the following blood pressures recorded on the following dates and times: 1. 7/20/2021 = 128/62 millimeters of mercury (mmHg - unit of measurement) at 9:00 a.m. 2. 7/23/2021 = 127/73 mmHg at 9:00 a.m. 3. 7/25/2021 = 118/62 mmHg at 9:00 a.m. 4. 7/26/2021 = 124/73 mmHg at 9:00 p.m. 5. 7/30/2021 = 124/69 mmHg at 9:00 a.m. 6. 7/30/2021 = 120/62 mmHg at 9:00 p.m. 7. 7/31/2021 = 108/63 mmHg at 9:00 a.m. A review of Resident 359's MAR with Minimum Data Set Nurse 1 (MDSN 1) indicated the resident received atenolol tablet 25 mg tablet 0.5 tablet on the following dates and times: 1. 7/20/2021 at 9:00 a.m. 2. 7/23/2021 at 9:00 a.m. 3. 7/25/2021 at 9:00 a.m. 4. 7/26/2021 at 9:00 p.m. 5. 7/30/2021 at 9:00 a.m. 6. 7/30/2021 at 9:00 p.m. 7. 7/31/2021 at 9:00 a.m. During an interview, on 8/06/21 at 9:20 a.m. MDSN 1 stated the charge nurse (licensed nurse) should have followed the physician order's holding (do not administer) parameter (limit) and should not have administered the atenolol for Resident 359 on 7/20/2021, 7/23/2021, 7/25/2021, 7/30/2021, and 7/31/2021 because Resident 359's systolic blood pressures (SBP) were less than 130. MDSN 1 also stated, it was important to hold atenolol because it can cause hypotension (low blood pressure). During an interview on 8/06/21 9:38 a.m., the Director of Nursing (DON), stated the charge nurse should have followed the physician order's holding parameter and should not have administered the Atenolol for Resident 359 on 7/20/2021, 7/23/2021, 7/25/2021, 7/30/2021, and 7/31/2021 because Resident 359's systolic blood pressures were less than 130. The DON also stated, it was important to hold atenolol because it can cause hypotension. A review of the facility's policy and procedures titled, Medication Administration, dated 10/2017, indicated medications are administered in accordance with written orders of the attending physician. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different or if there is any reason to question the dosage and direction, the physician's orders are checked for the correct dosage schedule. c. During a concurrent interview and record review, on 8/04/2021, at 2:45 p.m., Resident 62's blood pressure at 9 a.m., dated 7/13/2021, was documented as 108/59 millimeters of mercury (mm Hg). The record indicated LVN 6 administered Amlodipine (blood pressure medication) to lower blood pressure. LVN 6 stated that she made an error when it came to charting it on the Medication Administration Record (MAR). LVN 6 stated she was supposed to mark the medication as held because her blood pressure was below 110 mm Hg. A review of Resident 62's Physician Orders, indicated to administer Amlodipine Besylate Tablet 5 milligram (mg) one tablet by mouth one time a day for high blood pressure, hold if systolic blood pressure (SBP: the pressure in your arteries when your heart beats) is lower than 110 mm Hg or heartrate is lower than 60 beats per minute. A review of the care plan, dated 1/04/2020, titled Resident 62 has hypertension, indicated for staff to give hypertensive medications as ordered. A review of the facility's policy titled Preparation and General Guidelines for Medication Administration, indicated if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, 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 Pro Re Nata (PRN: as need) documentation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. On [DATE] at 10:53 p.m., during an observation (inspection) of Medication Cart 1, assigned to Licensed Vocational Nurse 5 (LVN 5) who indicated that one Novolog Aspart Flexpen (used to control diabetes mellitus [high blood sugar]) with open date of [DATE] and with no resident name label was still in the medication cart despite it being expired. In the same medication cart was an unopened Lantus Solostar Flexpen (helps to control blood sugar levels in diabetes mellitus) that the label indicated a fill date of [DATE]. During the concurrent interview and record review, Licensed Vocational Nurse 10 (LVN 10) stated that the expired Novolog Aspart Flexpen should have been discarded per facility`s policy and the Lantus Solostar Flexpen should have been stored in the refrigerator if unopened according to manufacturer`s instructions. A review of the facility`s undated policy and procedures titled Stability of Common Insulins in Pens and Vials, indicated that an unopened Lantus Solostar device should be stored in a refrigerator, 36 degrees - 46 degrees Fahrenheit (scale of temperature measurement) and discarded 28 days after being opened. The policy and procedures also indicated that an opened Novolog Aspart insulin is stable at room or refrigerator temperature for 28 days. Based on observation, interview, and record review the facility failed to: 1. Ensure Resident 20's discontinued controlled medication, lorazepam solution (class of drugs which act on the brain and nerves to produce a calming effect that relieve symptoms of anxiety) was removed from the medication cart and disposed of per facility policy in one of four inspected medication carts (Station 4 Medication Cart 2). This deficient practice had the potential for loss of accountability, which affected the controls against drug loss and diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) or theft. 