b. During a review of Resident 67`s admission Record, the admission Record indicated that the facility admitted the resident on 9/30/2024, with diagnoses including type two (2) DM, muscle weakness, and retention of urine (a condition in which you are unable to empty all the urine from your bladder). During a review of Resident 67's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 10/6/2024, the document 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 67 was dependent on staff (helper does all of the effort) for toileting hygiene, showering and bathing, lower body dressing, and required staff supervision when eating. The MDS further indicated that Resident 67 received seven (7) insulin injections within the last seven days/since admission. During a review of Resident 67`s Physician order dated 9/30/2024, the document indicated to administer insulin lispro (a rapid-acting insulin: a medicine used to control the amount of sugar in the blood of patients with diabetes. It starts to work very quickly, and you take it before meals to stop your blood sugar (BS) from going too high) subcutaneously (SQ- to inject under all the layers of the skin) as per sliding scale ( the increasing administration of the insulin dose based on the blood sugar level before the meal): if a resident`s blood sugar level is 70-150 milligrams per deciliter (mg/dl-unit of measurement [ normal range for a diabetic according to American Diabetes Association: 80-130 mg/dl]) administer 0 unit of insulin (a unit of measurement for insulin), BS 151-200 mg/dl=2 units, BS 201-250 mg/dl=3 units, BS 251-300 mg/dl= 4 units, BS 351-400 mg/dl=5 units, and if the BS level is more than 400 mg/dl administer 6 units of insulin and notify the physician. During a review of Resident 67`s Medication Administration Record (MAR-a record of medications administered to residents) for the months of September and October 2024, the document indicated that the licensed staff checked Resident 67 `s BS level and followed the insulin lispro sliding scale instructions for administration of the medication from 9/30/2024 to 10/15/2024. During a review of Resident 67`s Nursing Progress Notes dated 10/15/2024 at 2:05 p.m., the document indicated that both Resident 67 and a family member requested that BS level checks and the administration of insulin are discontinued. The Note further indicated that the licensed staff contacted Resident 67`s physician and received authorization to discontinue the BS level checks and the administration of insulin. During a review of Resident 67`s Care Plan dated 10/18/2024, the document indicated that the resident had non-insulin dependent DM2. Further review of the care plans indicated that there was no individualized person-centered care plan including measurable objectives, goal, and monitoring before 10/18/2024, for Resident 67`s insulin consumption and her refusal for BS level checks. During a concurrent interview and record review on 10/23/2024 at 10:51 a.m., with the Director of Nursing (DON), Resident 67`s care plans, MAR for September and October 2024, and physician orders were reviewed. The DON stated licensed staff developed a care plan for Resident 67`s diagnoses of diabetes on 10/18/2024. However, licensed staff did not develop a care plan with goal and interventions prior to 10/18/2024, for Resident 67`s insulin use. The DON stated Licensed staff were required to initiate a care plan with goal and interventions for Resident 67`s insulin use. They should have mentioned that Resident 67 and her family member refused BS level checks and insulin injections. The DON stated the potential outcome of not developing a care plan for insulin is the lack of monitoring and delivery of necessary services. During a review of the facility`s policy and procedure titled Interdisciplinary Team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) Guidelines, Care Planning, reviewed January 2024, the policy indicated that it is the policy of this facility to include appropriate members of IDT in the care planning process to effectuate as appropriate, person centered care. The IDT will allow the resident and/or representative to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care and any other factors related to effectiveness of the plan of care as they desire. Care plans shall include resident`s strengths, goals, life history and preferences. Based on interview and record review, the facility failed to: 1. Develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) addressing the resident`s vision impairment (occurs when an eye condition affects the visual system and its vision functions) for one of one sampled resident (Resident 93). 2. Develop individualized person-centered care plan for insulin (a medication used in the treatment and management of diabetes mellitus[DM- a disease that occurs when the sugar level is high in the blood]) use for one of ten sampled residents (Resident 67). These deficient practices had the potential to result in failure to deliver the necessary care and services for Resident 93 and had the potential to lead to the inadequate care of Resident 67. Findings: a. During a review of Resident 93's admission Record, the admission Record indicated the facility admitted the resident on 8/26/2024 with diagnoses that included depression (characterized by a prolonged low mood and loss of interest in activities that used to be enjoyable) and chronic respiratory failure (shortness of breath or feeling like you can't get enough air, extreme tiredness, an inability to exercise as you did before, and sleepiness). During a review of Resident 93's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/01/2024, the document 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 the resident was dependent on staff for toileting, shower, lower body dressing, and putting on and taking off footwear. During an interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 10/23/24 at 11:29 a.m., Resident 93`s Social Services-Admission-Evaluation (SSAE) notes, which indicated that the resident was visually impaired was reviewed. Upon assessment and confirmation by LVN1 of the resident`s visual functioning, at the resident`s bedside, the resident was unable to count how many of LVN 1`s finger was in front of her face with 1 ½ feet distance. The resident stated she could not see the LVN`s hand and could only see the shadow of the LVN 1`s face. During a follow up interview with LVN1 on 10/24/24 at 8:56 p.m., LVN1 stated that the Social Services staff that did the assessment should have discussed, with the nurses, the resident`s complaint of visual impairment. LVN1 stated that there should have been a Change of Condition (COC) triggered to further assess the resident and identify the risks and care needs of a visually impaired resident. LVN1 stated that a Care Plan should have been initiated upon identification of the resident`s visual impairment and development of a goal of treatment and outline interventions to achieve the goals. LVN1 stated that without a care plan for visual impairment, the resident`s care needs cannot not be met and could result in the resident`s becoming depressed about her situation. During a record review and concurrent interview with the Social Services Director (SSD) on 10/24/24 at 10:09 a.m., Resident 93's Social Services-admission Evaluation (SSAE) dated 9/2/2024 was reviewed. The SSD stated that in the section Psychosocial Evaluation, it indicated that the resident is visually impaired. The SSD stated that Resident 93 had told her that her vision is a little off. The SSD stated that she had informed the nurse about the resident`s vision problem but was unable to remember who was the nurse that she spoke to. Also reviewed with the SSD, the Resident 93`s Care Conference-Interdisciplinary, dated 9/3/2024. The SSD stated that she did not mention the resident`s complaint about her vision to the Interdisciplinary Team (a group of health care professionals with various areas of expertise who work together toward the goals of their clients), and nothing was discussed in this care conference the resident`s complaint about her vision problem. During a review of the facility`s policy on Interdisciplinary Team Guidelines, Care Planning, last reviewed on January 2024, the policy indicated that it is the policy of the facility to include appropriate members of the IDT in the care planning process to effectuate, as appropriate, person-centered care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 350's admission Record, the admission Record indicated that the facility admitted the resident on 10/18/2024, with diagnoses including type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), difficulty in walking, and spinal stenosis (narrowing of one or more spaces within your spinal canal [backbone]). During a review of Resident 350`s physician History and Physical (H&P) dated 10/21/2024, the document indicated that the resident was able to give informed consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) regarding his medical/physical treatment relating to an existing and continuing medical condition. The H&P further indicated that Resident 350 is competent (having the necessary ability) to enter into a contract including admission agreement. During a review of Resident 350's Care Plan dated 10/21/2024, the care plan indicated that the resident had a communication problem due to a language barrier. The care plan indicated that Resident 350 speaks Armenian, Russian, Greek, and Turkish and knows very little English. The care plan goal was for the resident to be able to communicate basic needs through the review period. The care plan interventions were to provide a translator as necessary to communicate with the resident, to encourage the resident to continue verbalizing his thoughts, and to focus on a word or phrase that makes sense or responds to the feeling resident is trying to express. The care plan interventions further indicated that the resident is able to communicate by: using communication board, gestures (a movement of part of the body, especially a hand or the head, to express an idea or meaning), signs, translator. During a concurrent observation and interview on 10/21/2024 at 10:03 a.m., inside Resident 350's room, Resident 350 was observed on his bed lying on his side. Certified Nursing Assistant 2 (CNA 2) was present at the resident`s bedside. CNA 2 stated Resident 350 speaks Farsi. He is confused, and I cannot understand him because he does not speak English well. CNA 2 stated for residents who do not speak English well, a communication board is required to be present at their bedside. CNA 2 then started searching for the communication board inside Resident 350`s room and outside on his wheelchair. However, she was unable to find one. Resident 350 stated that he speaks Armenian and Russian, and he does not speak Farsi. Resident 350 further stated that he has a hard time communicating with staff members because he does not speak English well and the staff does not speak Armenian. Resident 350 stated, I normally use sign language or gestures to make myself understood. Right now, I am soiled, and I need to be changed. However, I am not able to verbalize that I need to be changed. I have to wait for the staff to come and check on me. During a concurrent observation and interview on 10/21/2024 at 10:16 a.m., inside Resident 350`s room, Registered Nurse 1 (RN1) present at Resident 350`s bedside stated that Resident 350 speaks Farsi. RN 1 stated Resident 350 does not have a communication device or board at his bedside. RN 1 stated the communication device or board would make it easier to communicate with the resident in his primary language. RN 1 stated the potential outcome of not providing a communication board to the residents who do not speak English is inability to communicate with the resident accurately and understand his needs. During a review of the facility's policy and procedure titled, Communication with Persons with Limited English Proficiency, reviewed 1/2024, the policy indicated that the facility will take responsible steps to ensure that persons with Limited English Proficiency (LEP) have meaning full access and an equal opportunity to participate in services, activities programs and other benefits. All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the person being served. The facility will promptly identify the language and communication needs of the LEP person. If necessary, staff will use a language identification card or posters to determine the language. Based on observation, interview, and record review, the facility failed to ensure residents were provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) at their bedsides in the language that the residents were able to understand for two of four sampled residents (Resident 22 and Resident 350). These deficient practices prevented the residents from communicating with the staff and had the potential to delay receiving care/treatment the residents needed. Findings: a. During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted the resident on 02/13/2023, and readmitted on [DATE], with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and dysphagia (difficulty swallowing). During a review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/11/2024, the MDS indicated Resident 22`s preferred language was not English and need an interpreter to communicate with a doctor or health care staff. The MDS indicated that Resident 22 had the ability to make usually makes self-understood and had the ability to understand others. The MDS indicated Resident 22 required partial assistance with toileting hygiene, upper body dressing, putting on and taking off footwear and personal hygiene. During a room observation and concurrent interview on 10/22/24 at 7:52 a.m. with Registered Nurse 1 (RN1), observed that there was no communication board at the resident`s bedside which was confirmed by RN1. RN1 stated that non-English speaking residents have to be provided with a communication board in their own language to facilitate communication between the staff and the residents. RN1 stated that with a communication board the resident would be able to communicate their needs to the staff and it would be frustrating for the residents if they are not understood thereby their needs will not be met. During a review of Resident 22`s Care Plan (a document that outlines how a patient's health care needs will be met) dated 9/3/2024, the care plan indicated that the resident has a communication problem, and the goal is for the resident to maintain current level of communication function by using appropriate gestures, responding to yes or no questions appropriately using communication board through the review date. During a review of the facility`s policy and procedures titled Limited English Proficiency, last reviewed on January 2024, the policy indicated that, the facility will take reasonable steps to ensure that all persons with Limited English Proficiency have meaningful access and an equal opportunity to participate in our services, activities, and programs . all interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the person being served and patients/participants/residents and their families will be informed of the availability of such assistance at point of ministry or program access and that it is available free of charge .

Based on observation, interview and record review, the facility`s Interdisciplinary Care Team (a group of professionals from different disciplines who work together to treat a patient's condition) failed to collaborate and communicate with the care team members the resident`s concern about her vision loss for one of one sampled resident (Resident 93). This deficient practice resulted in nurses` not being aware of the resident`s visual function status which has the potential for the resident to fall and suffer serious injury due to inability to see. Findings: During a review of Resident 93's admission Record, the admission Record indicated the facility admitted the resident on 8/26/2024 with diagnoses that included depression (characterized by a prolonged low mood and loss of interest in activities that used to be enjoyable) and chronic respiratory failure (shortness of breath or feeling like you can't get enough air, extreme tiredness, an inability to exercise as you did before, and sleepiness). During a review of Resident 93's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/01/2024, 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 and the resident was dependent on staff for toileting, shower, lower body dressing, and putting on and taking off footwear. During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 10/23/24 at 11:29 a.m., Resident 93`s Social Services-Admission-Evaluation (SSAE) notes, which indicated that the resident was visually impaired, was reviewed. Upon assessment and confirmation by LVN1 of the resident`s visual functioning, at the resident`s bedside, the resident was unable to count how many of LVN 1`s fingers were in front of her face with 1 ½ feet distance. The resident stated she cannot see the LVN`s hand and can only see the shadow of the LVN 1`s face. During an interview on 10/23/24 11:40 a.m., with Registered Nurse Supervisor (RN1), RN1 stated that they are not aware that the resident was visually impaired. RN1 stated that there was no communication from the Social Services staff that the resident is visually impaired. RN1 then went into the resident`s room and verified the sign posted above the resident`s bed that says, Visually Impaired. RN1 stated they could have care planned (a plan for an individual's specific health needs and desired health outcomes) the resident`s risk factors such as a potential for fall which can cause injury if not prevented. During a follow up interview with LVN1 on 10/24/24 at 8:56 p.m., LVN1 stated that the Social Services staff that did the assessment should have discussed with the nurses` the resident`s complaint of visual impairment. LVN1 stated that there should have been a Change of Condition (COC) triggered to further assess the resident and identify the risks and care needs of a visually impaired resident. LVN1 stated that a Care Plan should have been initiated upon identification of the resident`s visual impairment and development of a goal of treatment and outline interventions to achieve the goals. LVN1 stated that without a care plan for visual impairment, the resident`s care needs would not be met and can result to the resident`s becoming depressed about her situation. During a concurrent interview and record review with the Social Services Director (SSD) on 10/24/24 at 10:09 a.m., Resident 93's Social Services-admission Evaluation (SSAE) dated 9/2/2024 was reviewed. The SSD stated that in the section Psychosocial Evaluation, it indicated that the resident is visually impaired. The SSD stated that Resident 93 had told her that her vision is a little off. The SSD stated that she had informed the nurse about the resident`s vision problem but was unable to remember who was the nurse that she spoke to. Also reviewed with the SSD, the Resident 93`s Care Conference-Interdisciplinary, dated 9/3/2024. The SSD stated that she did not mention the resident`s complaint about her vision to the Interdisciplinary Team (a group of health care professionals with various areas of expertise who work together toward the goals of their clients), and nothing was discussed in this care conference the resident`s complaint about her vision problem. During a review of the facility`s policy on Interdisciplinary Team Guidelines, Care Planning, last reviewed on January 2024, the policy indicated that it is the policy of this facility to include appropriate members of the IDT in the care planning process to effectuate, as appropriate, person-centered care . During a review of the facility`s policy and procedure titled Blind Resident, Care Suggestions, last reviewed on January 2024, the policy indicated that It is the policy of this facility to provide care for the blind resident in accordance with individual needs, preferences, and plan of care . During a review of the facility`s policy and procedures titled Fall/Accident Mitigation and Intervention, last reviewed in January 2024, the policy indicated that It is the policy of the facility to minimize the risk of serious injury associated with fall or accidents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents Resident 65 was free from significant medication error by failing to ensure metoprolol (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with parameter to hold (do not give) the medication if Resident 65's heart rate is less than 60 beats per minute (bpm-a normal resting heart rate for adults ranges from 60 to 100 beats per minute). This deficient practice placed Resident 65 at risk for bradycardia (low heart rate- can be life threatening if the heart is unable to maintain a rate that pumps enough oxygen-rich blood throughout the bod) which could lead to shortness of breath, chest pain, fatigues, and dizziness. Findings: During a review of Resident 65's admission Record, the admission Record indicated the facility originally admitted the resident on 6/11/2021 and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus and traumatic brain injury (a brain injury caused by an external force, such as a blow to the head or a sharp object piercing the brain), and hypertensive chronic disease (a common condition that occurs when blood pressure is consistently too high over time). During a review of Resident 65's Minimum Data Set (MDS-standardized assessment and screening tool) dated 7/26/2024, the MDS indicated resident was comatose (a deep state of unconsciousness where a person cannot be awakened or respond to stimuli). During a review of Resident 65's physician order dated 9/24/2024, the document indicated resident had an order for Metoprolol tartrate 25 mg, give one tablet by mouth two times a day for hypertension, hold for heart rate less than 60 bpm. During a concurrent interview and record review on 10/23/2024 at 9:40 a.m., with Licensed Vocational Nurse 1 (LVN1), Resident 65's Medication Administration Record (MAR-includes key information about the individual's medication including, the medication name, dose taken, special instructions and date and time) for the month of October 2024 was reviewed. LVN 1 stated that on 10/19/2024 at 9:00 a.m., Resident 65`s heart was 50 bpm and at 5:00 p.m. the resident`s heart rate was 59 bpm. LVN 1 stated that on this date, Metoprolol were administered despite the physician`s order to hold if the heart rate is below 60 beats per minute as documented in the MAR. LVN1 stated that the administration of Metoprolol could have caused the resident`s heart rate to drop some more which could lead to dizziness, headache, and life-threatening complications of bradycardia. During a review of the facility`s policy on Medication Administration-General Guidelines, last reviewed on 1/17/2024, the policy indicated that Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure leftover food brought from outside was stored in the refrigerator or discarded per facility policy for one of one sampled resident (Resident 43) investigated under Food Safety Requirement. This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 43. Findings: During a review of Resident 43's admission Record, the document indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included depression (a serious mood disorder that can affect a person's thoughts, feelings, behavior, and sense of well-being) and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 43`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/04/2024, 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 was totally dependent on staff for activities of daily living (ADL- are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a concurrent observation and interview on 10/21/2024 at 9:33 a.m., with Certified Nursing Assistant 1 (CNA 1), in Resident 43`s room, observed an overbed table with a clear cup containing a yellow flan and a container of an unknown nutriment (food) on top. CNA 1 stated that the content of the cup was a flan, and the other container was a partially eaten enchilada (a Mexican dish consisting of a corn tortilla rolled around a filling and covered with a savory sauce). CNA 1 stated that these were brought by the family the day before. During an interview on 10/21/2024 at 9:45 a.m., and while in the hallway across Resident 43`s room, Registered Nurse 2 (RN2) went to the resident`s room and confirmed that the cup containing a flan and the container of enchilada belonged to Resident 43. RN2 stated that leftover food had to be refrigerated and discarded after 24 hours. RN2 stated she could not tell when these food items were in the resident's room since it had no label. RN2 stated the food in those two containers were not safe for the resident to consume and that it may cause foodborne illnesses. During a review of the facility`s policy and procedure titled, Food for Residents From Outside Sources, last reviewed on 1/17/2024, the policy indicated that prepared food brought in for the resident must be consumed within one (1) hour of receiving it in an effort to prevent food borne illness. Unused food will be disposed of immediately thereafter.

Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) donned (put on) a gown prior to administering medications to a resident via gastrostomy tube (GT - a small tube that is surgically inserted into the stomach through the abdomen to provide nutrition, fluids, and medication) who was on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - bacteria that are resistant to three or more classes of antimicrobial drugs] in nursing homes) for one of 30 sampled residents (Resident 77). 2. Ensure a resident's nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) oxygen tubing was kept off the floor for one of 30 sampled residents (Resident 204). These deficient practices placed the residents at increased risk of developing an infection. Findings: 1. During a review of Resident 77's admission Record, the admission Record indicated the facility originally admitted the resident on 1/16/2023 and readmitted the resident on 10/8/2024 with diagnoses including chronic respiratory failure (a long-term condition in which the respiratory system is unable to adequately exchange oxygen to the body), encounter for attention to tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe [trachea] to insert a tube that helps with breathing), dependence on respirator (ventilator - a mechanical device that helps you breathe by moving air in and out of your lungs) status, and encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen and inserts a tube into the stomach). During a review of Resident 77's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/18/2024, the MDS indicated the resident had severely impaired cognition (the mental process of acquiring and using knowledge through the senses, experience, and thought) and was dependent on staff for activities of daily living (ADLs - activities related to personal care). During a review of Resident 77's care plan (a document that outlines a resident's health care needs and priorities, and the treatments and care services that will be provided to address them), initiated on 9/18/2024, the care plan indicated Resident 77 required EBP. Among some of the interventions listed included to wash hands or perform hand hygiene and don appropriate PPE prior to performing high-contact tasks. During a medication administration observation on 10/22/2024 at 8:17 a.m., observed LVN 3 prepare medications for Resident 77. Observed a sign outside Resident 77's room indicating the residents inside were on EBP. Observed LVN 3 administer medications to Resident 77 via GT without first donning a gown. During an interview on 10/22/2024 at 9:36 a.m., with LVN 3, when asked what the process was for administering medications via GT to a resident on EBP, LVN 3 stated she should have worn a gown but forgot to put one on. During an interview on 10/24/2024 at 9:16 a.m., with the Infection Preventionist (IP), the IP stated that residents with a GT are placed on EBP. The IP stated nurses should don a gown when performing high contact activities for residents on EBP, such as dressing, bathing, providing hygiene care, and giving medications through the GT, in order to prevent the spread of infection. During an interview on 10/24/2024 at 9:57 a.m., with the Director of Nursing (DON), the DON stated that nurses should wear a gown when giving medications to a resident on EBP for infection control. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed and revised on 1/17/2024, the policy indicated that EBP expands the use of PPE and refers to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices (a device that is left inside the body) regardless of MDRO colonization (when a microorganism [organism that can only been seen with a microscope] is present in or on a host but it doesn't cause disease or symptoms) as well as for residents with MDRO infection or colonization. 2. During a review of Resident 204's admission Record, the admission Record indicated the facility admitted the resident on 10/14/2024 with diagnoses including atrial fibrillation (a heart condition that causes an irregular heartbeat) and pneumonitis (inflammation of the lung tissue). During a review of Resident 204's History and Physical (H&P - a comprehensive assessment of a resident that includes taking a detailed medical history from the resident and then performing a physical examination to gather objective findings), dated 10/15/2024, the H&P indicated the resident had fluctuating (to change or vary) capacity to give informed consent (a process in which residents are given important information, including possible risks and benefits, about a medical procedure or treatment) regarding his medical/physical treatment relating to an existing and continuing medical condition. During a concurrent observation and interview on 10/21/2024 at 10:02 a.m., with Licensed Vocational Nurse 4 (LVN 4), observed Resident 204 awake in bed and wearing an oxygen nasal cannula. Observed the nasal cannula oxygen tubing on the floor. LVN 4 verified by stating that the oxygen tubing was on the floor and stated she would get a new one. During an interview on 10/24/2024 at 9:55 a.m., with the Director of Nursing (DON), the DON stated residents' oxygen tubing should be kept off the floor for infection control. During a review of the facility's policy and procedure titled, Precautions - Standard, last reviewed and revised on 1/17/2024, the policy indicated it is the policy of the facility to utilize standard precautions when caring for patients/residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. During an interview on 10/24/2024 at 10:27 a.m., with the DON, the DON stated the policy and procedure titled, Precautions - Standard, was the only policy and procedure she could find regarding the issue of keeping oxygen tubing off the floor.

Based on interview and record review, the facility failed to implement its policies and procedures related to the influenza (a high contagious viral infection of the respiratory passages) vaccine for one of five sampled residents (Resident 93). This deficient practice placed Resident 93 at an increased risk of acquiring (to get) and transmitting (pass on) the influenza virus to other residents in the facility. Findings: During a review of Resident 93`s admission Record, the admission Record indicated the facility admitted the resident on 8/26/2024, with diagnoses including encephalopathy (a change in your brain function due to injury or disease), abnormal posture (when the position of the body is not normal), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living). During a review of Resident 93's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 9/1/2024, 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 93 was dependent on staff (helper does all the effort) for toileting hygiene, showering and bathing, and lower body dressing. The MDS further indicated that Resident 93 was not in the facility during this year`s influenza vaccination season. During a review of Resident 93`s History and Physical (H&P) dated 9/3/2024, the H&P indicated that the resident was not competent (having the necessary ability or knowledge) to enter into a contract, including an admission agreement. During a review of Resident 93`s Immunization Report, the report indicated that the resident received the influenza vaccine on 9/11/2024. During a concurrent interview and record review on 10/24/2024 at 11:00 a.m., with the facility`s Infection Preventionist Nurse (IP), Resident 93`s vaccination records, Medication Administration Record (MAR) and informed consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for vaccinations were reviewed. The IP stated Resident 93 received her influenza vaccine on 9/11/2024, based on the Immunization Record. However, during a record review of Resident 93`s MAR for September 2024, the IP stated that Resident 93 did not receive her influenza vaccine on 9/11/2024. The IP stated when licensed staff administer the influenza vaccine to the residents, they documented in the MAR and this documentation was missing for Resident 93 on 9/11/2024. The IP further stated there was no informed consent obtained from Resident 93 or her Responsible Party (RP) regarding administration of the influenza vaccine. The IP stated licensed staff are required to speak with the residents or their RPs upon admission to see if they would like to receive the influenza vaccine. The IP stated, Seems like I did not check with Resident 93 or her RP to see if they were interested to receive the influenza vaccine. I documented by mistake that Resident 93 received her influenza vaccine on 9/11/2024. The IP stated the potential outcome of not offering a resident the influenza vaccine is the increased risk of getting the infection. During an interview on 10/24/2024 at 2:05 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to offer the Influenza vaccination to all residents upon admission. The DON stated Resident 93 did not receive the influenza vaccine since her admission to the facility. The DON stated the IP documented that she administered the influenza vaccine to Resident 93 on 9/11/2024 by mistake. The DON stated the potential outcome of not offering the influenza vaccine to a resident is placing them at the risk of contracting the virus and getting sick. During a review of the facility's policy and procedure titled Influenza and Pneumococcal Vaccine (helps protect against bacteria that cause lung inflammation) Administration, reviewed January 2024, the policy indicated that the resident or responsible party will be given the information to make a decision regarding the administration of the pneumococcal or flu vaccinations during the admission process. The facility may post that the flu vaccine will be administered beginning on a specific date and shall be part of consent for treatment. Promptly after administering the vaccinations, chart on MAR in accordance with the policy and procedures regarding medication administration noting the site and lot number of the vaccinations administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer the Coronavirus Disease (COVID-19, a severe respiratory illness caused by virus and transmitted from person to person) vaccination to one of five sampled residents (Resident 43). This deficient practice placed Resident 43 at a higher risk of acquiring (to get) and transmitting (pass on) the COVID-19 virus to other residents in the facility. Findings: During a review of Resident 43`s admission Record, the admission Record indicated that the facility originally admitted the resident on 2/3/2017, and readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), encounter for attention to tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), and dependence on respirator ( cannot breathe without a machine). During a review of Resident 43's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 7/6/2024, the MDS indicated 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 43 was dependent on staff (helper does all the effort) for toileting hygiene, showering and bathing, eating, and personal hygiene. During a review of Resident 43's Immunization Report, the report indicated that Resident 43 received the COVID-19 Pfizer (name of a company) Comirnaty Booster vaccine (an additional vaccine dose given to individuals) on 11/21/2023. During a review of Resident 43`s Nursing Progress Notes dated 11/17/2023 at 5:16 p.m., the document indicated that the facility`s licensed staff obtained a verbal consent for administration of the COVID-19 vaccine via telephone from Resident 43`s family member. During a review of Resident 43`s Medication Administration Record (MAR- includes key information about the individual's medication including, the medication name, dose taken, special instructions and date and time) for November 2023, the document indicated that a licensed nurse had marked other-see progress notes-9 for the administration of the COVID-19 Pfizer Comirnaty Booster vaccine. During a review of Resident 43`s Nursing Progress Notes dated 11/21/2023 at 11:47 p.m., the document indicated, Vaccine given by previous nurse, please see immunization record. During a review of Resident 43`s Care Plans, the document indicated no care plan was initiated to monitor potential adverse effects (a negative or harmful result) of administration of updated COVID-19 vaccine. During a concurrent interview and record review on 10/24/2024 at 11:35 a.m., with the facility`s Infection Preventionist Nurse (IP), Resident 43`s Immunizations Record, MAR and Nursing Progress Notes were reviewed. The IP stated Based on Resident 43`s Immunization Record, it looks like I administered the COVID-19 vaccine to the resident on 11/21/2023. However, on the Resident 43`s MAR for November 2023, my name is not indicated as a person who administered the vaccine. A licensed nurse had mentioned that this vaccine was administered by someone else. I do not remember if I administered this vaccine to Resident 43 and If I was the one, I don't understand why I did not document in the MAR myself. During a concurrent interview and record review on 10/24/24 at 1:08 p.m., with the facility`s Director of Nursing (DON), Resident 43`s Immunizations Record, MAR, and Nursing Progress Notes were reviewed. The DON stated Based on Resident 43`s Immunization records, it seems like the IP administered the COVID-19 vaccine on 11/21/2023. However, I do not know what time the COVID-19 vaccine was given to Resident 43. Resident 43`s Progress notes dated 11/21/2023, indicated that COVID-19 vaccine was given by a different nurse than the IP. The progress note does not say who the other nurse was. Why would a nurse document doing something that they did not do. The DON stated, I do not know if the COVID-19 vaccine was actually administered to Resident 43 on 11/21/2023. I would say the vaccine was not given to Resident 43 on 11/21/2023. During a telephone interview on 10/24/2024 at 1:30 p.m., with Resident 43`s Responsible Party 1 (RP1), the RP1 stated that the facility staff called him to get permission to administer the COVID-19 vaccine last year. However, the RP 1 stated that he is not sure whether or not Resident 43 received the COVID-19 vaccine. During a concurrent interview and record review on 10/24/2024 at 1:35 p.m., with the IP, Resident 43`s Care plans were reviewed. The IP stated no person-centered care plan was initiated for Resident 43 after the administration of the COVID-19 vaccine on 11/21/2023. The IP stated After the administration of the COVID-19 vaccine, I normally develop a care plan to monitor the resident post vaccine administration to see if the resident has any adverse reactions to the vaccine. I did not initiate a care plan with goal and interventions for Resident 43 post COVID-19 vaccine administration. It seems like the vaccine was never given to Resident 43. The IP stated the potential outcome of not administering the COVID-19 vaccine to an eligible resident increased the risk for the resident to contract COVID-19 and get sick. During a review of the facility's policy and procedure titled, COVID-19 Vaccination of Staff and Residents, reviewed January 2024, the policy indicated that if the purpose of this policy is to establish a process to encourage residents and staff to obtain the COVID-19 vaccine. If the resident is unvaccinated, the facility will make an effort to get them vaccinated within a week of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 26's admission Record, the document indicated that the facility originally admitted the resident on 7/11/2024, and readmitted on [DATE], with diagnoses including chronic respiratory failure (a long-term condition in which the respiratory system is unable to adequately exchange oxygen to the body), dependence on respirator (ventilator - a mechanical device that helps you breathe by moving air in and out of your lungs), encounter for attention to gastrostomy (G-tube-a surgical procedure used to insert a tube through the abdomen and into the stomach and used to provide a route for tube feeding), encounter for attention to tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe [trachea] to insert a tube that helps with breathing), and pain in leg. During a review of Resident 26's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 10/15/2024, the document indicated 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). During a review of Resident 26`s Physician orders dated 9/1/2024, the document indicated to document non-pharmacological interventions attempted for the resident`s pain and the effectiveness prior to the administration of PRN (as needed) pain medication as follows: 1-heat, 2-cold, 3-positioning, 4-massage, 5- music/television, 6-gentle Range of Motion (ROM- how far you can move or stretch a part of your body), 7-diversional activity ( is the act of switching your focus onto something else), 8- quiet environment, 9- other (chart on progress notes), 10-refused. During a review of Resident 26's Physician orders dated 9/1/2024, the document indicated that Resident 26 had an order for Hydrocodone-Acetaminophen oral tablet (used to treat moderate to severe pain) 5-325 mg, to administer one tablet via G-tube every six hours as needed for moderate to severe pain (4-10/ pain rating scale of zero being no pain and 10 being the worst pain possible). During a review of Resident 26`s Care Plan dated 7/11/2023, the document indicated that the resident had actual pain related to chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), tracheostomy, gastrostomy, and reduced mobility. The care plan interventions indicated to offer/provide non-pharmacological pain-relieving remedies (e.g. positioning, relaxation therapy, diversion/distraction), to observe/record/report to the nurse of the physician any sign and symptoms of non-verbal pain and to evaluate the effectiveness of pain interventions. During a review of Resident 26's MAR for the month of 9/2024, the document indicated the resident received hydrocodone-acetaminophen tablets two times on 9/2/2024 and 9/5/2024, three times on 9/8/2024, 9/9/2024, 9/10/2024, 9/12/2024, 9/15/2024, and four times on 9/11/2024. Resident 26 did not receive any non-pharmacological interventions prior to receiving PRN pain medication. During a review of Resident 26's MAR for the month of 10/2024, the document indicated the resident received hydrocodone-acetaminophen tablets four times on 10/4/2024, five times on 10/5/2024, two times on 10/11/2024, and three times on 10/18/2024, and 10/19/2024. Resident 26 did not receive any non-pharmacological interventions prior to receiving PRN pain medication. During a concurrent interview and record review on 10/23/2023 at 3:04 p.m., with the Director of Nursing (DON), reviewed Resident 26`s MARs dated 9/2024 and 10/2024 and physician orders. The DON stated licensed nurses are required to perform non-pharmacological pain interventions before administering any as needed pain medications. The DON stated Resident 26 received hydrocodone-acetaminophen tablet for pain four times on 10/4/2024, five times on 10/5/2024, two times on 10/11/2024, and three times on 10/18/2024 and 10/19/2024. The DON stated the licensed staff did not offer any non-drug methods to reduce Resident 26`s pain as ordered by the physician prior to administering PRN pain medication. The DON further stated Resident 26 received hydrocodone-acetaminophen tablets two times on 9/2/2024 and 9/5/2024, three times on 9/8/2024, 9/9/2024, 9/10/2024, 9/12/2024, 9/15/2024, and four times on 9/11/2024. The DON stated licensed staff did not provide non-pharmacological interventions prior to administering PRN pain medication. The DON stated the potential outcome is unrelieved pain and discomfort. During a review of the facility`s policy and procedures titled Pain Assessment, reviewed January 2024, the policy indicated it is the policy of this facility to assess residents for pain and provide adequate pain management as indicated. The plan of care may include non-pharmacological interventions which may include, but not limited to, repositioning, dimming lights, quit environment, application of hot or cold packs, relaxation techniques, distraction/activities, music, massage and /or any other individualized approaches. The effectiveness of any interventions , i.e. medication, positioning, distraction, etc., shall be documented. Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid pain medication (treats moderate to severe pain) to a resident for two of 30 sampled residents (Resident 204 and 26). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. During a review of Resident 204's admission Record, the admission Record indicated the facility admitted the resident on 10/14/2024 with diagnoses including atrial fibrillation (a heart condition that causes an irregular heartbeat) and pneumonitis (inflammation of the lung tissue). During a review of Resident 204's History and Physical (H&P - a comprehensive assessment of a resident that includes taking a detailed medical history from the resident and then performing a physical examination to gather objective findings), dated 10/15/2024, the H&P indicated the resident had fluctuating (to change or vary) capacity to give informed consent (a process in which residents are given important information, including possible risks and benefits, about a medical procedure or treatment) regarding his medical/physical treatment relating to an existing and continuing medical condition. During a review of Resident 204's care plan (a document that outlines a resident's health care needs and goals, and the treatments and activities that will help the resident achieve them) for chronic (persisting for a long time or constantly recurring) pain, initiated on 10/15/2024, the care plan indicated to offer/provide non-pharmacological pain relieving remedies (e.g. positioning, relaxation therapy, diversion/distraction, bathing, heat and cold application). During a review of Resident 204's physician's orders, the physician's orders indicated the following: - Hydrocodone-acetaminophen (medication used to treat moderate to severe pain) 10-325 milligrams (mg - unit of measurement), give one tablet by mouth every eight (8) hours as needed for moderate to severe pain 4-10/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered on 10/15/2024 and discontinued on 10/21/2024. - Hydrocodone-acetaminophen 5-325 mg, give one tablet by mouth every 8 hours as needed for moderate to severe pain 4-6/7-10/10, ordered on 10/21/2024. During a concurrent interview and record review on 10/24/2024 at 8:10 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 204's Medication Administration Record (MAR - a report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) dated 10/2024. LVN 1 verified by stating the following: - Hydrocodone-acetaminophen 10-325 mg was administered on 10/15/2024 at 3 p.m., and no non-pharmacological interventions were documented as being attempted. - Hydrocodone-acetaminophen 10-325 mg was administered on 10/16/2024 at 4:30 p.m., and no non-pharmacological interventions were documented as being attempted. - Hydrocodone-acetaminophen 10-325 mg was administered on 10/17/2024 at 9:52 a.m. and 6:46 p.m., and no non-pharmacological interventions were documented as being attempted. - Hydrocodone-acetaminophen 10-325 mg was administered on 10/18/2024 at 2:50 a.m., and no non-pharmacological interventions were documented as being attempted. - Hydrocodone-acetaminophen 10-325 mg was administered on 10/20/2024 at 4:29 p.m., and no non-pharmacological interventions were documented as being attempted. - Hydrocodone-acetaminophen 10-325 mg was administered on 10/21/2024 at 9:05 a.m., and no non-pharmacological interventions were documented as being attempted. - Hydrocodone-acetaminophen 5-325 mg was administered on 10/22/2024 at 8:30 a.m., and no non-pharmacological interventions were documented as being attempted. LVN 1 stated it was important to first attempt non-pharmacological interventions prior to administering an opioid pain medication to ensure that it was not being given unnecessarily. LVN 1 stated that residents could experience adverse side effects such as increased drowsiness, nausea/vomiting, and constipation, especially since they are taking so many other medications. LVN 1 stated that, sometimes, residents' pain can be alleviated through non-pharmacological interventions, and medication may not even be necessary. During an interview on 10/24/2024 at 10:26 a.m., with the Director of Nursing (DON), the DON stated it was good nursing practice to attempt non-pharmacological interventions prior to administering opioid pain medication because residents can experience side effects such as sleepiness, constipation, and central nervous system (CNS - made up of the brain and spinal cord) depression with the use of opioid pain medications. During a review of the facility's policy and procedure titled, Pain Assessment, last reviewed and revised on 1/17/2024, the policy and procedure indicated that the effectiveness of any intervention, i.e. mediation, positioning, distraction, etc., shall be documented.