2. Ensure a discharged resident's (Resident 160) controlled medication, tramadol (pain medication that acts in the central nervous system to relieve pain) was removed from the medication and disposed of per facility policy in one or four inspected medication carts (Station 3 Medication Cart 2). This deficient practice had the potential for loss of accountability, which affected the controls against drug loss and diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) or theft. 3. Remove and discard an expired Novolog Aspart Flexpen (used to control diabetes mellitus [high blood sugar]) with open date of [DATE]. This deficient practice had the potential for the resident to potentially receive an out-of-date insulin that may affect the resident's health condition. 4. Store an unopened Lantus (helps to control blood sugar levels in diabetes mellitus) Solostar Flexpen in a refrigerator according to the manufacturer's guidelines in one out of 4 inspected medication carts (Medcart 1). This deficient practice had the potential to compromise the effectiveness of the insulin if stored outside the required temperature range prior to opening. Findings: a. A review of Resident 20's admission Record (face sheet) indicated the resident was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnosis including psychosis (a mental disorder characterized by s disconnection from reality) and acute respiratory failure. A review of Resident 20's Minimum Data Set (MDS- as assessment and care screening tool) dated [DATE], indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated the resident did not receive antianxiety medication during the seven-day look-back period (time frame for observation). A review of Resident 20's Physician's Order dated [DATE], indicated an order to discontinue lorazepam solution 2 milligrams/milliliter (mg/ml - unit of measurement), give 0.5 mg sublingually (under the tongue) every four hours as needed for anxiety manifested by restlessness leading to shortness of breath (SOB). On [DATE] at 6:48 p.m., during an observation (inspection) of Station 4 Medication Cart 2, with Licensed Vocational 8 (LVN 8), observed Resident 20's unopened 30 ml of lorazepam solution 2 mg/ml stored in the cart. During a concurrent interview and record review of physician orders with LVN 8, LVN 8 stated the medication was discontinued on [DATE]. LVN 8 stated the medication should have been removed from the cart and given to the Director of Nursing (DON) on the day the medication was discontinued. On [DATE] at 8:54 a.m., during an interview with the DON, she stated the licensed nurses should have given the resident's discontinued controlled medication and other discharged residents' controlled medications to the DON and/or the Assistant Director of Nursing (ADON) to be stored in a double lock cabinet in the DON's office pending destruction of the medications with the facility pharmacist, who comes in monthly. The DON stated the facility has a policy to be followed to ensure accountability of discontinued medications because of the potential for drug abuse and diversion. A review of the facility policy and procedures titled, Medication Destruction, dated 03/2019, indicated discontinued medications and medications left in the facility after a resident's discharge are destroyed. Controlled substances are retained in a securely locked area using double lock procedures, with restricted access until destroyed by the facility director of nursing or a registered nurse by the facility and a consultant pharmacist. b. A review of Resident 160's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including acute kidney failure and dysphagia (difficulty swallowing). The admission Record indicated the resident was discharged to a general acute care hospital (GACH) on [DATE]. A review of Resident 160's Order Summary Report indicated a physician's order of tramadol hydrochloride (HCl) tablet 50 milligrams (mg - unit of measurement), give 1 tablet by mouth one time a day for pain management on [DATE]. On [DATE] at 3:45 p.m., during an observation (inspection) of the of Station 3 Medication Cart 2, with Licensed Vocational Nurse 6 (LVN 6), observed a bubble pack (a blister pack, medication package with compartments of single doses) wrapped with a Controlled Drug Record (CDR - accountability record of medications that are considered to have a strong potential for abuse) form. The bubble pack and the CDR indicated there were three remaining doses of tramadol 50 mg tablet for Resident 160. During a concurrent interview, LVN 