2. During a review of Resident 70's admission Record, the admission Record indicated the facility originally admitted the resident on 11/23/2022 and readmitted the resident on 9/12/2024 with diagnoses including, but not limited to, ESRD (ESRD - irreversible kidney failure), acute (when symptoms begin and worsen quickly) and chronic (long-term) respiratory failure with hypoxia (when your blood doesn't carry enough oxygen to your tissues), and metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood). During a review of Resident 70's History and Physical, dated 9/19/2024, the History and Physical indicated Resident 70 could make his needs known but could not make medical decisions. During a review of Resident 70's Order Summary Report, the Order Summary Report indicated the following active orders: 1. Bedside hemodialysis to be performed by Dialysis Company (DC) 1 every Monday, Wednesday, and Friday. 2. Give one metoprolol 50 milligram tablet every eight hours for hypertension (high blood pressure). Hold the dose at 2:00 p.m. on dialysis days (Monday, Wednesday, and Friday). During a concurrent interview and record review on 10/24/2024 with Licensed Vocational Nurse (LVN) 2, Resident 70's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated October 2024, indicated metoprolol was administered to Resident 70 at 2:00 p.m. on Monday 10/7/2024, Wednesday 10/16/2024, and Monday 10/21/2024. LVN 2 stated the metoprolol should have been held on those shifts. LVN 2 stated Resident 70's blood pressure could be low if he is given metoprolol at those times. During a review of Resident 70's dialysis assessments, dated 10/7/2024, 10/16/2024, and 10/24/2024, the dialysis assessments indicated Resident 70 received dialysis on these dates. During a current interview and record review on 10/24/2024 at 3:26 p.m. with the Director of Nursing (DON), DON confirmed Resident 70's MAR, dated October 2024, indicated metoprolol was administered to Resident 70 at 2:00 p.m. on 10/7/2024, 10/16/2024, and 10/21/2024. The DON stated the metoprolol should have been held at those times, and the resident could experience hypotension (low blood pressure) if it is not held. During a review of the facility's policy and procedure titled, Dialysis Resident, Care Of, last reviewed 1/17/2024, the policy and procedure indicated medications on days of dialysis should only be held by physician's order. During a review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/17/2024, the policy and procedure indicated medications are administered in accordance with written orders of the prescriber. The policy and procedure further indicated the physician's orders should be checked for the correct dosage schedule before administration of any medication. Based on interview and record review, the facility failed to ensure that two of 30 sampled residents (Residents 24 and 70) were administered medications as prescribed by the physician when: 1. Lorazepam (anti-anxiety medication) was not administered to Resident 24 in accordance with physician's orders. 2. Three doses of metoprolol (a medication that treats high blood pressure, chest pain, and heart failure) were not held as ordered when Resident 70 received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). These deficient practices had the potential to place Resident 24 at increased risk of being given extra doses of lorazepam and Resident 70 to experience low blood pressure. Findings: 1. During a review of Resident 24's admission Record, the admission Record indicated the facility admitted the resident on 8/16/2024 with diagnoses including acute and chronic respiratory failure (inadequate gas exchange by the respiratory system). During a review of Resident 24's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/7/2024, the MDS indicated the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through the senses, experience, and thought) and was dependent on staff for activities of daily living (ADLs - the basic tasks people need to do every day to care for themselves and stay safe and healthy). On 10/24/2024 at 8:22 a.m., a concurrent interview and record review of Resident 24's physician's orders were conducted with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated the resident had an order for lorazepam 0.5 milligrams (mg - unit of measurement) via gastrostomy tube (GT - a surgically inserted tube that provides direct access to the stomach for nutritional support, hydration, and medication) as needed (prn) for anxiety manifested by inability to stay still and pulling out tubes for 30 days at midnight. Reviewed the resident's 10/20204 Medication Administration Record (MAR - a report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) with LVN 1. LVN 1 stated lorazepam 0.5 mg prn was given to the resident on the following dates and times: 1. 10/4/2024 at 8 a.m. 2. 10/5/2024 at 3:36 p.m. 3. 10/7/2024 at 2:44 p.m. 4. 10/9/2024 at 5:17 p.m. 5. 10/10/2024 at 3:16 p.m. 6. 10/14/2024 at 11:45 a.m. 7. 10/18/2024 at 4:32 p.m. 8. 10/19/2024 at 9:38 a.m. LVN 1 stated lorazepam was ordered to be given at midnight because that was usually the time when the resident became increasingly agitated. LVN 1 stated the nurses should have been administering the lorazepam at midnight. LVN 1 stated if the nurses needed to administer the lorazepam at any other time than midnight, then they should have called to inform the doctor first. LVN 1 stated she could not find any documentation indicating that the doctor was notified that the resident needed lorazepam at other times besides midnight. During a review of Resident 24's care plan (a document that outlines a patient's health care needs and goals, and the treatments and activities that will help the patient achieve them) for behavior of anxiety manifested by inability to stay still leading to pulling out tubing, initiated on 8/30/2024, the care plan indicated to administer anti-anxiety medication as ordered. On 10/24/2024 at 9:57 a.m., during an interview, the Director of Nursing (DON) stated the licensed nurses should have informed the doctor that the resident was manifesting behaviors and needed lorazepam at other times than midnight. When asked if the nurses were following the physician's orders, the DON stated, No. During a review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed and revised on 1/17/2024, the policy and procedure indicated that medications are administered as prescribed in accordance with good nursing principles and practices .The five rights - right resident, right drug, right dose, right route, and right time are applied for each medication being administered .Medications are administered in accordance with written orders of the prescriber.

Based on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) lorazepam (medication used to treat anxiety disorder [intense, excessive, and persistent worry and fear about everyday situations]) to a resident for one of 30 sampled residents (Resident 24). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from lorazepam. Findings: During a review of Resident 24's admission Record, the admission Record indicated the facility admitted the resident on 8/16/2024 with diagnoses including acute (sudden) and chronic (persisting for a long time or constantly recurring) respiratory failure (inadequate gas exchange by the respiratory system). During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/7/2024, the MDS indicated the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through the senses, experience, and thought) and was dependent on staff for activities of daily living (ADLs - activities related to personal care). During a review of Resident 24's care plan (a document that outlines a resident's health care needs and goals, and the treatments and activities that will help the resident achieve them) for behavior of anxiety manifested by inability to stay still leading to pulling out tubing (medical device), initiated on 8/30/2024, the care plan indicated to provide non-pharmacological interventions to alleviate anxiety: reposition for comfort, reposition GT tubing as needed, deep breathing exercises, relaxation therapy, diversion/distraction, music therapy, and storytelling. During a concurrent interview and record review on 10/24/2024 at 8:22 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 24's physician's orders and Medication Administration Record (MAR - a report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional). LVN 1 stated Resident 24 had an order for lorazepam 0.5 milligrams (mg - unit of measurement) via gastrostomy tube (GT - a surgically inserted tube that provides direct access to the stomach for nutritional support, hydration, and medication) as needed for anxiety manifested by inability to stay still and pulling out tubes for 30 days at midnight, ordered 9/20/2024. LVN 1 verified by stating the following: - On 10/4/2024 at 8 a.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. - On 10/5/2024 at 3:36 p.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. - On 10/7/2024 at 2:44 p.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. - On 10/9/2024 at 5:17 p.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. - On 10/10/2024 at 3:16 p.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. - On 10/14/2024 at 11:45 a.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. - On 10/16/2024 at 12 a.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. - On 10/18/2024 at 4:32 p.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. - On 10/19/2024 at 12:26 a.m. and 9:38 a.m., the nurse administered lorazepam to Resident 24 but did not document that non-pharmacological interventions were attempted first. LVN 1 stated it was important to first attempt non-pharmacological interventions prior to administering lorazepam to ensure that it was not being given unnecessarily. LVN 1 stated that residents could experience adverse side effects such as increased drowsiness. LVN 1 stated that medication may not even be necessary if non-pharmacological interventions can alleviate the resident's symptoms. During an interview on 10/24/2024 at 9:57 a.m., with the Director of Nursing (DON), the DON stated it was good nursing practice for nurses to attempt non-pharmacological interventions prior to administering medication because residents can experience adverse side effects, such as sedation (state of relaxation or sleepiness caused by drugs), from lorazepam. During a review of the facility's policy and procedure titled, Psychoactive Medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), last reviewed and revised on 1/17/2024, the policy and procedure did not indicate any information regarding non-pharmacological interventions. During an interview on 10/24/2024 at 10:26 a.m., with the DON, the DON stated that was the only policy and procedure the facility had regarding the use of psychoactive medications.

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 to the State Survey Agency (SSA) an injury of unknown source within two (2) hours for one of three sampled residents (Resident 1). 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 1 ' s admission Record indicated the facility originally admitted Resident 1 on 5/13/2021 and readmitted the resident on 4/11/2024 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/3/2024 indicated Resident 1 ' s cognition (ability to think and make decisions) was severely impaired. The MDS further indicated that Resident 1 needed moderate assistance from staff with eating and extensive assistance from staff with bed mobility (movement), personal hygiene, lower body dressing, transfer, and toilet use. A review of Resident 1 ' s Change in Condition (COC- when there is a sudden change from a resident ' s health) Evaluation Form dated 4/10/2024, timed at 8:15 a.m., indicated, Resident 1 was observed with left hand swelling, purplish discoloration (change in a person ' s natural skin tone), and pain if touched. Resident 1 holds her left hand with her right-hand indicating pain or discomfort. Resident 1 was frowning and moaning when left hand was touched. Resident 1 was given PRN (as needed) pain medication. Further review of Resident 1 ' s COC indicated that Resident 1 ' s physician was notified on 4/10/2024 at 8:38 a.m. and ordered to obtain STAT (immediately) X-radiation (X-ray - a diagnostic test that captures images of the structures inside the body) of Resident 1 ' s left hand. A record review of Resident 1 ' s X-ray report of the left hand dated 4/10/2024, indicated that Resident 1 had an acute (severe and sudden onset) fracture (break in bone) of the 4th metacarpal (palm bones). A review of the facility reporting verification of the initial report to the SSA dated 4/16/2024, titled Facility Fax Cover Sheet, indicated that the facility faxed it to the SSA on 4/16/2024 at 4:35 p.m. During a concurrent interview and record review with the Director of Nursing (DON) on 4/30/2024 at 1:03 p.m., the DON reviewed Resident 1 ' s X-ray report of the left hand dated 4/10/2024. The DON stated that the facility did not report to the SSA within two (2) hours because the facility determined that Resident 1 ' s fracture was not a result of abuse or mistreatment and instead was more of a pathological (caused by disease) fracture. When the DON was asked if Resident 1 was able to explain what happened and if the source of the injury was observed by a staff or another resident, the DON stated Resident 1 was unable to describe what happened to her left hand and no one witnessed how Resident 1 sustained the injury. A review of the facility ' s P&P titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin revised August 2022 and last reviewed on 1/17/2024, indicated, Facility Reporting any reports made by residents, employees or visitors, that a resident may have been subject to inappropriate conduct and/or have an injury of unknown source then the Administrator, DON, and/or mandated reporter must: 1. Call local law enforcement immediately, but no later than two hours after the allegation is made; and 2. File a written or electronic report to the Long Term Care Ombudsman (advocates for residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), local law enforcement and District Office (SSA) within two hours .

Based on observation, interview, and record review, the facility failed to ensure that Certified Nursing Assistant 2 (CNA 2) was seated and at eye level while assisting a resident with feeding for one of one sampled residents (Resident 32) investigated for dignity. This deficient practice had the potential to affect Resident 32's sense of self-worth and self-esteem. Findings: A review of Resident 32's admission Record indicated the facility originally admitted the resident on 8/14/2014 and readmitted the resident on 8/4/2016 with diagnoses including personal history of transient ischemic attack (temporary blockage of blood flow to the brain) and cerebral infarction (refers to damage to tissues in the brain due to loss of oxygen to the area), and dysphagia (difficulty swallowing). A review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/13/2023, indicated the resident had severely impaired cognitive (relating to or involving the process of thinking and reasoning) skills of daily decision making and was totally dependent (the individual needs another person to completely or totally perform the task for the individual) on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 32's Care Plan for activities of daily living (ADL - activities related to personal care) self-care performance deficit, initiated on 5/15/2017 and last revised on 4/17/2023, indicated the resident is totally dependent on staff with one-person assist for eating. During a concurrent observation and interview on 10/2/2023 at 1:04 p.m., observed Certified Nursing Assistant 2 (CNA 2) feeding Resident 32 while the resident was in bed. Observed CNA 2 standing next to the bed, not at eye level with the resident. Observed a chair inside Resident 32's room behind the door. CNA 2 stated he should be sitting and at eye level while feeding the resident so that the resident does not feel rushed. CNA 2 stated he would also be able to observe the resident better while he was eating. During an interview on 10/4/2023 at 8:34 a.m., with Registered Nurse 2 (RN 2), RN 2 stated that Resident 32 needed assistance with eating. RN 2 stated that the resident should be sitting upright while eating, and the CNA feeding him should be sitting next to him at eye level so that he/she can observe if the resident is choking. RN 2 stated that it's also a form of respect to the resident to be sitting next to him/her at eye level. During an interview on 10/4/2023 at 3:32 p.m., with the Director of Staff Development (DSD), the DSD stated he has given inservices to CNAs regarding how to properly feed totally dependent residents. The DSD stated that, as part of the lesson, he tells the staff that the CNA should be sitting and positioned at eye level with the resident, so the resident can be comfortable, and so that the CNA can observe for swallowing and aspiration (when food, liquid, or other material accidentally enters a person's airway and eventually the lungs). The DSD stated that, if not at eye level, the resident can aspirate or feel like they are being rushed with eating. During an interview on 10/5/2023 at 10:16 a.m., with the Director of Nursing (DON), the DON stated that they do provide inservices to their staff regarding how to assist residents with feeding. The DON stated she teaches her staff to make sure they are at eye level with the resident while feeding them. The DON stated it was important to be at eye level with the resident because it was an issue of dignity; the resident could possibly feel like the staff is looking down at him/her if they are not at eye level. The DON stated there was no policy specifying that staff should be at eye level with the resident while feeding them. A review of the facility's policy and procedure titled, Resident [NAME] of Rights, last reviewed on 1/2023, indicated that residents have the right to be treated with consideration, respect and full recognition of dignity and individuality .

Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was set according to the resident's weight and comfort for one of two sampled residents (Resident 94). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 94's admission Record indicated the facility admitted the resident on 05/08/2023, with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and morbid obesity (is when you weigh 100 pounds over your recommended weight). A review of Resident 94's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 08/12/2023, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS indicated the resident required extensive assistance from staff for bed mobility, dressing, eating, personal hygiene, and total dependence on staff for toilet use and bathing. During a concurrent observation, interview, and record review on 10/03/2023 at 7:26 a.m., with the Director of Nursing (DON), reviewed Resident 94's weight and the DON stated Resident 94's current weight on 10/3/2023 was 260 pounds (lbs.- a unit of weight). Observed with the DON, Resident 94's LALM set between 200-230 lbs. The DON stated the setting (200 lbs.-230 lbs.) of the LALM was not appropriate for Resident 94's weight of 260 lbs. When interviewed, Resident 94 stated that he is not comfortable with his bed as it sometimes moves, and the side of the bed is sometimes lower when he moves. The DON stated LALM are used for wound management if a resident has pressure ulcers and some for comfort. The DON stated that the setting of the LALM would correspond to the resident`s weight and the treatment nurses must ensure it is the correct setting since they provide wound care every day. The DON stated that if not correctly set, it may affect and delay wound healing and could delay the time to resolve the wound. A review of the facility-provided manufacture's guidelines titled, LALM Weight and Comfort Level Reference, undated, indicated a setting of six (6) light bars corresponded to a weight of 230 lbs. to 265 lbs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure only medications that were administered were documented in the Medication Administration Record (MAR-report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for two of ten sampled residents (Residents 11 and 35) observed for medication administration. This deficient practice resulted in residents' medical records that were not accurate and not in accordance with professional standards of practice. Findings: a. A review of Resident 11's admission Record indicated the facility originally admitted the resident to the facility on 4/8/2008 and readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), other disorders of phosphorous (type of mineral) metabolism, and dysphagia (difficulty swallowing). A review of Resident 11's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 8/10/2023, indicated Resident 11's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was moderately impaired. The MDS also indicated the resident required extensive assistance from staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 11's Physician's Orders indicated magnesium (type of mineral) chloride-calcium (types of minerals) (MgCl2- Ca) delayed release 64-106 milligram (mg- a unit of measurement) two tablets by mouth two times a day for low magnesium, dated 11/10/2021. b. A review of the Resident 35's admission Record indicated the facility originally admitted the resident to the facility on 7/3/2019 and readmitted on [DATE], with diagnoses that included heart failure (heart is not pumping as well as it should be), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and hyperlipidemia (condition in which there are high levels of lipids [fat particles] in the blood). A review of Resident 35's MDS dated [DATE], indicated Resident 35's cognitive skills for daily decision-making was intact. The MDS also indicated the resident required extensive assistance from staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 35's Physician's Orders dated 6/3/2022 included Vascepa (medication used to lower the risk of certain cardiovascular [relating to the heart and blood vessels] problems in adults with high triglyceride [type of fat] levels) capsule 0.5 gram (gm- a unit of measurement) give one capsule by mouth two times a day for hypertriglyceridemia (a high level of a certain type of triglycerides in the blood). During a concurrent medication pass observation and interview on 10/4/2023 at 04:20 PM, with Licensed Vocational Nurse 5 (LVN 5), LVN 5 held Resident 11's MgCl2-Ca delayed release 64-106 mg two tablets by mouth two times a day for low magnesium. LVN 5 stated that MgCl2- Ca is not available. During the continued medication observation, LVN5 prepared the 5:00 p.m. doses for Resident 35 and stated that the Vascepa 0.5 gm capsule one tablet by mouth daily bubble pack (a package that contains multiple sealed compartments with medication/s) is empty. LVN 5 stated that he would call the pharmacy to request for a refill of the Vascepa and MgCl2-Cal, which were not administered due to the medications not being available. During a concurrent interview and record review on 10/5/2023 at 9:12 a.m., with LVN 5, reviewed the MAR for Residents 11 and 35. The MAR indicated the following: - For Resident 11, MgCl2-Ca was documented in the MAR as administered on 10/4/2023 at 5:00 p.m. - For Resident 35, Vascepa was documented in the MAR as administered on 10/4/2023 at 5:00 p.m. LVN 5 stated that he did not give the MgCl2-Ca and Vascepa for Resident 11 and Resident 35 respectively. LVN 5 stated that it was a mistake that he charted the medications as given, although he stated he knew that it was not given. A review of the facility's policy and procedure titled, Medication Administration- General Guidelines, last reviewed on 1/26/2023, indicated that medications are administered in accordance with written orders of the attending physician .medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes .if a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was documented evidence that the pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) was offered to one of five sampled residents (Resident 34). This deficient practice placed Resident 34 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. Findings: A review of Resident 34's admission Record indicated the facility originally admitted the resident on 1/7/2015 and readmitted on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), gastrostomy (GT-tube inserted through the belly that brings nutrition directly to the stomach) and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). A review of Resident 34's Minimum Data Set (MDS-standardized assessment and screening tool) dated 9/6/2023, indicated resident had severely impaired cognition (ability to think and make decisions). A review of Resident 34's Immunization Record indicated Resident 34 had the pneumococcal vaccine on 2/11/2015. During a concurrent interview and record review on 10/3/2023 at 10:22 a.m. with the Infection Preventionist Nurse (IPN), reviewed Resident 34's Immunization Record. The IPN stated that Resident 34 had the pneumococcal vaccine on 2/11/2015. The IPN also indicated that Resident 34 was admitted on [DATE]. The IPN stated that there was no record of what kind of pneumococcal vaccine Resident 34 had. The IPN stated that the pneumococcal vaccine needs to be verified during admission to make sure that the resident had the vaccination. The IPN also stated that Resident 34 should have been offered another pneumococcal vaccine every five years. The IPN stated that there was no documented evidence Resident 34 or Resident 34's resident representative (RP) was offered the pneumococcal vaccine since admission. A review of the facility's policy and procedure titled, Influenza and Pneumococcal Vaccine Administration, reviewed on 1/26/2023, indicated it is the policy of the facility to offer and provide influenza and pneumococcal vaccinations to residents in accordance with the Centers for Disease Control and Prevention (CDC) recommendations and physician orders. A review of the CDC guidance for pneumococcal vaccine titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, last reviewed 12/13/2023, indicated that adults who have never received a pneumococcal conjugate vaccine should receive PCV15 (type of pneumococcal vaccine) or PCV20 (type of pneumococcal vaccine) if they are 65 years and older and are 19 through [AGE] years old and have certain medical conditions or other risk factors. If PCV15 is used, it should be followed by a dose of PPSV23 (type of pneumococcal vaccine). Adults who received an earlier pneumococcal conjugate vaccine (PCV13 or PCV7 [types of pneumococcal vaccine]) should talk with a vaccine provider to learn about available options to complete their pneumococcal vaccine series. Adults 65 years or older have the option to get PCV20 if they have already received PCV13 (type of pneumococcal vaccine) (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain residents' room temperatures at a range between 71 and 81 degrees Fahrenheit (° F, a measurement of temperature) for four of four sampled residents (Resident 354, 59, 105, and 104). This deficient practice resulted in increased levels of discomfort for the residents and had the potential to negatively impact the resident's quality of life. Findings: a. A review of Resident 354's admission Record indicated the facility admitted the resident on 9/18/2023 with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain) affecting the right dominant (strong) side and aphasia (difficulty speaking). A review of Resident 354's Minimum Data Set (MDS - an assessment and screening tool) dated 9/24/2023, indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS indicated the resident required extensive staff assistance with bed mobility, transfer, walking in the room, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 10/2/2023 at 9:36 a.m. with Resident 354, observed Resident 354 in her room with a blanket on. Resident 354 stated that she was too cold. During a concurrent observation and interview on 10/3/2023 at 11:52 a.m. with Maintenance (MT), Resident 354's room was observed. MT stated the temperature of the facility is to be kept between 71 and 78 ° F . Observed MT point a laser thermometer (a device that measures ambient temperatures) at various locations of Resident 354's room. MT stated the laser thermometer indicted the room temperature was 69 ° F . MT stated the room was not within the facility guidelines for temperature. MT then stated he remembered there was a complaint on 10/2/2023 regarding the temperature in Resident 354's room being cold. During an interview on 10/3/2023 at 12:30 p.m. with MT, MT stated on 10/2/2023 he was notified of a temperature concern by Resident 354. MT stated that he adjusted the thermostat (device that can increase or decrease the temperature in an area) in an effort to increase the temperature in Resident 354's room. MT stated he did not return to ensure the temperature had increased. b. A review of Resident 59's admission Record indicated the facility admitted the resident on 4/20/2023 with diagnoses that included gastroenteritis (infection and inflammation of the digestive system) and colitis (inflammation in the colon), presence of right artificial (made by humans rather than naturally occurring) knee joint (area of the leg that bends and allows movement), and aftercare following joint replacement surgery. A review of Resident 59's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS indicated the resident required extensive staff assistance with bed mobility, transfer, walking, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 10/2/2023 at 1:20 p.m. with Resident 59, observed Resident 59 sitting in a wheelchair wearing a sweater and covered with a blanket. Resident 59 stated her room is always very cold. Resident 59 stated she had complained to staff but did not remember to whom. Resident 59 stated she moved from the bed near the vent to the bed furthest away from the vent, but it did not help, and she was still cold every day. Resident 59 stated that the facility staff did not fix the problem. During a concurrent observation and interview on 10/3/2023 at 11:40 a.m. with Resident 59, observe Resident 59 sitting in a wheelchair wearing a sweater and covered with a blanket, the room felt cool. Resident 59 stated her room was still cold and she told staff and they did nothing about it. During a concurrent observation and interview on 10/3/2023 at 11:52 a.m. with MT, observed MT point the laser thermometer in various locations of Resident 59's room. MT stated that the laser thermometer indicted Resident 59's room temperature was 68 ° F. MT stated the temperature of the facility is kept between 71 and 78 ° F. MT stated that there was a complaint on 10/2/2023 regarding the temperature in rooms in the same area as Resident 59's room. MT stated he adjusted the thermostat for the area, but he did not return to ensure the temperature had adjusted and that residents were comfortable. c. A review of Resident 105's admission Record indicated the facility admitted the resident on 9/17/2023 with diagnoses that included polyneuropathy (a condition that causes a decreased ability to move and feel). A review of Resident 105's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS indicated the resident required extensive staff assistance with bed mobility, transfer, walking, dressing, eating, toilet use, and personal hygiene. During an interview on 10/03/23 at 09:58 a.m., Resident 105 stated it had been freezing in her room. Resident 105 stated she had spoken with MT about her room temperature. Resident 105 stated MT told her they kept the facility cold to prevent bacteria from growing. During a concurrent observation and interview on 10/3/23 at 11:52 a.m. with MT, observed MT pointed the laser thermometer gun in various locations of Resident 105's room and stated it indicated the room temperature was 68 °F. MT stated the temperature of the facility should be kept between 71 and 78 ° F. MT stated that Resident 105's room was not within the facility guidelines for temperature. During a concurrent observation and interview on 10/3/2023 at 3:15 p.m. with Resident 105, observed Resident 105 sitting in her room in a wheelchair wearing a sweater. Resident 105 stated she has complained about the cold temperature inside her room to maintenance staff, nurse aids, and nurses, but Resident 105 was unable to recall the names of the staff she informed. Resident 105 stated staff never fixed the cold temperature of her room. Resident 105 stated she must bundle up in extra clothing when she starts shivering due to the cold temperature in her room. d. A review of Resident 104's admission Record indicated the facility admitted the resident on 9/14/2023 with diagnoses that included urinary tract infection (UTI, an infection in the urinary system). A review of Resident 104's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS indicated the resident required extensive staff assistance with bed mobility, transfer, walking, dressing, eating, toilet use, and personal hygiene. During an interview on 10/03/23 at 10:11 a.m., Resident 104 stated her room has been cold for several nights. Resident 104 stated that she has been given extra blankets, but staff has not adjusted the temperature of her room. During a concurrent observation and interview on 10/3/23 at 11:52 a.m. with MT, observed MT point the laser thermometer in various locations of Resident 104's room and stated it indicted the room temperature was 68 °F. MT stated the temperature of the facility should be kept between 71 and 78 ° F. MT stated that Resident 104's room was not within the facility guidelines for temperature. During an interview on 10/3/2023 at 5:10 p.m. with MT, MT stated it was his job to listen to residents and ensure the temperature of the facility was comfortable for the residents. MT stated the facility policy indicates that the temperature of the facility should actually be maintained between 71 to 81 ° F. During an interview on 10/4/2023 at 1:10 p.m. with the Director of Nursing (DON), the DON stated the facility room temperatures should be between 71 to 81 ° F. The DON stated the importance of maintaining this temperature range is so that the residents are comfortable. A review of the facility policy and procedure titled, Weather Fluctuation Policy, last reviewed 1/26/2023, indicated the purpose of the policy was to ensure the facility maintains a comfortable environment for residents, visitors, and staff. The policy further states that the facility will maintain a temperature between 71 to 81 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes, board and care homes, and assisted living facilities) of the transfers and discharges from the facility for 12 of 12 sampled residents (Resident 102, 304, 306, 307, 308, 309, 310, 311, 312, 313, 76, and 91) investigated addressing the care area of discharge. These deficient practices had the potential to deny residents protection from being inappropriately discharged . Findings: a. A review of Resident 102's admission Record indicated the facility admitted the resident on 8/10/2023 with diagnoses including aftercare following joint replacement surgery (surgical procedure in which part of the damaged joint are removed and replaced with a metal, plastic or ceramic device), anemia (blood has a lower than normal number of red blood cells), and hypertension (high blood pressure). A review of Resident 102's Minimum Data Set (MDS-standardized assessment and screening tool) dated 8/16/2023, indicated the resident had intact cognition (ability to think and make decisions). A review of Resident 102's Physician's Orders dated 8/25/2023, indicated the resident had an order to be discharged home on 8/29/2023 with home health (HH-skilled services provided at home) follow-up for physical therapy (PT), occupational therapy (OT), bath aid and nursing services. A review of Resident 102's Notice of Transfer and Discharge form dated 8/28/2023, indicated the resident was discharged due to the resident's health being improved sufficiently so that she no longer required services provided by the facility. b. A review of Resident 304's admission record indicated the facility admitted the resident on 3/20/2023 with diagnoses including hemiplegia (muscle weakness or paralysis on onside of the body), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), and dysphagia (difficulty swallowing). A review of Resident 304's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 304's Physician's Order dated 8/30/2023, indicated the resident had an order for discharge home on 8/30/2023 as per the resident and family's request. A review of Resident 304's Notice of Transfer and Discharge form dated 8/29/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. c. A review of Resident 306's admission Record indicated the facility originally admitted the resident on 4/9/2018 and readmitted on [DATE] with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system), heart failure (heart does not pump blood as well as it should), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes sugar in the blood). A review of Resident 306's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 306's Physician's Order dated 8/25/2023, indicated the resident had an order for discharge home on 8/26/2023 with HH follow, PT, OT and nursing services. A review of Resident 306's Notice of Transfer and Discharge form dated 8/24/2023 with an effective date of 8/26/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. d. A review of Resident 307's admission Record indicated the facility admitted the resident on 8/7/2023, with diagnoses including left lower leg cellulitis (infection of the skin), type 2 diabetes mellitus, and UTI. A review of Resident 307's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 307's Physician's Order dated 8/25/2023, indicated the resident had an order for discharge home on 8/25/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 307's Notice of Transfer and Discharge form dated 8/23/2023 with an effective date of 8/25/2023, indicated resident was discharged due their last cover date issued on 8/24/2023. During a concurrent interview and record review on 10/5/2023 at 8:47 a.m. with Case Manager (CM 1), reviewed Resident 307's Notice of Transfer and Discharge form dated 8/23/2023. CM 1 stated Resident 307 was discharged because the discharge was appropriate because her health had improved sufficiently so that she no longer required services provided by the facility. e. A review of Resident 308's admission Record indicated the facility admitted the resident on 8/4/2023, with diagnoses including heart failure, UTI and dysphagia. A review of Resident 308's MDS dated [DATE], indicated the resident had moderately impaired cognition. A review of Resident 308's Physician's Orders dated 8/22/2023, indicated the resident had an order for discharge home on 8/23/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 308's Notice of Transfer and Discharge form dated 8/22/2023 with an effective date of 8/23/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. f. A review of Resident 309's admission Record indicated the facility admitted the resident on 8/4/2023, with diagnoses including aftercare following joint replacement surgery, morbid obesity (weight is more 80 to 100 pounds above ideal body weight) and anxiety disorder (intense, excessive, and persistent worrying and fear about everyday situations). A review of Resident 309's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 309's Physician's Order dated 8/18/2023, indicated the resident had an order for discharge home on 8/22/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 309's Notice of Transfer and Discharge form dated 8/21/2023 with an effective date of 8/21/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. g. A review of Resident 310's admission Record indicated the facility admitted the resident on 8/11/2023, with diagnoses including fracture (broken bone) of the spine, type 2 diabetes mellitus, and low back pain. A review of Resident 310's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 310's Physician's Orders dated 8/18/2023, indicated the resident had an order for discharge home on 8/20/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 310's Notice of Transfer and Discharge form dated 8/18/2023 with effective date of 8/20/2023, indicated the resident was discharged due to resident and family request. h. A review of Resident 311's admission Record indicated the facility admitted the resident on 8/4/2023, with diagnoses including pneumonia (infection of the lungs), sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), and type 2 diabetes mellitus. A review of Resident 311's MDS dated [DATE], indicated the resident had moderately impaired cognition. A review of Resident 311's Physician's Order dated 8/18/2023, indicated the resident had an order for discharge home on 8/19/2023 per family's request with HH follow, PT, OT, bath aid and nursing services. A review of Resident 311's Notice of Transfer and Discharge form dated 8/18/2023 with an effective date of 8/19/2023, indicated the resident was discharged due to resident and family request. i. A review of Resident 312's admission Record indicated the facility admitted the resident on 6/19/2023, with diagnoses including chronic respiratory failure, dysphagia, and diabetes. A review of Resident 312's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 312's Physician's Order dated 8/11/2023, indicated the resident had an order for discharge home on 8/15/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 312's Notice of Transfer and Discharge form dated 8/14/2023 with an effective date of 8/14/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. j. A review of Resident 313's admission Record indicated the facility admitted the resident on 6/30/2022, with diagnoses including hemiplegia, diabetes, and dysphagia. A review of Resident 313's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 313's Physician's Orders dated 7/31/2023, indicated the resident had an order for discharge home on 8/1/2023 with family and HH follow, PT, OT, bath aid and nursing services. A review of Resident 313's Notice of Transfer and Discharge form dated 7/31/2023 with an effective date of 8/1/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. During an interview on 10/4/2023 at 8:35 a.m., with the Social Services Director (SSD), the SSD stated that the Medical Record Director (MRD) was assigned to notify the Ombudsman of all the discharges and transfers to the hospital by faxing the list of the resident discharges and transfers at the end of the month to the Ombudsman. During a concurrent interview and record review on 10/4/2023 at 9:40 a.m., with the MRD, reviewed the list of residents who were transferred to the hospital and discharged from the facility for the month of 8/2023. The MRD stated that she faxes the list of resident transfers and discharges from the facility at the end of the month to the Ombudsman. The MRD was unable to provide documented evidence that the Ombudsman was notified of Resident 102, 304, 306, 307, 308, 309, 310, 311, 312, and 313's discharges from the facility. The MRD was unable to provide the fax confirmation to the Ombudsman of the resident discharges and transfers for the month of 8/2023. The MRD stated that it meant that the Ombudsman was not notified of all the discharges and transfers from the facility for the month of 8/2023. During an interview on 10/4/2023 at 9:33 a.m., with the Ombudsman, the Ombudsman stated that it is important for the facility to notify the Ombudsman about the transfers and discharges as soon as possible so they can check and follow-up with the residents who are being discharged and make sure that they are not being discharged inappropriately. The Ombudsman stated that the notice of transfer and discharge form should be faxed to them as soon as the resident or resident representative (RP) signed the form. During an interview on 10/5/2023 at 8:32 a.m., with the SSD, the SSD stated that the Notice of Transfer and Discharge forms should be faxed as soon as the resident signed the form and for emergency transfers as soon as practicable to the Ombudsman. The SSD stated that the purpose of faxing a copy of the Notice of Transfer and Discharge form to the Ombudsman was to notify the Ombudsman that the residents are being discharged and transferred and to make sure that they are not being discharged inappropriately. A review of the facility's policy and procedure titled, Discharge and Transfer of Resident, reviewed date 1/26/2023, indicated that it is the policy of the facility to effectuate an orderly transfer or discharge .Notices of discharge will be accordance with state and federal regulations .Notify appropriate departments. k. A review of Resident 76's admission Record indicated the facility originally admitted the resident on 11/23/2022, with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dysphagia (swallowing difficulties). A review of Resident 76's MDS dated [DATE], indicated the resident had the ability to sometimes make self-understood and ability to sometimes understand others. The MDS indicated that the resident was totally dependent on staff for bed mobility, dressing, eating, personal hygiene, toilet use and bathing. A review of Resident 76's Change of Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated 8/21/2023, indicated Resident 76's hemoglobin (Hb- protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) was 6.9 grams per deciliter (g/dl- a unit of measurement) and blood urea nitrogen (BUN- waste product made when your liver breaks down protein) was 90 milligram/dl (mg/dl- a unit of measurement). A review of Resident 76's Physician's Order dated 8/22/2023, indicated an order to transfer to acute hospital for abnormal Hb and BUN. l. A review of Resident 91's admission Record indicated that the facility originally admitted the resident on 7/26/2023 and readmitted the resident on 8/26/2023, with diagnoses including dysphagia, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and end-stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). A review of Resident 91's MDS dated [DATE], indicated the resident's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS indicated that the resident was totally dependent on staff for bed mobility, dressing, eating, personal hygiene toilet use and bathing. A review of Resident 91's COC dated 8/28/2023, indicated that the resident was noted to have swelling behind the left ear down to his neck. A review of Resident 91's Physician's Order dated 8/28/2023 indicated to transfer the resident via 911(an emergency that requires immediate assistance from the police, fire department or ambulance) related to bradycardia (a condition where your heart beats more slowly than expected, under 60 beats per minute). During a concurrent interview and record review on 10/4/2023 at 9:40 a.m., with the Medical Record Director (MRD), reviewed the list of residents who were transferred to the hospital and discharged from the facility for the month of 8/2023. The MRD stated that she faxes the list of resident transfers and discharges from the facility at the end of the month to the Ombudsman. The MRD was unable to provide documented evidence that the Ombudsman was notified of Resident 76 and 91's transfer from the facility. The MRD was unable to provide the fax confirmation to the Ombudsman of the resident discharges and transfers for the month of 8/2023. The MRD stated that it meant that the Ombudsman was not notified of all the discharges and transfers from the facility for the month of 8/2023. A review of the facility's policy and procedure titled, Discharge and Transfer of Resident, reviewed date 1/26/2023, indicated that it is the policy of the facility to effectuate an orderly transfer or discharge .Notices of discharge will be accordance with state and federal regulations .Notify appropriate departments.