6 stated Resident 160 was discharged and the medication should have been removed from the cart immediately and given to the Director of Nursing (DON) for storage. On [DATE] at 8:54 a.m., during an interview with the DON, she stated the licensed nurses should have given the discharged resident's controlled medication and other residents' discontinued controlled medications to the DON and/or the Assistant Director of Nursing (ADON) to be stored in a double lock cabinet in the DON's office pending destruction of the medications with the facility pharmacist, who comes in monthly. The DON stated the facility has a policy to be followed to ensure accountability of discontinued medications because of the potential for drug abuse and diversion. A review of the facility policy and procedures titled, Medication Destruction, dated 03/2019, indicated discontinued medications and medications left in the facility after a resident's discharge are destroyed. Controlled substances are retained in a securely locked area using double lock procedures, with restricted access until destroyed by the facility director of nursing or a registered nurse by the facility and a consultant pharmacist.

Based on the Resident Council (group meeting) interview and record review, the facility failed to offer and distribute bedtime snacks every night for ten out of ten (Residents 61, 306, 87, 157, 105, 409, 90, 11, 408, 358, 74, and 410) sampled residents who attended the group meeting. The deficient practice resulted in the residents not knowing the facility offered bedtime snacks which prolonged the hours in-between dinner and breakfast meals. Findings: During the Resident Council (group meeting) interview, on 08/04/2021 at 1:15 p.m., ten out of ten residents (Residents 61, 306, 87, 157, 105, 409, 90, 11, 408, 358, 74, and 410) stated they were are not aware that bedtime snacks were available for request and those were not offered by nurses unless the residents asked for the snacks. Resident 90 stated snacks were not routinely offered to her and she has diabetes (high blood sugar). Resident 90 stated she had to ask for snacks. During an interview on 08/05/2021 at 9:00 a.m., Minimum Data Set Nurse 1 (MDSN 1) stated residents should get snacks especially residents with diabetes. MDSN 1 also stated providing snacks for residents is part of nursing measures unless there's restrictions on the amount of food residents can have. During an interview on 08/05/2021 at 9:45 a.m., the Director of Nursing (DON) stated residents are supposed to have recommendations from the dietitian regarding snacks for residents. The DON also stated, residents should have bedtime snacks especially those with diabetes and they can go into hypoglycemia (low blood sugar) if bedtime snack was not provided. During an interview on 08/05/2021 at 11:13 a.m., Registered Dietitian 1 (RD 1) stated that snacks are only provided if residents asked for it. Snacks are available at the nurse stations for nursing to provide if needed. A review of the facility policy and procedures titled Nourishments and Snacks dated 07/2016 indicated snacks are offered to residents throughout the day, including bedtime and are available upon resident request. The policy and procedures also indicated residents will be asked if he or she would like a snack at bedtime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection prevention control measures by failing to: 1. Disinfect (clean with a chemical in order to destroy the bacteria) the pill crusher (Silent Night - brand of pill crusher that crushes pills quickly with minimal force and quietly so it doesn't disturb residents) in between resident use for one (Resident 105) out of nine sampled residents investigated for infection control. 2. Keep a resident's urinary catheter drainage bag off the floor for two (Residents 407 and 360) out of nine sampled residents investigated for infection control. 3. Ensure the oxygen tubing was not touching the floor for one (Resident 50) out of nine sampled residents investigated for infection control. 4. Indicate the date when oxygen tubing was changed per facility policy for two (Residents 359 and 360) out of nine sampled residents investigated for infection control. 5. Ensure urinals were labeled with the residents' names and room numbers for two (Residents 22 and 40) out of nine sampled residents investigated for infection control. 6. Ensure the medication storage room was free from potentially contaminated items for one out of two inspected medication storage rooms (Station 2). 