**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 for two of two sampled residents (Resident 81 and 32) by: 1. Failing to ensure nurses rotated injection sites when administering Lovenox (enoxaparin - medication that decreases the ability of blood to clot) for Resident 81. 2. Failing to ensure nurses rotated injection sites when administering insulin (hormone that lowers the level of glucose [sugar] in the blood) NPH Isophane (intermediate-acting insulin) and Regular suspension (short-acting insulin) 70-30 (combination of 70% NPH insulin and 30% regular insulin) for Resident 32. These deficient practices had the potential to result in Residents 81 and 32 experiencing lipohypertrophy (a lump of fatty tissue under the skin caused by repeated injections in the same place) and ineffective management of diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar) for Resident 32. Findings: 1.a. A review of Resident 81's admission Record indicated the facility originally admitted the resident on 8/24/2022 and readmitted the resident on 10/3/2022 with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (one-sided muscle weakness) and cirrhosis of the liver (permanent scarring that damages the liver and interferes with its functioning). A review of Resident 81's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/13/2023, indicated the resident had severely impaired cognitive (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) skills for daily decision making and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS also indicated the resident received an anticoagulant (medications that decrease the ability of blood to clot). A review of Resident 81's Physician's Orders, dated 4/30/2023, indicated an order for Lovenox (enoxaparin- generic name) 40 milligram (mg- a unit of measurement)/milliliter (ml- a unit of measurement), inject 40 mg subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for deep vein thrombosis (DVT - when a blood clot forms in one or more of the deep veins in the body) prevention, rotate injection sites. A review of Resident 81's Care Plan (a document that helps organize and communicate patient care) for anticoagulant therapy, initiated on 9/1/2022, indicated to administer anticoagulant medications (Lovenox/enoxaparin) as ordered by the physician. During a concurrent interview and record review on 10/5/2023 at 8:01 a.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 81's Medication Administration Record (MAR - includes key information about a patient's medication including, the medication name, dose taken, special instructions and date and time) dated 7/2023, 8/2023, and 9/2023. LVN 4 verified by stating the following: On 7/7/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection Resident 81's left upper quadrant (LUQ) abdomen. On 7/8/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 7/19/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's left lower quadrant (LLQ) abdomen. On 7/20/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 7/23/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 7/24/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 7/27/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 7/28/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 8/4/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 8/5/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 8/9/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 8/10/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 8/17/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's right lower quadrant (RLQ) abdomen. On 8/18/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's RLQ abdomen. On 8/30/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's right upper quadrant (RUQ) abdomen. On 8/31/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's RUQ abdomen. On 9/7/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to the resident's LUQ abdomen. On 9/8/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 9/14/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 9/15/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 9/20/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 9/21/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 9/22/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 9/23/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. During an interview on 10/5/2023 at 10:16 a.m., with the Director of Nursing (DON), the DON stated that licensed nurses should be rotating subcutaneous injection sites because, if they don't, it can cause bruising to the resident and hardening of the tissue, which can affect proper absorption of the medication. The DON stated the facility did not have a specific policy indicating that subcutaneous injection sites should be rotated. The DON stated it is a standard of practice. A review of the facility's policy and procedure titled, Subcutaneous Medication Administration, last reviewed on 1/26/2023, indicated to administer a parenteral (any medication administration other than oral) medication into the subcutaneous tissue in a safe, accurate, and effective manner in order to promote slow medication absorption and prolong medication action. b. A review of Resident 32's admission Record indicated the facility originally admitted the resident on 8/14/2014 and readmitted the resident on 8/4/2016 with diagnoses including personal history of transient ischemic attack (temporary blockage of blood flow to the brain) and cerebral infarction (refers to damage to tissues in the brain due to loss of oxygen to the area), and dysphagia (difficulty swallowing). A review of Resident 32's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills of daily decision making and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 32's Physician's Order, dated 4/25/2017, indicated to administer insulin NPH Isophane (intermediate-acting insulin) and Regular suspension (short-acting insulin) 70-30 (combination of 70% NPH insulin and 30% regular insulin) 100 units (U- a unit of measurement)/ml, inject seven (7) units subcutaneously three times a day. During a concurrent interview and record review on 10/4/2023 at 8:34 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 32's MAR dated 9/2023. RN 2 verified by stating the following: On 9/7/2023 at 6 a.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RUQ abdomen. On 9/7/2023 at 2 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RUQ abdomen. On 9/8/2023 at 6 a.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RLQ abdomen. On 9/8/2023 at 2 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RLQ abdomen. On 9/9/2023 at 6 a.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RLQ abdomen. On 9/9/2023 at 2 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to the Resident 32's RLQ abdomen. On 9/9/2023 at 10 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RLQ abdomen. On 9/22/2023 at 6 a.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's LUQ abdomen. On 9/22/2023 at 2 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's LUQ abdomen. RN 2 stated that nurses should rotate injection sites to ensure proper absorption of the medication. RN 2 stated it could cause injury to the resident's tissue if nurses continued to use the same sites. During an interview on 10/5/2023 at 10:16 a.m., with the DON, the DON stated that licensed nurses should be rotating subcutaneous injection sites because, if they don't, it can cause bruising to the resident and hardening of the tissue, which can affect proper absorption of the medication. The DON stated the facility did not have a specific policy indicating that subcutaneous injection sites should be rotated. The DON stated it is a standard of practice. A review of the facility's policy and procedure titled, Subcutaneous Medication Administration, last reviewed on 1/26/2023, indicated to administer a parenteral medication into the subcutaneous tissue in a safe, accurate, and effective manner in order to promote slow medication absorption and prolong medication action.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%-unit of measure). Five (5) medication errors out of 36 opportunities contributed to an overall medication error rate of 13.8% affecting three of 10 sampled residents (Resident 11,35, and 46) observed for medication administration. The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 11, 35, and 46 may have experienced health complications related to incorrect medication administration which could have negatively impacted their health and well-being. Findings: a. A review of the Resident 11`s admission Record indicated that the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM-a serious condition where your blood glucose [sugar] level is too high) and dysphagia (difficulty swallowing). A review of Resident 11's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 08/10/2023, indicated that Resident 11`s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was moderately impaired. The MDS also indicated that Resident 11 required extensive assistance from staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 11`s physician`s orders dated 5/05/2010 included the following orders: 1. Metformin Hydrochloride (Metformin HCL- medication to help lower sugar levels in the blood) one (1) tablet 1000 milligrams (mg-unit of measure) by mouth two times a day for Type 2 DM with meals, order dated 5/5/2010. 2. Calcium Acetate one (1) capsule 667 mg by mouth three times a day for hyperphosphatemia (a condition in which you have too much phosphate [an essential mineral] in your blood) with meals, order dated 6/29/2022. 3. Magnesium Chloride- Calcium Tablet ( a magnesium [an essential mineral] supplement) Delayed Release (released over a period of time once consumed) 64-106 mg, give two tablets by mouth two times a day for low magnesium, order dated 11/10/2021. On 10/04/23 at 04:20 PM, during a medication pass observation with Licensed Vocational Nurse 5 (LVN5), observed LVN 5 administered one (1) tablet of Metformin 1000 mg and one (1) capsule of Calcium Acetate 667 mg without Resident 11's meal as per the physician order. LVN 5 stated that Resident 11 would be served dinner sometime between 5:00 p.m. to 5:30 p.m. LVN 5 stated he should have followed the physician order for Resident 11's metformin and Calcium acetate and provided both medications when the resident had his dinner available as the efficiency of the medication could potentially be affected if given without meals. LVN 5 was then observed not providing Resident 11 with the resident's due medication of Magnesium Chloride-Calcium tablet 64-106 mg. LVN 5 stated that Resident 11's dose of Magnesium Chloride-Calcium table 64-106 mg was not available. LVN 5 stated the only available dose for Resident 11 was Slow Magnesium 71 mg Calcium, however Resident 11's medication packet of Slow Magnesium 71mg Calcium was already empty. On 10/05/23 at 07:45 a.m. during an interview with Registered Nurse 5 (RN5), RN5 stated that Metformin should be given to a resident with food for better absorption. RN 5 stated that if Metformin was to be given without food, the medication may lower the resident's blood sugar levels leading to hypoglycemia (a potentially dangerous medical condition that occurs when your blood glucose (sugar) levels are too low). On 10/05/23 at 08:17 a.m., during a follow up interview with RN5, RN5 called the pharmacy and placed the call on speaker phone wherein RN5 obtained clarification that the order for Resident 11's Magnesium Chloride-Calcium table 64-106 mg. The pharmacy informed RN 5 that the equivalent medication for Resident 11 is the resident's Slow Magnesium 71 mg Calcium. RN 5 stated that if LVN 5 was confused about the available Slow Magnesium 71mg Calcium medication for Resident 11, LVN 5 should have then clarified the medication with the pharmacy. RN 5 stated that Resident 11's Slow Magnesium 71mg Calcium medication pack was already empty. RN5 stated that the nurses are just giving the medications to residents without knowing what they are giving. A review of the facility`s policy and procedure titled Medication Administration-General Guidelines, last reviewed on 1/26/2023, indicated that medications are administered in accordance with written orders of the attending physician .medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes . b. A review of the Resident 35`s admission Record indicated that the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and hyperlipidemia (condition in which there are high levels of fat particles [lipids] in the blood). A review of Resident 35's MDS dated [DATE] indicated that Resident 35`s cognitive skills for daily decision-making was intact. The MDS also indicated Resident 35 required extensive assistance from staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 35`s physician`s orders indicated an order for Vascepa (medication that lowers the amount of fat in the blood) Capsule 0.5 grams (gm-unit of measure) give one (1) capsule by mouth two times a day for Hypertriglyceridemia (A high level of fat [triglycerides] in the blood) dated 06/03/2022. On 10/04/23 at 04:20 PM, during a medication pass observation with Licensed Vocational Nurse 5 (LVN5), observed LVN 5 prepared the 5:00 p.m. doses for Resident 35 and confirmed that the resident's Vascepa 0.5 gram capsule 1 tablet by mouth daily was not available. LVN5 stated that he would call the pharmacy to request for a refill of Resident 35's Vascepa. LVN 5 stated that he would not be able to administer Resident 35's Vascepa as ordered by the physician because it was not made available. A review of the facility`s policy and procedure titled Medication Administration-General Guidelines, last reviewed on 1/26/2023, indicated that medications are administered in accordance with written orders of the attending physician .medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes . c. A review of Resident 46' s admission Record indicated the facility admitted the resident on 6/24/2023 with diagnoses that included glaucoma (high pressure in the eyes that damages nerves). A review of Resident 46' s MDS dated [DATE], indicated Resident 46 had severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 46 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, eating and personal hygiene. A review of Resident 46's Physician's Orders indicated an order for Brimonidine Tartrate Ophthalmic solution (eye drops used to lower pressure in the eyes in residents who have glaucoma) 0.2 percent (%-unit of measure)- instill one drop in both eyes three times a day for glaucoma, dated 7/11/2023. During a medication pass observation started on 10/03/2023 at 12:05 p.m., observed Licensed Vocational Nurse 1 (LVN 1) preparing and administering Resident 46's due medications which included Brimonidine eye drops. During a concurrent interview and record review with LVN 1, on 10/03/2023 at 2:38 p.m., reviewed Resident 46 Medication Administration Record (MAR-a record that logs the medications given to a resident on a daily basis) audit report (a report that shows the exact time an entry is documented) dated 10/3/2023. LVN 1 stated medications can be given an hour before or hour after the physicians prescribed ordered time. The Medication Audit for Resident 46's Brimonidine Tartrate Ophthalmic solution indicated that LVN 1 administered the medication to Resident 46 at 12:24 p.m. LVN 1 stated that Resident 46's Brimonidine Tartrate Ophthalmic solution was given at the wrong time as the medication was not due to be administered until 2:00 p.m. LVN 1 stated that he should have waited until at least 1:00 p.m. to administer Resident 46's Brimonidine Tartrate Ophthalmic solution. LVN 1stated that Resident 46 had the potential to receive a higher than prescribed concentration of the Brimonidine Tartrate Ophthalmic solution as the medication was given too close to the time as the previous dose. LVN 1 stated that by providing Resident 46's Brimonidine Tartrate Ophthalmic solution earlier than prescribed, he placed Resident 46 at increased risk for red or irritated eyes. During an interview with the Director of Nurses (DON) on at 10/05/2023 at 2:50 p.m., the DON stated Resident 46's Brimonidine Tartrate Ophthalmic solution medication was to be given three times a day and the afternoon dose was due to be given at 2 p.m. The DON stated medications are permitted to be given one hour before the scheduled administration time or one hour after. The DON stated, since 12:24 p.m. was over one hour before the scheduled dose of 2:00 p.m., it would be considered as being administered early to Resident 46. The DON stated Resident 46 was at risk for having too high of a concentration of the medication at one time. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that six of six sampled residents (Resident 54, 36, 52, 49, 47, and 2) were free from significant medication errors by: a) Failing to ensure that Amlodipine besylate (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with a parameter to hold (do not give) the medication if Resident 54's systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) was less than 110 millimeters of mercury (mmHg-a unit of measure). b) Failing to ensure that Carvedilol (medication to treat high blood pressure) was administered in accordance with the physician's order with a parameter to hold if Resident 36's SBP was less than 120 mmHg. c) Failing to ensure that Metoprolol Tartrate (medication used to treat high blood pressure) was administered in accordance with the physician's order with a parameter to hold if Resident 52's SBP was less than 100 mmHg, the diastolic blood pressure (DBP, measures the pressure in your arteries when your heart rests between beats) and their heart rate (a normal resting heart rate should be between 60 to 100 beats per minute[BMP]) less than 60 bpm. d) Failing to ensure that Amiodarone (a medication which relaxes the blood vessels to increase the supply of blood to the heart) was administered to Resident 49 in accordance with the physician's order to hold for heart rate less than 60 BPM. e) Failing to ensure that Isosorbide mononitrate (a medication which relaxes the blood vessels to increase the supply of blood to the heart) was administered to Resident 49 in accordance with the physician's order with a parameter to hold for SBP less than 110 mm Hg, and heart rate (HR) less than 55 BPM. f) Failing to ensure that Admelog (a fast-acting [works immediately] mealtime insulin that works to control blood sugar when you eat) was administered to Resident 2 in accordance with the physician's order to hold the medication if the residents blood sugar (BS) is below 100 milligrams per deciliter (mg/dl- unit of measure). These deficient practices placed Resident 54, 36, 52, 49 at risk for hypotension (low blood pressure) which could lead to dizziness, headache, fainting, blurred vision, shallow breathing, and injury from falls, and placed Resident 2 at risk for experiencing hypoglycemia (a condition in which your blood sugar [glucose] level is lower than the standard range). Findings: a. A review of Resident 54's admission Record indicated the facility admitted the resident on 11/2/2018 and readmitted the resident on 8/2/2023 with diagnoses that included hypertension (HTN, high blood pressure) and dysphagia (difficulty swallowing). A review of Resident 54's Minimum Data Set (MDS - an assessment and screening tool) dated 8/31/2023, indicated the resident was usually able to understand others and rarely to never able to make herself understood. The MDS further indicated that Resident 54 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 54's Physician Orders indicated an order for amlodipine besylate 2.5 milligrams (mg- a unit of measurement) tablet, give one tablet via Gastrostomy Tube (G-tube a tube placed directly into the stomach to give direct access for supplemental feeding, hydration or medicine) one time a day for HTN, hold for SBP less than 110 mmHg, dated 8/2/2023. During a concurrent interview and record review on 10/3/2023 at 3:52 p.m. with Licensed Vocational Nurse 4 (LVN 4), Resident 54's Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 9/2023 was reviewed. LVN 4 noted the following: a) On 9/2/2023 at 9 a.m., Resident 54's SBP was noted at 108 mmHg, the MAR indicated amlodipine was administered to Resident 54. b) On 9/20/2023 at 9 a.m., Resident 54's SBP was noted at 102 mmHg, the MAR indicated amlodipine was administered to Resident 54. LVN 4 stated that prior to administering blood pressure medications to a resident, the licensed nurse is to obtain the resident's blood pressure and heart rate to ensure it is safe for the resident to take the prescribe blood pressure medication. LVN 4 stated that if blood pressure medications are administered to a resident when their blood pressure is low, a resident may become hypotensive (low blood pressure) resulting in headaches, dizziness, or a change in the level of consciousness. LVN 4 stated that the licensed nurses should not have administered amlodipine on the days where Resident 54's SBP was less than 110 mmHg. LVN 4 stated Resident 54 was at risk for falls as a possible outcome when amlodipine was given out of parameters. During an interview on 10/4/2023 at 1:10 p.m. with the Director of Nursing (DON), the DON stated that medications are to be administered in accordance with physician's orders. The DON stated the physician's blood pressure medication orders include hold parameters. The DON stated if blood pressure medication is given outside the hold parameters, it may lower a resident's blood pressure. The DON stated that Resident 54 has a history of falls and hypotension could result in dizziness. The DON stated that the licensed nurses did not follow the facility's medication policy because Resident 54 was administered Amlodipine despite the resident's SBP being less than 110 mmHg . A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. b. A review of Resident 36's admission Record indicated the facility admitted the resident on 6/10/2016 and readmitted the resident on 1/14/2022 with diagnoses that included chronic respiratory failure (serious condition that makes it difficult to breathe on your own), hypertensive heart and chronic kidney disease (high blood pressure over an extended amount of time and damage to the kidneys that results in ineffective filtering of the blood) with heart failure (a condition that develops when your heart doesn't pump enough blood for the body's needs), dysphagia, and gastrostomy tube. A review of Resident 36's MDS dated [DATE], indicated the resident was rarely to never able to understand others and rarely to never able to make himself understood. The MDS further indicated that Resident 36 was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 36's Physician Orders indicated an order for Carvedilol 3.125 mg tablet, give 3.125 mg via G-tube two times a day for HTN, hold for SBP less than 120 mmHg or HR less than 60 bmp, dated 8/2/2023. During a concurrent interview and record review on 10/3/2023 at 3:52 p.m. with LVN 4, Resident 36's Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 9/2023 was reviewed. LVN 4 noted the following: a) On 9/7/2023 at 9 a.m., Resident 36's SBP was noted at 114 mmHg, the MAR indicated carvedilol was administered to Resident 36. b) On 9/12/2023 at 9 a.m., Resident 36's SBP was noted at 118 mmHg, the MAR indicated carvedilol was administered to Resident 36. LVN 4 stated that prior to administering blood pressure medications to a resident, the licensed nurse is to obtain the resident's blood pressure and heart rate to ensure it is safe for the resident to take the prescribe blood pressure medication. LVN 4 stated that if blood pressure medications are administered to a resident when their blood pressure is low, a resident may become hypotensive resulting in headaches, dizziness, or a change in the level of consciousness. LVN 4 stated that licensed nurses should not have administered carvedilol on the days where Resident's 36 SBP was less than 120 mmHg. LVN 4 stated Resident 36 was at risk hypotension when carvedilol was given out of parameters. During an interview on 10/4/2023 at 1:10 p.m. with the DON, the DON stated that medications are to be administered in accordance with physician's orders. The DON stated the physician's blood pressure medication orders include hold parameters. The DON stated if blood pressure medication is given outside the hold parameters, it may lower a resident's blood pressure. The DON stated for Resident 36 the importance of holding carvedilol when the blood pressure was below the parameters was to prevent inadequate tissue perfusion (the lack of oxygenated blood flow to areas of the body. The DON stated if the resident did not have adequate tissue perfusion it could result in cardiac and renal (kidney) problems. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. e. A review of Resident 49's MAR from 3/2023 until 9/2023 indicated there were 42 instances when isosorbide mononitrate was held when Resident 49's HR was either lower than 55 bpm or within the physician ordered parameters, but the SBP was not below 110 mm Hg. These dates were as follows: 1. 3/12/2023 at 9:00 a.m. SBP = 131 heart rate = 51 2. 3/17/2023 at 9:00 a.m. SBP =139 heart rate = 54 3. 3/22/2023 at 9:00 a.m. SBP = 137 heart rate = 51 4. 3/24/2023 at 9:00 a.m. SBP = 120 heart rate = 54 5. 4/07/2023 at 9:00 a.m. SBP = 155 heart rate = 46 6. 4/08/2023 at 9:00 a.m. SBP = 160 heart rate = 55 7. 4/15/2023 at 9:00 a.m. SBP = 150 heart rate = 52 8. 4/20/2023 at 9:00 a.m. SBP = 140 heart rate = 52 9. 4/22/2023 at 9:00 a.m. SBP = 136 heart rate = 53 10. 4/30/2023 at 9:00 a.m. SBP = 156 heart rate = 52 11. 5/03/2023 at 9:00 a.m. SBP = 154 heart rate = 52 12. 5/07/2023 at 9:00 a.m. SBP = 152 heart rate = 54 13. 5/08/2023 at 9:00 a.m. SBP = 144 heart rate = 51 14. 5/12/2023 at 9:00 a.m. SBP = 159 heart rate = 48 15. 5/16/2023 at 9:00 a.m. SBP = 136 heart rate = 50 16. 5/17/2023 at 9:00 a.m. SBP = 152 heart rate = 54 17. 5/18/2023 at 9:00 a.m. SBP = 147 heart rate = 53 18. 526/2023 at 9:00 a.m. SBP = 162 heart rate = 50 19. 6/04/2023 at 9:00 a.m. SBP = 153 heart rate = 53 20. 6/07/2023 at 9:00 a.m. SBP = 154 heart rate = 54 21. 6/09/2023 at 9:00 a.m. SBP = 145 heart rate = 52 22. 6/10/2023 at 9:00 a.m. SBP = 159 heart rate = 54 23. 6/24/2023 at 9:00 a.m. SBP = 143 heart rate = 51 24. 6/26/2023 at 9:00 a.m. SBP = 157 heart rate = 52 25. 7/01/2023 at 9:00 a.m. SBP = 151 heart rate = 54 26. 7/03/2023 at 9:00 a.m. SBP = 134 heart rate = 54 27. 7/17/2023 at 9:00 a.m. SBP = 152 heart rate = 50 28. 7/19/2023 at 9:00 a.m. SBP = 156 heart rate = 50 29. 7/21/2023 at 9:00 a.m. SBP = 146 heart rate = 54 30. 7/24/2023 at 9:00 a.m. SBP = 146 heart rate = 54 31. 7/27/2023 at 9:00 a.m. SBP = 122 heart rate = 58 32. 7/28/2023 at 9:00 a.m. SBP = 132 heart rate = 49 33. 7/29/2023 at 9:00 a.m. SBP = 160 heart rate = 52 34. 9/02/2023 at 9:00 a.m. SBP = 146 heart rate = 53 35. 8/04/2023 at 9:00 a.m. SBP = 152 heart rate = 54 36. 8/06/2023 at 9:00 a.m. SBP = 145 heart rate = 52 37. 8/07/2023 at 9:00 a.m. SBP = 122 heart rate = 50 38. 8/09/2023 at 9:00 a.m. SBP = 128 heart rate = 52 39. 8/13/2023 at 9:00 a.m. SBP = 137 heart rate = 53 40. 8/14/2023 at 9:00 a.m. SBP = 115 heart rate = 54 41. 8/26/2023 at 9:00 a.m. SBP = 153 heart rate = 57 42. 9/01/2023 at 9:00 a.m. SBP = 130 heart rate = 54 During an interview with the Director of Nurses (DON) on 10/05/2023 at 2:50 p.m., DON stated that Resident 49's isosorbide mononitrate is to be held only if both the resident's HR was less than 55 bmp and SBP was less than 110 mmHg. The DON stated licensed nursing staff did not follow the physician's order each time Resident 49's isosorbide mononitrate was held when the resident's SBP was greater than 110 mmHg, but the resident's HR was 55 bmp or less. The DON stated Resident 49 could have had negative health side effect by licensed nursing staff not following the physician's order for isosorbide mononitrate. During an interview with Resident 49's physician Medical Doctor 1 (MD 1) on 10/05/2023 at 3:52 p.m., MD 1 stated that for Resident 49's isosorbide mononitrate order, both hold parameters should be outside of MD 1's specified parameters of SBP and heart rate are to be met before holding the medication. A review of the facility's policy and procedure titled, Medication Administration, reviewed 1/26/2023, indicated licensed nursing staff are to give medications in accordance with written orders of the attending physician. f. A review of Resident 47's admission record indicated the resident was originally admitted on [DATE], with diagnoses including chronic respiratory failure, tracheostomy (opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and atrial fibrillation (irregular heart rate) A review of Resident 47's MDS dated [DATE], indicated Resident 47 had severely impaired cognition. A review of Resident 47's physician order dated 8/20/2022, indicated Resident 47 had an order for Amiodarone Hydrochloride (HCL), give 100 mg via G-tube one time a day for atrial fibrillation and to hold if heart rate below 60 bmp. A review of Resident 47's MAR for 9/2023 indicated that on 9/17/2023 at 9:00 a.m., Resident 47's HR was noted at 58 bmp. The MAR indicated that Amiodarone HCL tablet, give 100 mg was administered to Resident 47. During a concurrent interview and record review on 10/4/2023 at 10:47 a.m. with Infection Preventionist Nurse (IPN) Resident 47's MAR for month for 9/2023 was reviewed. IPN stated that Resident 47's heart rate was 58 bpm on 9/17/2023 at 9:00 a.m., and the resident's prescribed Amiodarone was still administered. IPN stated that there was a hold parameter to hold the medication if the heart rate was less than 60 bpm. IPN stated that the licensed nurse should have held the dose of Amiodarone and documented in the MAR that the medication was not given. IPN stated that if the amiodarone was administered to a resident with the heart rate less than 60 bpm, it can place resident at risk for bradycardia (low heart rate). A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. g. A review of Resident 2's admission Record indicated the facility admitted the resident on 7/11/2006 with diagnoses including type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high ). A review of Resident 2's MDS, dated [DATE], indicated the resident had moderately impaired cognition and required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 2's physician orders indicated an order for Admelog, six (6) units (U-unit of measure) subcutaneously (SQ - situated or applied under the skin) before meals, hold if BS is below 100 mg/dl dated 6/4/2019. On 10/4/2023 at 8:06 a.m., during a concurrent interview and record review with Registered Nurse 2 (RN 2), Resident 2's MAR for 9/2023 was reviewed. RN 2 noted the following: a) On 9/7/2023 at 7:30 a.m., Resident 2's BS was 84 mg/dl. The licensed nurse documented that insulin was administered. b) On 9/7/2023 at 12 p.m., Resident 2's BS was 84 mg/dl. The licensed nurse documented that insulin was administered. c) On 9/15/2023 at 7:30 a.m., Resident 2's BS was 91 mg/dl. The licensed nurse documented that insulin was administered. d) On 9/17/2023 at 7:30 a.m., Resident 2's BS was 97 mg/dl. The licensed nurse documented that insulin was administered. e) On 9/22/2023 at 7:30 a.m., Resident 2's BS was 72 mg/dl. The licensed nurse documented that insulin was administered. f) On 9/29/2023 at 7:30 a.m., Resident 2's BS was 72 mg/dl. The licensed nurse documented that insulin was administered. RN 2 stated that Admelog should not have been administered to Resident 2 since the resident's BS was outside of the prescribed parameters. RN 2 stated that because Admelog can further drop Resident 2's BS, it can lead to unresponsiveness. On 10/5/2023 at 10:16 a.m., during an interview, the DON stated that medications are to be administered in accordance with physician's orders. The DON stated that if insulin is given when Resident 2's blood sugar is below the physician's prescribed parameters, then there is a risk for Resident 2's blood sugar to decrease even more, which can cause the resident to go into a coma. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. c. A review of Resident 52`s admission Record indicated that the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included heart failure, dysphagia, and gastroesophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). A review of Resident 52's MDS dated [DATE], indicated that Resident 52`s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was severely impaired. The MDS also indicated that Resident 52 is totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 52`s physician`s order dated 4/23/2021, indicated an order for Metoprolol Tartrate 75 mg, give one (1) tablet via a G-tube two times a day for hypertension and hold for SBP less than 100 mmHg and HR less than 60 bpm. During a concurrent interview and record review on 10/3/2023 at 3:52 p.m. with LVN 4, Resident 52's MAR for 9/2023 was reviewed. LVN 4 noted the following: a) On 9/10/2023 at 5:00 p.m., Resident 52`s SBP was noted at 99 mmHg with a HR of 69 bpm. The MAR indicated that metoprolol tartrate was administered to Resident 52. b) On 9/16/2023 at 9:00 a.m., Resident 52's SBP was 93 mmHg with heart rate of 79 bpm. The MAR indicated that metoprolol tartrate was administered to Resident 52. LVN 4 stated that the medication metoprolol tartrate 75 mg should have been withheld from Resident 52 on 9/10/2023 for the 5:00 p.m. dose; and on 9/16/2023 for the 9:00 a.m. dose. LVN 4 stated that withholding the medication based on the physician's parameter to hold will prevent complications such as hypotension for Resident 52 which could lead to dizziness, lightheadedness and may increase the risk of fall and injury. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. d. A review of Resident 49's admission Record indicated the facility originally admitted the resident on 7/15/2022 and re-admitted on [DATE] with diagnoses that included hypertension, angina pectoris (chest pain), and atherosclerotic heart disease (hardening on the heart arteries which can cause chest pain). A review of Resident 49's MDS, dated [DATE], indicated Resident 49 had intact cognition with skills required for daily decision making. The MDS indicated Resident 49 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with eating and personal hygiene. A review of Resident 49's Physician's Orders indicated the following: 1. Amiodarone tablet, 200 mg, give one tablet by mouth one time a day for coronary artery disease (CAD, hardening of the heart arteries which can cause chest pain), hold if HR is less than 60 bmp dated 2/11/2023. 2. Isosorbide Mononitrate extended release (released in the body over 24 hours) oral tablet 60 mg, give one tablet by mouth in the morning to prevent chest pain, hold for SBP less than110 mmHg and HR less than 55 BPM, dated 3/09/2023. A review of Resident 49's MAR from 8/2023 and 9/2023 indicated there were three instances when Amiodarone was given even when the heart rate was below 60 BPM. These dates were as follows: 1. 8/24/2023 at 9:00 a.m. heart rate = 59 2. 9/05/2023 at 9:00 a.m. heart rate = 51 3. 9/19/2023 at 9:00 a.m. heart rate = 56 During a concurrent record review and interview with Licensed Vocational Nurse 3 (LVN 3) on 10/04/2023 at 3:10 p.m., reviewed Resident 49's 9/2023 MAR. LVN 3 stated he documented the amiodarone as being given to Resident 49 on 9/05/2023 and 9/19/2023. When asked if LVN 3 remembered giving amiodarone to Resident 49 on 9/05/2023 and 9/19/2023, LVN 3 stated he could not remember. LVN 3 stated that he assumed he administered amiodarone to Resident 49 on 9/05/2023 and 9/19/2023 because he documented that he administered the medication in Resident 49's MAR. LVN 3 stated that by not follow the physician's ordered hold parameters, Resident 49 could have been at risk for symptoms of bradycardia. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure one of six medication carts (Med Cart 5) was locked and secure and was under direct observation of authorized staff in an area where residents could access it. 2. Ensure one of five sampled residents' (Resident 314) fluticasone-salmeterol (medications to help relieve shortness of breath) and budesonide-formoterol fumarate dihydrate (medication that helps with breathing by decreasing the inflammation in the lungs) inhalers were labeled with an open date according to manufacture guidelines. 3. Ensure two of five sampled residents' (Resident 71 and 25) levetiracetam (medication to control seizures [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements]) oral (by mouth) solution was labeled with an open date according to manufacture guidelines. 4. Ensure two of five sampled residents' (Resident 8 and 20) opened bottle of potassium chloride 10% liquid was labeled with an open date. These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medications given to the residents and had the potential for residents or unauthorized personnel at risk of accessing the medications. Findings: 1. During an observation on 10/2/2023 at 9:38 a.m., Med Cart 5 was observed unlocked. There were no licensed nurses observed in the area. During a concurrent observation and interview on 10/2/2023 at 9:40 a.m. with Licensed Vocational Nurse 1 (LVN 1), observed Med Cart 5 unlocked. LVN 1 was then observed locking Med Cart 5. LVN 1 stated that all medication carts should be locked if not in use and unsupervised. During an interview on 10/3/2023 at 9:52 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated that all medication carts should be locked when unsupervised. The IPN stated if medication carts are left unlocked and unsupervised, the residents can access the medications. A review of facility's policy and procedure titled, Storage of medications, reviewed on 1/26/2023, indicated that medications and biological are stored safely, securely and properly. It also indicated that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administered medications. A review of the facility's policy and procedure titled, Medication Administration-General Guidelines, reviewed on 1/26/2023, indicated that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. 2. A review of Resident 314's admission Record indicated the facility originally admitted the resident on 5/16/2017 and readmitted on [DATE] with diagnoses including pneumonitis (inflammation of the lungs), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and interstitial lung disease (lung disease that causes progressive scarring of the lung tissue that affects the ability to breath). A review of Resident 314's Minimum Data Set (MDS-standardized assessment and screening tool) dated 9/19/2023, indicated the resident had intact cognition (ability to think and make decisions). A review of Resident 314's Physician's Orders indicated an order for the following medications: Fluticasone-salmeterol 250-50 microgram/dose (mcg/dose- a unit of measurement) one puff inhale orally every 12 hours for interstitial pulmonary (refers to the lungs) disease, ordered 9/28/2023. Budosonide-formoterol fumarate dihydrate inhalation aerosol 160-4.5 mcg/act, two puff inhale orally two times a day for interstitial lung disease, ordered 9/22/2023. During a concurrent observation and interview on 10/2/2023 at 10:25 a.m. with Registered Nurse 2 (RN 2), observed Medication Cart 2 (Med cart 2). RN 2 opened Med Cart 2 which had Resident 314's opened fluticasone-salmeterol and budosonide-formoterol fumarate dihydrate inhalers not labeled with an open date. RN 2 stated that it should be labeled with an open date once the medication is opened. A review of the fluticasone-salmeterol manufacturer's guidelines, indicated to throw away the medication in the trash one month after the foil pouch was opened. A review of the budosonide-formoterol fumarate dihydrate manufacturer's guidelines, indicated to throw away the inhaler three months after taking it out from the foil pouch. 3a. A review of Resident 71's admission Record indicated the facility originally admitted the resident on 3/20/2021 and readmitted on [DATE], with diagnoses including hemorrhage of cerebrum (blood vessel that burst in the brain causing bleeding), dysphagia (difficulty swallowing), and hemiparesis (weakness of one side of the body) following stroke. A review of the Resident 71's MDS dated [DATE], indicated the resident had a moderately impaired cognition. A review of the Resident 71's Physician's Order dated 9/21/2023, indicated an order for levetiracetam solution 100 milligram/milliliters (mg/ml- a unit of measurement), give 750 mg by mouth every 12 hours for seizure. During a concurrent observation and interview on 10/2/2023 at 10:30 a.m. with RN 2, observed Med Cart 2. RN 2 opened Med Cart 2 which had Resident 71's opened bottle of levetiracetam oral solution not labeled with an open date. RN 2 stated that the bottle should have been labeled with an open date. A review of the levetiracetam's manufacturer's guidelines indicated that after opening the bottle, the oral solution must be used within seven months. 3b. A review of Resident 25's admission Record indicated the facility admitted the resident on 6/10/2013 and re-admitted on [DATE] with diagnoses that included epilepsy (brain disorder that causes recurring, unprovoked seizures). A review of Resident 25's MDS, dated [DATE], indicated Resident 25 had severely impaired cognition with skills required for daily decision making. The MDS indicated Resident 25 required two-person total dependence with bed mobility, transfer, and toilet use. A review of Resident 25's Physician's Orders indicated an order for levetiracetam 100 mg/ml give 5 ml via gastrostomy tube (G-Tube, a tube inserted through the belly that brings nutrition and medications directly to the stomach) two times a day for seizures, ordered 9/3/2023. A review of Resident 25's Care Plan for altered neurological (relating to the nervous system [brain, spinal cord, and a complex network of nerves]) status initiated 4/4/2022, indicated a goal that the resident will be free of seizure activity through the review date. The care plan indicated to give seizure medication as ordered by the doctor. During a medication cart observation on 10/05/2023 at 8:05 a.m. with Licensed Vocational Nurse 5 (LVN 5), observed the contents of Medication Cart 1. Observed Resident 25's levetiracetam 100 mg/ml solution bottle not labeled with an open date. LVN 5 stated these bottles should have open dates documented on them. LVN 5 stated this was important so residents will not receive medications that have lost their effectiveness. A review of the levetiracetam's manufacturer's guidelines indicated that after opening the bottle, the oral solution must be used within seven months. 4a. A review of Resident 8's admission Record indicated the facility admitted the resident on 1/18/2008 and re-admitted on [DATE] with diagnoses that included chronic kidney disease (a disease when the kidneys do not filter waste and excess fluid from the blood properly). A review of Resident 8's MDS, dated [DATE], indicated Resident 8 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 8 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, eating and personal hygiene. A review of Resident 8's Physician's Orders indicated an order for potassium chloride liquid 20 milliequivalents per 15 milliliters (mEq/ml, a unit of measure for liquids) - give 10 mEq by mouth one time a day for hypokalemia (low potassium levels which can result in muscle cramps and abnormal heart rate), dated 12/30/2022. A review of Resident 8's Care Plan for cardiovascular status (related to the heart), initiated 8/22/2020, indicated a goal that the resident will be free from cardiac problems through the review date. The care plan indicated an intervention to administer medications (which includes potassium). During a medication cart observation on 10/05/2023 at 8:05 a.m. with Licensed Vocational Nurse 5 (LVN 5), observed the contents of Medication Cart 1. Observed Resident 8's potassium chloride 10% liquid bottle not labeled with an open date. LVN 5 stated the bottle should have an open date documented on it. LVN 5 stated labeling was important so residents will not receive medications that have lost their effectiveness. 4b. A review of Resident 20's admission Record indicated the facility admitted the resident on 2/17/2015 and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure). A review of Resident 20's MDS, dated [DATE], indicated Resident 20 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 20 required two-person extensive assistance with dressing and personal hygiene. A review of Resident 20's Physician's Orders indicated an order for potassium chloride liquid 20 mEq/15 ml - give 10 mEq by mouth one time a day for Lasix (medication that helps reduce the amount of excess fluid in the body; one side effect is hypokalemia), dated 5/22/2022. A review of Resident 20's Care Plan for potential fluid and electrolyte (minerals in the blood that carry an electric charge and is important for fluid balances; potassium is an electrolyte) imbalance, initiated 2/22/2020 and last revised on 6/13/2023, indicated a goal that the resident's electrolytes will be within normal limits. The care plan indicated an order to administer potassium chloride per physician's orders. During a medication cart observation on 10/05/2023 at 8:05 a.m. with Licensed Vocational Nurse 5 (LVN 5), observed the contents of Medication Cart 1. Observed Resident 20's potassium chloride 10% liquid bottle not labeled with an open date. LVN 5 stated the bottle should have an open date documented on it. LVN 5 stated labeling was important so residents will not receive medications that have lost their effectiveness. During an interview on 10/05/2023 at 2:50 p.m., with the Director of Nurses (DON), the DON stated licensed nursing staff should write the opened date on the medication bottle. The DON stated this was important because licensed nurses would know when to discard the medication since the medication would lose its potency over time and would not be effective in the medication's intended purpose. A review of the facility's policy and procedure titled, Medication Storage in the facility, reviewed on 1/26/2023, indicated, medications and biologicals are stored safely, securely and properly following manufacture's recommendation or those of the supplier.