7. Ensure there was a disposal bin inside a yellow zone resident room to dispose of used PPE for two (Residents 256 and 257) out of nine sampled residents investigated for infection control. These deficient practices had the potential to result in the spread of infection. Findings: a. A review of Resident 105's admission Sheet (face sheet) indicated the resident was admitted on [DATE] with diagnosis that included wedge compression fracture (broken bone typically caused by a loss of bone mass of thoracic 11 (T11) - thoracic 12 (T12) vertebrae (backbone). A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 07/10/2021, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding), had the ability to make self-understood, and had the ability to understand others. During a medication administration observation for Resident 105 and a concurrent interview with Registered Nurse 1 (RN 1) on 08/03/2021 at 9:30 a.m., observed residues of medications on the pill crusher (Silent Night - brand of pill crusher that crushes pills quickly with minimal force and quietly so it doesn't disturb residents) mechanism. RN 1 confirmed that the pill crusher was dirty. RN 1 immediately cleaned the pill crusher with Sani wipes (chemical wipe for disinfecting surfaces). A review of the facility's Infection Control policy and procedures, dated 1/12/2017, indicated resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected using Environmental Protection Agency (EPA) guidelines to minimize the risk and spread of infectious agents. It indicated that reusable items can be cleaned and sanitized where they are used, and reusable items are cleaned and disinfected or sterilized between residents. b. A review of Resident 407's admission Sheet (face sheet) indicated the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and urinary tract infection (infection in any part of your urinary system), site not specified. A review of Resident 407's History and Physical dated 07/07/2021 indicated the resident had a Foley catheter (sterile tube that is inserted into your bladder to drain urine). A review of Resident 407's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 07/12/2021, indicated the resident sometimes had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated Resident 407 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. During a concurrent observation and interview on 08/03/2021 at 9:35 a.m., with Certified Nurse Assistant 2 (CNA 2), observed Resident 407's urinary catheter bag touching the floor. CNA 2 stated that the bag should not be touching the floor. CNA 2 immediately adjusted the height of the bed to keep the urinary catheter bag off the floor. A review of the facility's Catheter Care - Urinary policy and procedures, dated 7/1/2020, indicated on infection control to be sure the catheter tubing and drainage bag are kept off the floor. c. On 08/03/2021 at 11:39 a.m., during an observation, Resident 360 was lying in bed with an indwelling catheter (sterile tube that is inserted into your bladder to drain urine) drainage bag with a dignity bag (a pouch in which an indwelling catheter drainage bag is placed for privacy) anchored to the right lower side of the bed touching the floor. During an interview on 08/03/2021 at 11:25 a.m., Registered Nurse 2 (RN 2) stated indwelling catheter drainage bag should not be touching the floor for infection control purposes and this places the resident at risk for acquiring infection. During an interview on 08/06/2021 at 9:36 a.m., the Director of Nursing (DON) stated indwelling catheter drainage bag should not be touching the floor due to infection control purposes and places the resident at risk for acquiring infection. A review of the admission Record (face sheet) indicated Resident 360 was admitted to the facility on [DATE], with diagnoses that included right femur neck (thigh bone) fracture (broken bone), right hip replacement (a type of surgery that replaces parts of the hip joint with artificial implants), hypertension (high blood pressure), and diabetes mellitus (DM - abnormally high levels of the sugar in the blood). A review of History and Physical (H & P) dated 07/18/2021 indicated Resident 360 was capable of making own decisions. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool) dated 07/21/2021 indicated Resident 360 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident needed extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, eating, and personal hygiene; and was totally dependent with toileting and bathing. A review of Resident 360's Order Summary Report dated 07/15/2021, indicated a physician's order for indwelling urinary catheter size French #16/10 milliliter (ml - unit of measurement) balloon. Monitor placement and functioning every shift. Indwelling urinary catheter: change as needed (PRN) if pulled out, leaking, or clogged as needed. A review of the facility policy and procedures titled, Catheter Care - Urinary dated 7/1/2020, indicated to be sure the catheter tubing and drainage bag are kept off the floor. d. On 08/03/2021 at 11:23 a.m., during an observation, Resident 359 was lying in bed with oxygen at two liters per minute via nasal cannula (a tube used to deliver oxygen). Upon inspection of the resident`s environment and equipment, it was