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure hand hygiene (cleaning one's hands that substantially reduces potential pathogens [harmful microorganisms] on the hands) was done for two of two sampled residents (Resident 44 and 34). Hand hygiene was not performed after giving pain medication to Resident 44 and before preparing Resident 34's gastrostomy (GT-tube inserted through the belly that brings nutrition directly to the stomach) feeding. 2. Ensure hand hygiene was done for two of two sampled residents (Resident 17 and 40). Hand hygiene was not performed after turning off Resident 17's GT feeding pump and before preparing Resident 40's medications. 3. Ensure Family Member (FM 1) was wearing a disposable gown and gloves before entering the room for one of one sampled residents (Resident 6), who was on contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other resident care equipment). These deficient practices had the potential to result in the spread of diseases and infection. Findings: 1. A review of Resident 34's admission Record indicated the facility originally admitted the resident on 1/7/2015 and readmitted on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), gastrostomy, and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood glucose [sugar]). A review of Resident 34's Minimum Data Set (MDS-standardized assessment and screening tool) dated 9/6/2023, indicated the resident had severely impaired cognition (ability to think and make decisions). The MDS also indicated that Resident 34 needed extensive assistance with staff for eating. A review of Resident 34's Physician's Orders dated 1/13/2023, indicated the resident had an order for gastrostomy tube feeding at 65 milliliter (unit of measurement) per hour (ml/hr) for 20 hours to provide 1300 ml and 1560 calorie per day via GT. A review of Resident 44's admission Record indicated the facility admitted the resident on 7/20/2023 with diagnoses including fracture (broken bone) of the right lower leg, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves causing nerve damages that disrupts communication between brain and the body) and history of falling. A review of Resident 44's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 44's Physician's Order dated 7/28/2023, indicated the resident had an order for Norco (used to relieve moderate to severe pain) oral tablet 10-325 milligrams (mg- a unit of measurement) give one tablet by mouth every six hours as needed for pain. During an observation on 10/2/2023 at 12:57 p.m., observed Licensed Vocational Nurse 2 (LVN 2) administering Resident 44's Norco inside the room. Observed LVN 2 leave Resident 44's room without performing hand hygiene and went in front of the Resident 34's room where the medication cart was. During a concurrent observation and interview on 10/2/2023 at 1:00 p.m., observed LVN 2 in front of Resident 34's room with the medication cart. LVN 2 stated that she was preparing Resident 34's GT feeding. LVN 2 was observed putting on a new pair of gloves and started priming (filling the tubing of the feed bag with the liquid nutrition that is going to be fed) the GT feeding inside Resident 34's room. LVN 2 connected the tube feeding to Resident 34. When asked if she needed to do hand hygiene before leaving Resident 44's room and before preparing the GT feeding for Resident 34, LVN 2 stated that she had to but forgot to do hand hygiene. LVN 2 stated that it is important to do hand hygiene after leaving a resident's room and before preparing the GT feeding. 2. A review of Resident 17's admission Record indicated the facility originally admitted the resident on 1/7/2011 and readmitted on [DATE] with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), tracheostomy (surgically created hole in your windpipe that provides an alternative airway for breathing), and gastrostomy. A review of Resident 17's MDS dated [DATE], indicated resident had severely impaired cognition. A review of Resident 40's admission Record indicated the facility originally admitted the resident on 5/20/2016 and readmitted on [DATE] with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. A review of Resident 40's MDS dated [DATE], indicated the resident had intact cognition. During an observation on 10/3/2023 at 9:10 a.m., observed Licensed Vocational Nurse 1 (LVN 1) entering Resident 17's room and turn off the GT feeding pump. LVN 1 was observed leaving Resident 17's room without performing hand hygiene and went in front of Resident 40's room where the medication was. LVN 1 unlocked Medication Cart 5 and started preparing medications. During an interview on 10/3/2023 at 9:13 a.m., with LVN 1, LVN 1 stated that he was preparing the medication for Resident 40 and turned off the tube feeding for Resident 17. When asked if he did hand hygiene after leaving Resident 17's room and before preparing Resident 40's medication, LVN 1 stated that he did not use any hand sanitizer or wash his hands prior to preparing Resident 40's medication. LVN 1 stated that he was supposed to do hand hygiene after leaving Resident 17's room and before preparing Resident 40's medications. A review of the facility's policy and procedure titled, Medication Administration, reviewed on 1/26/2023, indicated that the person administering medication adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medications, after coming into direct contact with a resident, and before and after administration given via enteral tubes (tubes used for GT feeding). A review of the facility's policy and procedure titled, Hand Hygiene, reviewed on 1/26/2023, indicted it is the policy to promote an environment that minimizes the risk of transmission of bacteria between residents, staff and visitors. It also indicated that the facility uses alcohol-based sanitizing gels for hand sanitization in addition to hand washing with soap and water. It also indicates to decontaminate hands by washing with soap and water, and rinsing under running water: before having direct contact with patients, before donning gloves, after removing gloves, and before moving from a contaminated body site to a clean body site during patient care. 3. A review of Resident 60's admission Record indicated the facility originally admitted the resident on 10/13/2022 and was readmitted on [DATE] with diagnoses including chronic respiratory failure, urinary tract infection (UTI- an infection in any part of the urinary system), tracheostomy and pseudomonas aerugosa (bacteria that causes infection and can spread to people). A review of Resident 60's MDS dated [DATE], indicated resident had severely impaired cognition. A review of Resident 60's Physician's Orders dated 8/15/2023, indicated the resident had an order for contact isolation for Carbapenem Resistant Pseudomonas Aerugosa (CRPA-type of bacteria that can cause serious infections in the blood, lungs and other parts of the body that are typically resistant to most antibiotic [medication to treat infection]) of the sputum (thick mucus produced in the lungs). A review of Resident 60's urine culture (laboratory test that check for bacteria or other germs in a urine sample) result dated 7/31/2023, indicated Resident 60 was positive for CRPA organism in sputum. A review of Resident 60's Care Plan dated 8/4/2023, indicated the resident has CRPA in the sputum. One of the interventions was to instruct family/visitors and caregivers to wear disposable gown and gloves during physical contact with resident and discard in appropriate receptable and wash hands before leaving. During an observation on 10/4/2023 at 10:58 a.m., observed Family Member 1 (FM 1) inside Resident 60's contact isolation room. Observed a sign posted at the door for contact isolation. During a concurrent observation and interview on 10/4/2023 at 11:02 a.m. with Registered Nurse 1 (RN 1), observed FM 1 inside Resident 60's room with no disposable gowns and gloves. RN 1 immediately told FM 1 to wear a disposable gown and gloves before entering Resident 60's room. RN 1 stated that all visitors entering a contact isolation room should wear gowns and gloves while inside the resident's room. During an interview on 10/4/2023 at 11:03 a.m., FM 1 stated that he was not aware he needed to wear a disposable gown and gloves before entering Resident 60's room. During an interview on 10/4/2023 at 1:30 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated that all family and visitors entering a contact isolation room should wear gowns and gloves. The IPN stated that the receptionist in the front desk should be educating all the family and visitors regarding the necessary personal protective equipment (PPE-equipment worn to prevent or minimize exposure from infection) needed in contact isolation room. The IPN also stated that the staff should also educate family and visitors regarding the need for PPE use while inside a contact isolation room. A review of the facility's policy and procedure titled, Transmission Based Precaution, reviewed on 1/26/20223, indicated that it is the policy of the facility to use transmission-based precautions (TBP- used to help stop the spread of germs from one person to another) when caring for patients/residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. It also indicated that contact precautions shall be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic [medications that fight bacterial infections] medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct infection surveillance and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for four of five sampled residents (Residents 43, 47, 76, 87). This deficient practice had the potential for Residents 43, 47, 76 and 87 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections. Findings: a. A review of Resident 43's admission Record indicated the facility admitted the resident on 2/3/2017 with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), tracheostomy (surgically created hole in your windpipe that provides an alternative airway for breathing) and urinary tract infection (UTI- an infection in any part of the urinary system). A review of Resident 43's Minimum Data Set (MDS-standardized assessment and screening tool) dated 7/10/2023, indicated resident had moderately impaired cognition (ability to think and make decisions). A review of Resident 43's Physician's Order dated 9/15/2023, indicated an order for cefepime (antibiotic) hydrochloride (HCL) one gram (gm- a unit of measurement) intravenously (IV-given via the vein) one time a day for UTI. A review of Resident 43's Lab Results Report with a collected date of 9/15/2023 and reported date of 9/19/2023, indicated Resident 43's urine culture (lab test to check for bacteria or other germs in a urine sample) test results indicated the resident had klebsiella pneumonia (bacteria that causes infection) and was resistant to cefepime antibiotic. A review of Resident 43's Physician's Order dated 9/19/2023, indicated an order for ertapenem sodium (antibiotic), one gram intravenously one time a day for seven days. A review of Resident 43's Surveillance Data Collection form (a form to monitor signs and symptoms [s/s] for infections) for UTI for resident without an indwelling catheter (catheter inserted into the bladder to drain urine) dated 9/15/2023, indicated Resident 43 had a temperature of 97.5 Fahrenheit (?), pulse (heart rate- normal 60-100 beats per minute) was 66 beats per minute, and respiration of 18 (normal respirations 12-20 breaths per minute). It also indicated that there was no check mark on any of the criteria for the antibiotic. A review of Resident 43's Surveillance Data Collection form for UTI for resident without an indwelling catheter dated 9/19/2023, indicated Resident 43 had a temperature of 97.8 ?, pulse was 73, and respiration was 18. It also indicated that there was no check mark on any of the criteria for the antibiotic. During a concurrent interview and record review on 10/3/2023 at 10:41 a.m., with the Infection Preventionist Nurse (IPN), reviewed Resident 43's Physician's Orders for the month of 9/2023 and the Surveillance Data Collection form dated 9/15/2023 and 9/19/2023. The IPN stated that the Surveillance Data Collection form was not filled out completely for both of the antibiotics. The IPN stated that the Surveillance Data Collection form should have been filled out for antibiotics ordered. The IPN stated that if the resident was asymptomatic (having no symptoms), the doctor should have been notified and should have been documented in the progress notes. b. A review of Resident 47's admission Record indicated the facility originally admitted the resident on 9/21/2020, with diagnoses including chronic respiratory failure, tracheostomy, and atrial fibrillation (irregular heart rate). A review of Resident 47's MDS dated [DATE], indicated resident had severely impaired cognition. A review of Resident 47's Physician's Order dated 9/15/2023, indicated the resident had an order for cefepime HCL intravenous solution one gram, intravenously one time a day for UTI for seven days. A review of Resident 47's urinalysis (UA-urine test) collected on 9/14/2023 and reported on 9/15/2023, indicated resident had cloudy urine. A review of Resident 47's urine culture test results, collected on 9/14/2023 and reported on 9/19/2023, indicated resident had escherichia coli (E. Coli- common bacteria that causes UTI) in the urine. A review of Resident 47's Surveillance Data Collection form for a resident without an indwelling catheter dated 9/15/2023, indicated resident had an antibiotic treatment for UTI. During a concurrent interview and record review on 10/3/2023 at 10:41 a.m., with the IPN, reviewed Resident 47's UA, urine culture, antibiotic order, and Surveillance Data Collection form dated 9/15/2023. The IPN stated that on 9/15/2023, the doctor ordered cefepime antibiotic for Resident 47's UTI. The IPN also stated that the Surveillance Data Collection form for UTI, was not filled out by the licensed nurse. The IPN stated that when the licensed nurse received an order for any antibiotic, the Surveillance Data Collection form will need to be filled out and check if the resident meets the criteria for antibiotic. The IPN stated that for UTI, both criteria of the Surveillance Data Collection form must be present. The IPN stated that according to Surveillance Data Collection form, Resident 47 did not have any of the first criteria. The IPN stated that the physician should have been notified that Resident 47 did not meet the criteria for the antibiotic. The IPN stated there was no documentation that the doctor was notified. c. A review of Resident 76's admission Record indicated the facility admitted the resident on 11/23/2022 and readmitted on [DATE] with diagnoses including chronic respiratory failure, tracheostomy, and resistance to antibiotic. A review of Resident 76's MDS dated [DATE], indicated resident had severely impaired cognition. A review of Resident 76's Physician's Order dated 9/21/2023, indicated an order for macrodantin (antibiotic) capsule 100 milligrams (mg- a unit of measurement), one capsule via gastrostomy tube (GT-tube inserted through the belly that brings nutrition directly to the stomach) give one dose now and then two times a day for UTI. A review of Resident 76's Surveillance Data Collection form for UTI for resident with an indwelling catheter dated 9/21/2023, indicated that the resident's urinary catheter specimen culture with at least 10 colony forming unit (cfu- a unit of measurement)/milliliter (mL- a unit of measurement) of any organism criteria was marked with a check. During a concurrent interview and record review on 10/3/2023 at 10:41 a.m., with the IPN, reviewed Resident 76's Physician's Orders for the month of 9/2023 and the Surveillance Data Collection form dated 9/21/2023. The IPN stated that Resident 76 did not meet the criteria because only one of two criteria were met. The IPN stated that Resident 76 did not meet criteria one because the resident did not have at least one of the sign or symptoms of a UTI. During an interview on 10/3/2023 at 10:50 a.m., with the IPN, the IPN stated that according to their antibiotic stewardship, when the resident had an order for any kind of antibiotic, the Surveillance Data Collection form specific for the infection, should be filled out by the licensed nurse as soon as possible. The IPN stated that the resident will need to meet all of the criteria for infection. The IPN also stated that if the criteria was not met, the licensed nurse should call the physician. The IPN stated if the physician still insisted to continue with the antibiotic, then they would have to document in the progress notes. The IPN stated that the risk of not following the antibiotic stewardship program would place residents at risk for unnecessary medications and antibiotic resistance. A review of the facility's policy and procedure titled, Antibiotic Stewardship, reviewed 1/26/2023, indicated the facility implements an Antibiotic Stewardship Program (ASP) to optimize antimicrobial therapy use by promoting optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance .The ASP will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing. d. A review of Resident 87's admission Record indicated the facility admitted the resident on 1/16/2023 and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), acute lower respiratory infection (lung infection), and required the use of a ventilator (a machine to help one to breathe who would otherwise not be able to breathe on their own). A review of Resident 87's MDS dated [DATE], indicated Resident 87 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 87 required two-person total dependence (full staff performance every time) with transfer, dressing, toilet use, and personal hygiene. A review of Resident 87's Laboratory (Lab) Results, dated 9/17/2023, indicated Resident 87 was positive for extended spectrum beta-lactamase bacteria (ESBL, found in some strains of bacteria and can't be killed by many of the antibiotics, making it more difficult to treat) in a sputum (a mixture of saliva and mucus coughed up from the respiratory tract) culture taken. A review of Resident 87's Lab Results, dated 9/18/2023, indicated Resident 87's white blood cell (WBC, blood cells that protect the body from infection) count was 7,070 white blood cells per microliter (or 7.07 x 109/L, normal reference range is 4,500 to 11,000 WBCs per microliter (4.5 to 11.0 x 109 /L). A review of Resident 87's Radiology Results (x-ray results), dated 9/25/2023, indicated Resident 87 had bacterial pneumonia (lung infection caused by bacteria in which one sometimes exhibits increased heart rate, low blood pressure, increased respirations, and fever). A review of Resident 87's Physician's Order indicated an order for ertapenem (an antibiotic to treat lung infections) one gram intravenously, one time a day for lung infection for 10 days, dated 9/21/2023. A review of Resident 87's Surveillance Data Collection Form, dated 9/21/2023, indicated Resident 87 had a lung infection due to a presence of ESBL > 100,000 to the sputum. The form indicated Resident 87 was started on ertapenem 1 gram by intravenous route for 10 days on 9/21/2023. The form indicated Resident 87 had a temperature of 97.6O Fahrenheit (o F, a unit of measure for temperature, normal reference range is 97 - 99o F). The form indicated Resident 87 had a heart rate of 76 beats per minute. A review of Resident 87's resolved (completed) Care Plan for Antibiotic Therapy, initiated 9/21/2023, indicated Resident 87 was started on ertapenem one gram intravenously daily for 10 days for lung infection. The care plan indicated Resident 87's condition will show evidence of responding to antibiotic therapy. The care plan indicated an intervention to administer antibiotic medication as ordered by the physician. During a concurrent interview and record review with the Infection Prevention Nurse (IPN) on 10/05/2023 at 1:27 p.m., reviewed a blank Surveillance Data Collection Form for Respiratory Tract Infections. The IPN stated the facility follows the McGeer's criteria (certain s/s of infection that are recommended be present to establish a true infection and prescribe an antibiotic medication; this is to ensure one does not receive an unnecessary medication) as part of their infection surveillance program. The IPN stated that form should be filled out by the licensed nursing staff and reviewed by her when a resident has a respiratory infection. The form indicated to see Table 2 to check for further criteria. When asked where Table 2 is located, the IPN was unable to locate the paper that indicated the contents of Table 2. Reviewed Resident 87's Vital Signs (clinical measurements such as heart rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) between the dates 9/19/2023 and 9/25/2023. The IPN stated there we no abnormal vital signs such as low blood pressure, high heart rate, high respirations, or abnormal oxygen saturation (how much oxygen is in the blood). The IPN stated she should have completed a Surveillance Data Collection Form for Respiratory Tract Infections for Resident 87 to ensure the McGeer's criteria have been met for the need for receiving an antibiotic. The IPN stated if she had completed the form and it did not meet the criteria for the antibiotic, she could have called Resident 87's physician to see if he still wanted to prescribe the antibiotic. The IPN stated Resident 87 had the potential to be prescribed an unnecessary medication that could cause antibiotic resistance to future infections. During an interview on 10/05/2023 at 2:50 p.m., with the Director of Nurses (DON), the DON stated the IPN conducts the antibiotic stewardship program. The DON stated the IPN should have completed a Surveillance Data Collection Form for Respiratory Tract Infections which would determine if the McGeer's Criteria is being followed for the antibiotic medication. The DON stated, if a resident does not meet the McGeer's criteria then a resident's doctor would be notified to determine whether he still wanted to prescribe the antibiotic or not. The DON stated the importance of following these steps is so the medication is not prescribed unnecessarily and not be effective in treating future bacterial infections. A review of the facility's policy and procedure titled, Antibiotic Stewardship, reviewed 1/26/2023, indicated the facility implements an Antibiotic Stewardship Program (ASP) to optimize antimicrobial therapy use by promoting optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance .The ASP will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing.