observed that the oxygen cannula was is not labeled with the date on when it was changed. During an interview on 08/03/2021 at 11:25 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated oxygen tubing should be changed once a week. LVN 4 also stated oxygen tubing should be labeled with date for infection control reasons and the situation placed the resident at risk for acquiring an infection if date changed was unknown. During an interview on 08/04/2021 at 8:48 a.m., Certified Nurse Assistant 4 (CNA 4) stated that nurses are in charge of placing labels on oxygen tubing. During an interview on 08/04/2021 at 8:53 a.m., Registered Nurse 2 (RN 2) stated applying label with date changed on oxygen tubing is nurses' responsibility and oxygen tubing are changed every week on a Friday. RN 2 also stated, oxygen tubing should have been labeled on the day it was changed due to infection control issues and places the resident at risk for acquiring infection if not changed per policy. During an interview on 08/06/2021 at 10:15 a.m., the Director of Nursing (DON), stated oxygen tubing should be dated upon admission and changed weekly every Friday for infection control purposes. A review of admission Record (face sheet) indicated Resident 359 was admitted to the facility on [DATE], with diagnoses that included diastolic heart failure (a condition where the lower left chamber of the heart is not able to fill properly, reducing the amount of blood pumped out to the body), hypertension (high blood pressure), and diabetes mellitus (DM - abnormally high levels of the sugar in the blood). A review of History and Physical (H & P) dated 07/20/2021 indicated Resident 359 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool) dated 07/26/2021 indicated Resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident needed extensive assistance with bed mobility, dressing, toileting, and personal hygiene. A review of Resident 359's Order Summary Report dated 07/19/2021, indicated a physician's order for oxygen at 2 liters per minute via nasal cannula every shift. Change nasal cannula/tubing & storage bag every week. Date tubing and bag. Every day shift. Every Friday. A review of the undated facility policy and procedure titled, Oxygen, indicated to change oxygen humidifier and tubing weekly. e. On 8/3/2021 at 11:23 a.m., during an observation, Resident 360 was lying in bed with oxygen at two liters per minute via nasal cannula (a tube used to deliver oxygen). Upon inspection of the resident`s environment and equipment, it was observed that the oxygen cannula was is not labeled with the date on when it was changed. During an interview on 08/03/2021 at 11:25 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated oxygen tubing should be changed once a week. LVN 4 also stated oxygen tubing should be labeled with date for infection control reasons and the situation placed the resident at risk for acquiring an infection. During an interview on 08/04/2021 at 8:48 a.m., Certified Nurse Assistant 4 (CNA 4) stated that nurses are in charge of placing labels on oxygen tubing. During an interview on 08/04/2021 at 8:53 a.m., Registered Nurse 2 (RN 2) stated applying label with date changed on oxygen tubing is nurses' responsibility and oxygen tubing are changed every week on a Friday. RN 2 also stated, oxygen tubing should have been labeled on the day it was changed due to infection control issues and places the resident at risk for acquiring infection if not changed per policy. During an interview on 08/06/2021 at 10:15 a.m., the Director of Nursing (DON), stated oxygen tubing should be dated upon admission and changed weekly every Friday for infection control purposes. A review of the admission Record (face sheet) indicated Resident 360 was admitted to the facility on [DATE], with diagnoses that included right femur neck (thigh bone) fracture (broken bone). right hip replacement (a type of surgery that replaces parts of the hip joint with artificial implants), hypertension (high blood pressure), and diabetes mellitus (DM - abnormally high levels of the sugar in the blood). A review of History and Physical (H & P) dated 07/18/2021 indicated Resident 360 was capable of making own decisions. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool) dated 07/21/2021 indicated Resident 360 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident needed extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, eating, and personal hygiene; and was totally dependent with toileting and bathing. The MDS also indicated resident was on oxygen therapy. A review of Resident 360's Order Summary Report dated 07/15/2021, indicated a physician's order for oxygen at 2 to 4 liters per minute via nasal cannula to keep oxygen saturation (a measurement of your blood oxygen) at greater than 94 percent (>94 %) every shift. A review of the undated facility policy and procedures titled, Oxygen, indicated to change oxygen humidifier and tubing weekly. i. A review of Resident 256's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (occurs when fluid builds up in the air sacs in your lungs) with hypoxia (low oxygen in the blood) and pneumonia (an infection that inflames the air sacs in one or both lungs). A review of Resident 256's care plan (contains all of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders, and a plan for evaluation), initiated on 07/29/2021, indicated the resident is at risk for coronavirus (COVID-19 - an infectious disease caused by SARS-CoV-2) infection with a goal that the resident will not acquire COVID-19 infection. Among some of the interventions listed was to implement isolation precautions (precautions that help prevent the spread of germs) per the Centers for Disease Control and Prevention (CDC - the national public health agency of the United States) guidelines. A review of Resident 257's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included history of transient ischemic attack (TIA - a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain or the eye), abnormalities of gait and mobility, and generalized muscle weakness. A review of Resident 257's care plan, initiated on 08/01/2021, indicated the resident is at risk for COVID-19 infection related to nursing home residency with a goal that the resident will not acquire COVID-19 infection. On 08/03/2021 at 8:32 a.m., during a tour of the yellow zone (exposed or unknown exposure and negative), observed Resident 256 and Resident 257 inside their room. There was a personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) bin outside of the room and signs posted indicating to don PPE prior to entering the room. A sign also indicated isolation precautions. On 08/03/2021 at 8:41 a.m., during a concurrent observation and interview, Certified Nursing Assistant 5 (CNA 5) verified there was no disposal bin inside the residents' room to dispose of used PPE. CNA 5 stated there should have been a bin inside the room to put their used gowns in. On 08/06/2021 at 10:41 a.m., during an interview, the Director of Staff Development (DSD) stated it was important to have a place to dispose of used PPE inside the residents' room so nurses did not walk out of the room wearing the PPE. On 08/06/2021 at 11:45 a.m., during an interview, the Director of Nursing (DON) stated there should be disposal bins inside every isolation precaution room so that there is a place to put contaminated PPE. The DON stated it was an infection control issue. A review of the facility's policy and procedure titled, Infection Prevention and Control Program, effective 06/01/2020, indicated an important facet of infection prevention includes instituting measures to avoid complications or dissemination. Trash disposal bins are positioned as near as possible to the exit inside of the resident room to make it easy for staff to discard contaminated PPE after removal, prior to exiting the room. j. A review of Resident 40's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urinary tract infection (UTI - an infection in any part of your urinary system - your kidneys, ureters, bladder and urethra), encounter for surgery aftercare following surgery on the genitourinary system (refers to the urinary and genital organs), and benign prostatic hyperplasia (enlarged prostate gland). A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tools), dated 06/11/2021, indicated the resident was severely impaired in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 08/03/2021 at 9:23 a.m., during an observation, Resident 40 was asleep in bed. Resident 40's roommate was asleep in his wheelchair. There was a commode (an adult potty chair made up of a frame equipped with a toilet seat and a removable bucket) at Resident 40's bedside and an unlabeled urinal (bottle for urination) on top of the commode. On 08/04/2021 at 8:52 a.m., during an observation, observed an unlabeled urinal at Resident 40's bedside. On 08/04/2021 at 8:56 a.m., during a concurrent observation and interview, Registered Nurse 1 (RN 1) verified there was an unlabeled urinal at the resident's bedside and stated the urinal should have been labeled with the resident's name so nurses knew to whom it belonged. On 08/06/2021 at 11:23 a.m., during an interview, the Director of Staffing Development (DSD) stated that bedpans and urinals should be labeled with residents' names so nurses knew to whom it belonged. On 08/06/2021 at 11:45 a.m., during an interview, the Director of Nursing (DON) stated that residents' urinals should be labeled for the purposes of infection control. A review of the facility's undated policy and procedure titled, Bedpan/Urinal Offering/Labeling, indicated it is the policy of this facility to provide a bedpan/urinal to the resident as needed and to label each bedpan/urinal per resident. Label the bedpan/urinal (room number and name). f. A review of Resident 22`s admission Record indicated the resident was admitted on [DATE] with diagnoses that included hypertension (high blood pressure) and gastroesophageal reflux disease (occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach). A review of Resident 22's Minimum Data Set (MDS- an assessment and screening tool) dated 02/26/2021 indicated the resident had the ability to make self- understood and had the ability to understand others. The MDS also indicated that Resident 22 required extensive assistance on staff for transfer, toilet use, personal hygiene, and bathing. On 8/03/2021 at 10:21 a.m., during the initial facility tour and room visit observation, observed Resident 22 in bed, awake, alert and oriented to person, place, time, and situation. Also observed hanging by the bed foot board was one male plastic urinal with no room and bed number label. Resident 22 stated he uses the urinal to pee and the nurses will empty them in the toilet. On 8/04/2021 at 1:14 p.m., during a return room visit observation, and after obtaining permission to come in to the room, observed Resident 22 in bed with the over bed table covering the mid-section of his body, Resident 22 stated he was urinating. Excused self and stepped out of the room and told the resident will come back shortly after he relieves himself. Upon return to the room, accompanied by the Assistant Director of Nursing (ADON), Resident 22 was asked if somebody had emptied the urinal bottle, Resident 22 replied in the negative and took out the male plastic urinal from the trash can still filled with urine. As observed, the male plastic urinal had no label indicating the resident's room and bed number. This observation was attested to by the ADON. According to the ADON, the male plastic urinal should be labeled with the bed and room number as an infection control measure to prevent the same from being inadvertently used by another resident thereby preventing transmission of infection. A review of the facility`s undated policy and procedures titled Bedpan/Urinal offering/Labelling, indicated that it is the policy of this facility to provide bedpan/urinal to the resident as needed and to label each bedpan/urinal per resident. g. A review of Resident 50's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hypertension (high blood pressure) and low back pain. A review of Resident 50's Minimum Data Set (MDS- an assessment and screening tool) dated 03/08/2021 indicated the resident's cognitive skills (refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact. The MDS also indicated that Resident 50 required extensive on staff for transfer, toilet use, personal hygiene, and bathing. On 8/03/2021 at 11:45 a.m., during a room visit observation, observed Resident 50 in bed, awake, alert and oriented to person, place, time and situation. Resident 50 responded to interview and stated she uses oxygen when doing breathing exercises. Resident 50 pointed to the oxygen cannula and tubing inside a bag that was laying on the floor. On 8/3/2021 at 11:55 a.m. during a concurrent observation at Resident 50`s room and an interview with Restorative Nurse Assistant 1 (RNA 1), RNA 1 stated that oxygen tubing and cannula are changed by the nurses and should be placed in a plastic bag when not in use, and should never be touching the floor because then it will be contaminated, and can lead to infection. RNA1 added that they get in-serviced (trained) about infection control on how to care for the resident's oxygen tubing and cannula. RNA1 saw and observed that Resident 50`s oxygen tubing and cannula were laying on the floor inside the resident`s room. A review of the Centers for Disease Control (CDC) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, dated 2003, indicated floors can become rapidly recontaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. h. During a concurrent observation and interview on 08/05/2021 at 7:30 a.m., with Licensed Vocational Nurse 4 (LVN 4), observed Medication Storage Room in Station 2 with a plastic pallet on the floor. On top of the plastic pallet, were a pair of leg orthotics (an artificial support or brace for the limbs or spine), a bag of resident's belongings, and a wound vac (used to help heal wounds). LVN 4 stated the discharged resident's belongings should have been given to the Social Services Director for storage. During an interview with the Director of Nursing (DON) on 08/06/2021, at 9:03 a.m., the DON stated the resident's belongings should have not been stored in the Medication Room for infection control purposes. The Medication Storage Room was for storing medications and other supplies used for medication administration such as syringes. A review of the facility policy and procedures titled, Medication Storage in the Facility, dated 04/2008, indicated medication storage areas are kept clean, well-lit, and free of clutter.