**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's suction tip (an oral suctioning tool used in medical procedures) was changed weekly or as needed per the facility's policy and procedure for one of three sampled residents (Resident 1). 2. Ensure a resident's oxygen tubing and gastrostomy tube (g-tube - a tube inserted through the abdominal wall that brings nutrition and medication directly to the stomach) tubing were kept off the floor for one of three sampled residents (Resident 1). These deficient practices had the potential to result in contamination and placed Resident 1 at increased risk for contracting an infection. Findings: a. A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/22/2023 and readmitted the resident on 6/8/2023 with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) with hypoxia (low levels of oxygen in your body tissues), tracheostomy (a surgically created hole in the windpipe that provides an alternative airway for breathing), dependence on ventilator (a machine that helps you breathe or breathes for you), and pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/12/2023, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS also indicated Resident 1 required oxygen therapy, suctioning, tracheostomy care, and a ventilator. During a concurrent observation and interview on 7/27/2023 at 12:57 p.m., with Respiratory Therapist 1 (RT 1), observed RT 1 suction Resident 1's tracheostomy and then suction the resident's mouth with a suction tip. When asked how often the suction tip was changed, RT 1 stated twice a week or as needed. When asked what the date was indicated on the suction tip, RT 1 stated it was dated 6/25/2023. RT 1 stated it was old and should have been thrown out. RT 1 stated that if it was not changed regularly, it could harbor bacteria, which can possibly cause an infection to the resident. During an interview on 7/27/2023 at 3:41 p.m., with the Director of Respiratory Services (DRS), the DRS stated the facility's policy was to change the suction tip once a week. The DRS stated he thought the suction tip had just been misdated by the Respiratory Therapist (RT). When asked if he could prove that the suction tip had been changed recently, the DRS could not provide an answer. When asked, if assuming the suction tip had been misdated, why the following assigned RTs had not changed it out after seeing an old date, the DRS stated the RTs store the suction tip and its plastic covering inside a black bag and just pull it out without the plastic covering when they need to use it. The DRS stated that was probably why the RTs did not see the date written. The DRS stated that the purpose of changing the suction tip weekly and as needed was to prevent infection to the resident. During an interview on 7/31/2023 at 11:10 a.m., with the Director of Nursing (DON), the DON stated it was the facility's policy to change the suction tip once a week or as needed. When asked if the RTs were checking the dates on the suction tips, the DON stated she could not answer because they are stored in a plastic covering inside a black bag, and the RT pulls it out of the bag without removing the entire plastic covering with it. The DON stated it would be good practice for the RT to check the date on it to ensure that the suction tip was being changed regularly. The DON stated the purpose of changing the suction tip was to ensure that it was clean, so that organisms would not be introduced to the resident. A review of the facility's policy and procedure titled, Changing of Respiratory Equipment, last reviewed on 1/26/2023, indicated that disposable equipment is for single resident use and will be changed regularly and on an as needed (PRN) basis to minimize the risk of nosocomial infections (infections acquired during the process of receiving health care that was not present during the time of admission). Yankauer suction tips will be changed weekly and PRN. b. A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/22/2023 and readmitted the resident on 6/8/2023 with diagnoses that included chronic respiratory failure with hypoxia, tracheostomy, dependence on ventilator, pneumonia, and encounter for attention to gastrostomy (the creation of an artificial external opening into the stomach for nutritional support). A review of Resident 1's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 7/29/2023 at 8:38 a.m., with Respiratory Therapist 3 (RT 3), observed Resident 1's oxygen tubing and the end of Resident 1's disconnected g-tube tubing on the floor. RT 3 stated the oxygen tubing and the g-tube tubing should not be on the floor because they can become contaminated, which can cause infection to the resident. During an interview on 7/29/2023 at 9:41 a.m., with the DON, the DON stated the facility did not have a specific policy indicating that oxygen tubing and g-tube tubing should not be on the floor. During an interview on 7/31/2023 at 11:10 a.m., with the DON, the DON stated it was important to ensure that oxygen tubing and the connecting end of the g-tube feeding was off the floor because it was important to ensure that anything connected to the resident was clean to prevent infection. A review of the facility's policy and procedure titled, Changing of Respiratory Equipment, last reviewed on 1/26/2023, indicated that disposable equipment is for single resident use and will be changed regularly and on an as needed (PRN) basis to minimize the risk of nosocomial infections (infections acquired during the process of receiving health care that was not present during the time of admission). A review of the facility's policy and procedure titled, Infection Control Precautions - Standard, last reviewed on 1/26/2023, indicated it is the policy of the facility to utilize standard precautions when caring for patients/residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Handle used patient/resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other patients/residents and environments.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) followed physician ' s order for one of three sampled residents (Resident 1) when Resident 1 was given spironolactone (medication used to treat high blood pressure and also known as water pill that helps get rid of extra water and salt from the body) tablet 25 milligram (mg-unit of measure) by mouth one time a day for hypertension (uncontrolled elevated blood pressure) despite the physician ' s order to hold the medication for systolic blood pressure (sbp-measures the pressure in the arteries when heart beats) below 100 millimeters of mercury (mmHg- measurement of pressure). This deficient practice had the potential to result in further drop in Resident 1 ' s blood pressure (bp- pressure of circulating blood against the walls of blood vessels). Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 11/17/2022 with diagnoses that included right femur (thigh) fracture (broken bone), hypertension, and history of falling. A review of Resident 1 ' s History and Physical, dated 11/17/2022, indicated Resident 1 had the capacity to make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care- screening tool), dated 11/23/2022, 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 for moving in bed, transferring to bed to chair, toilet use, and personal hygiene. A review of Resident 1 ' s Physician Orders, dated 11/17/2022, indicated an order for spironolactone tablet 25 mg by mouth one time a day for hypertension, hold for sbp below 100 mmHg. A review of Resident 1 ' s Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 11/2022, indicated spironolactone was given on 11/25/2022 at 9 a.m., with sbp of 93 mmHg with Licensed Vocational Nurse 1's (LVN 1's) initial. During a concurrent interview and record review on 12/23/2022, at 10:43 a.m., with the Director of Nursing (DON), Resident 1 ' s Physician order and MAR, dated 11/2022, was reviewed. The DON stated it looked like it was given on 11/25/2022 at 9 a.m., with a blood pressure of 93/57 mmHg. The DON stated, spironolactone is diuretic (medication used to get rid of extra water and salt from the body) which may or may not affect the blood pressure. During an interview on 12/23/2022 at 12:36 p.m., LVN 1 stated that on 11/25/2022 at 9 a.m., Resident 1 ' s blood pressure was 93/57 mmHg and was given spironolactone even with physician ' s order to hold for sbp below 100 mmHg. LVN 1 stated he should have held the medication to prevent occasional drop of blood pressure. A review of Resident 1 ' s care plan on hypertension, dated 11/17/2022, indicated an intervention to give anti-hypertensive medications as ordered. A review of facility ' s policy and procedure titled, Medication Administration-General Guidelines, dated 1/2017, indicated, Medications are administered in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 44's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included cerebral infarction (damage to part of the brain caused by a blood clot) and acute respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 44's Minimum Data Set (MDS - an assessment and care screening tool), dated 3/5/2021, indicated the resident had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS also indicated the resident sometimes was able to understand others and sometimes was able to make self understood. The MDS indicated Resident 44's daily preferences of choosing what clothes to wear was very important to the resident. The MDS also indicated the resident was totally dependent on staff with bed mobility, personal hygiene, dressing, and bathing. During an interview, on 4/7/21 at 8:56 AM, the Administrator (ADM) reported about an ongoing investigation about an interaction between Resident 44 and Certified Nursing Assistant 3 (CNA 3). The recording was reported by the resident's Responsible Party (RP) to ADM and to the Director of Staff Development (DSD). The investigation included Resident 44's preference to wear pants and stating her pants fit fine, while CNA 3 repeatedly stated the resident cannot use pants because the pants don't fit. CNA 3 provided gown pants (bottom pants of a hospital gown) for the resident to wear instead. During a telephone interview, on 4/8/21 at 10:53 AM, CNA 3 stated she was aware of the recording of the interaction between her and Resident 44. CNA 3 stated she did not mean to offend Resident 44. A review of Resident 44's Care Plan (written guide that organizes information about the resident's care) addressing communication problem, initiated on 2/28/21, indicated a goal for the resident to communicate basic needs. The interventions included allowing adequate time for resident to respond; not rushing the resident; requesting clarification from the resident to ensure understanding; and using simple, brief, consistent words/cues. A review of the facility-provided Resident [NAME] of Rights, dated 5/2011, indicated patients shall have the right to be treated with consideration, respect and full recognition of dignity and individuality including privacy in treatment and in care of personal needs Based on observation, interview, and record review, the facility failed to ensure all residents have a right to a dignified existence, self-determination, and communication in personal care by failing to: 1. Ensure one of one resident (Resident 76) had a privacy bag over the urinary drainage bag (bag used to collect urine) 2. Ensure one of two resident's (Resident 44) preferences and choice in what she can wear were considered for. These deficient practices had the potential to affect resident rights to a dignified existence for Resident 44 and Resident 76. Findings: a. A review of Resident 76's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included acute and chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), dependence on ventilator (an appliance for artificial respiration), urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder or urethra]), unspecified dementia (disease that include decline in memory, language, problem-solving and other thinking skills) and pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 3/16/2021, indicated the resident rarely/never made self understood and rarely/never understood others. The MDS also indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed total assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). During an observation, on 4/5/21 at 10:51 AM, observed there was no privacy bag over Resident 76's urinary drainage bag (bag used to collect urine). During a concurrent observation and interview, on 4/5/2021 at 11:05 AM, Certified Nursing Assistant 1 (CNA 1) confirmed that Resident 76 did not have a privacy bag over the resident's urinary drainage bag. CNA 1 stated resident should have a dignity bag (privacy bag) over the urinary drainage bag and is one of resident's rights. A review of Resident 76's Care Plan (written guide that organizes information about the resident's care) on indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage), dated 12/9/2020, included an intervention to provide privacy bag over the urinary drainage bag. During an interview, on 4/7/2021 at 1:03 PM, the Director of Nursing (DON) stated Resident 76's urinary drainage bag should have been covered with a dignity bag and is a good nursing practice. The DON also stated the licensed nurses and certified nursing assistants are responsible to place the dignity bag over the urinary drainage bag. A review of the facility-provided, undated admission Agreement titled California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, indicated patients shall have the right to be treated with consideration, respect and full recognition of dignity and individuality including privacy in treatment and in care of personal needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's Advanced Directive (written document that indicates a person's wishes regarding medical treatment if that person is no longer able to communicate to make medical decisions) was in the resident's medical record for one of two sampled residents (Resident 80). This deficient practice had the potential to cause conflict with Resident 80's wishes regarding health care. Findings: A review of Resident 80's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included delusional disorders (a type of serious mental illness when a person cannot tell what is real from what is imagined), and dementia with behavioral disturbance (decline in mental ability severe enough to interfere with daily functioning/life). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 12/17/2020, indicated Resident 80 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS also indicated Resident 80 required extensive physical assistance with bed mobility, transfer, walking in room and corridor, dressing, toilet use, and personal hygiene. The MDS indicated the resident was totally dependent with movement on and off the unit. A review of Resident 80's Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration), dated 09/15/2015, indicated POLST complements an advance directive and is not intended to replace that document. A review of Resident 80's Advanced Directive Acknowledgement form signed on 9/26/2015, indicated the resident had executed an Advanced Directive. A copy of the Advanced Directive was not found in the resident's medical records. On 4/7/2021 at 2:19 p.m., during an interview, Social Services Director (SSD) stated she could not find a copy of Resident 80's Advanced Directive. On 4/8/2021 at 9:50 a.m., during an interview, the Director of Nursing (DON) stated the facility received a copy of the Resident 80's Advanced Directive many years ago but she was unable to locate it. The DON stated the SSD called Resident 80's family member to obtain a copy of the Advanced Directive. A review of the facility's policy and procedures titled, Advance Directives, revised in November 2016, indicated it is the policy of the facility to comply with state and federal law regarding the development and implementation of a resident's advance directives. If there is an advanced directive, then this information shall be placed in the clinical record when provided by the resident or their representative. This document will be filed in the resident's clinical record in a place that is easily accessible in the event of an emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report the allegation of abuse between Resident 17 and Certified Nursing Assistant 5 (CNA 5). The facility reported the allegation of abuse later than 2 hours to the Department of Public Health. This deficient practice had the potential to place the resident at risk for further abuse. Findings: A review of Resident 17's admission Record (face sheet), indicated the resident was initially admitted to the facility on [DATE], with diagnoses including depressive disorder (mental illness characterized by sadness severe or persistent enough to interfere with daily activities of life) and anxiety disorder (a group of mental disorders characterized by significant feelings of anxiety and fear). A review of Resident 17's Minimum Data Set (MDS- a resident assessment and care-screening tool), indicated the resident can understand others and can make self-understood with intact cognition. The MDS indicated the resident required requires extensive assistance with most areas of activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). During an interview, on 4/8/21 at 3:53 pm, Social Services Director (SSD) stated Resident 17 reported hearing Certified Nursing Assistant 5 (CNA 5) make racial comments about her and her race, while the CNA was providing care to another resident. During a concurrent interview and record review, on 04/08/21 at 11:33 AM, the electronic fax log indicated the facility sent faxes on 3/23/21 to the Ombudsman (resident advocacy group) at 7:20 pm and to the California Department of Public Health (CDPH) District Office at 7:35 pm. The Administrator (ADM) stated it is the policy of the facility to report abuse in 2 hours; serious harm no less than 2 hours; and submit the final report within 5 days. During an interview, on 04/08/21 at 12:12 pm, ADM stated he was first made aware of the abuse allegation on 3/22/21 when SSD reported about Resident 17's concern from the prior 11 pm to 7 am shift. The concern was about Resident 17's hearing racial comments from CNA 5. The ADM also stated the SOC 341 (a form that reports allegations of abuse) submission was late and that he should have reported the allegation no later than 2 hours after the allegation was made. A review of the policy and procedures titled Prevention, Reporting, and Correction of Inappropriate Conduct Including Abuse, Neglect, and Mistreatment of Residents and Investigations of Injuries of Unknown Origin, dated 11/2017, indicated to promptly report such information to the local district office within 2 hours via telephone or electronic communication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 5 (LVN 5) did not use one spoon to mix seven different crushed medications before administering them via gastrostomy tube (g-tube - a tube inserted through the belly that brings nutrition or medications directly to the stomach) to one (Resident 36) out of three g-tube residents observed during medication administration facility task. This deficient practice had the potential to result in medication interactions, which can render the medications ineffective or less effective. Findings: A review of Resident 36's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), encounter for attention to tracheostomy (a medical procedure that involves creating an opening in the neck in order to place a tube into a person's windpipe), and encounter for attention to gastrostomy (g-tube - a tube inserted through the belly that brings nutrition or medications directly to the stomach). A review of Resident 36's most recent quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/23/21, indicated the resident was in a persistent vegetative state/had no discernible consciousness (completely unresponsive and displays no sign of higher brain function, being kept alive only by medical intervention). The MDS indicated the resident was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident had a feeding tube used for nutrition. On 4/6/21 at 9:26 AM, during a g-tube medication administration observation, observed Licensed Vocational Nurse 5 (LVN 5) administering the following medications to Resident 36: 1. Lisinopril (blood pressure medication) 10 milligrams (mg - unit of measurement) 2. Vitamin D (supplement) 1000 units 3. Pro-stat liquid supplement 4. Atenolol (blood pressure medication) 12.5 mg 5. Famotidine (antacid medication used to treat excess stomach acid) 20 mg 6. Ferrous sulfate (iron supplement) 7.5 milliliters (ml) 7. Ascorbic acid (vitamin C supplement) 500 mg During the observation, LVN 5 crushed each pill and placed them in separate medication cups. LVN 5 diluted each medication with some water. LVN 5 then proceeded to mix each individual medication using one wooden spoon before administering them separately. On 4/6/21 at 10:02 AM, during an interview, LVN 5 stated she should have used different spoons to mix each medication because the spoon can have residual particles of other medications, which can interact with each other. LVN 5 stated she had brought a cup with several spoons in it with the intention of using different spoons but forgot to use them. On 4/7/21 at 9:20 AM, during an interview, Registered Nurse 2 (RN 2) stated she had to administer g-tube medications sometimes. RN 2 stated she would use different spoons to mix each separate medication to ensure there were no medication interactions. On 4/7/21 at 4:20 PM, during an interview, the Director of Nursing (DON) stated it was good practice to use different spoons to mix different medications. On 4/8/21 at 9:31 AM, during an interview, Licensed Vocational Nurse 1 (LVN 1) stated he would dilute each medication with about 15 ml of water and mix each medication with a different spoon to prevent the medications from mixing with each other. LVN 1 stated he had learned to do it that way from nursing school. On 4/8/21 at 9:35 AM, during an interview, Registered Nurse 1 (RN 1) stated she had to pass g-tube medications sometimes. RN 1 stated she would crush each medication separately, put them into separate cups, and mix each one with 10 ml of water. RN 1 stated she would then use multiple spoons to mix each medication to avoid medication interactions. RN 1 stated she had been doing it that way for years because it was a practice she learned in nursing school. RN 1 stated it was good practice to do it that way. On 4/8/21 at 9:39 AM, during an interview, Registered Nurse 3 (RN 3) stated she had to pass g-tube medications sometimes. RN 3 stated she would crush each medication separately and dilute each medication with some water before administering them separately. RN 3 stated she mixed each medication with different spoons, which is how she learned in nursing school. RN 3 stated the rationale for using different spoons to mix each medication was to avoid any medication interactions. On 4/8/21 at 9:53 AM, during an interview, Licensed Vocational Nurse 3 (LVN 3) stated she would pour out each medication into a separate medication cup and dilute each medication with 10 ml of water. LVN 3 stated she used different spoons to mix each medication. LVN 3 stated this practice was the facility's protocol. On 4/8/21 at 10 AM, during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she poured out each medication into separate cups and diluted each medication with a little bit of water. LVN 4 stated she would then use different spoons to mix each medication, which is what she learned in nursing school. A review of an article by the Institute for Safe Medication Practices titled, Preventing Errors When Administering Drugs Via an Enteral Feeding Tube, dated 5/6/10, indicated that compatibility between multiple drugs being administered together can be a problem, particularly if two or more drugs are crushed and mixed together before administration. Mixing two or more drugs together, whether solid or liquid forms, creates a brand new, unknown entity with an unpredictable mechanism of release and bioavailability. A review of the facility's policy and procedure titled, Enteral Tube Medication Administration, updated in January 2017, indicated the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 77's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included unspecified asthma (inflammatory disease of the airways to the lungs) and traumatic brain injury (sudden injury that causes damage to the brain). A review of Resident 77's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 3/17/2021, indicated the resident had the ability to make self understood and understand others. The MDS also indicated Resident 77 needed extensive to total assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 77's prescription dated 2/23/2021, indicated a physician's order to apply small amount of erythromycin (antibiotic - medication used to treat variety of bacterial infection) eye ointment to both eyes every bedtime. A review of Resident 77's Medication Administration Record (MAR) indicated resident received erythromycin eye ointment from 2/23/2021 to 3/24/2021 while the resident refused from 3/25/2021 to 4/5/2021. During a concurrent interview and record review, on 4/8/2021 at 11:51 AM, the Infection Preventionist (IP) confirmed there was no indication and duration included on erythromycin eye ointment prescription ordered on 2/23/2021. The IP stated erythromycin eye ointment prescription should have included the diagnosis (indication - reasons for use) and stop date (duration - length of time of use). The IP nurse also stated antibiotic prescriptions should include name of medication, dose, route, frequency, stop date and diagnosis for its use. She stated, the antibiotics cannot be used for long time because it loses its potency (effectiveness) over time and cause antibiotic resistance (germs develop the ability to defeat the drugs designated to kill them). The IP nurse further stated, if the antibiotic prescription did not include the stop date, the order should have been clarified with the ordering doctor. During an interview, on 4/8/2021 at 1:35 PM, the Director of Nursing (DON) stated the duration of erythromycin eye ointment order should have been clarified by the licensed nurse who received the medication order. The DON also stated the duration of antibiotic administration should be written to prevent the development of antibiotic resistance. A review of the facility's policies and procedures titled Antibiotic Stewardship, dated 11/2017, indicated it is the policy of this facility to implement an antibiotic stewardship program (ASP - a coordinated program that promotes the appropriate use of antibiotics to improve patient outcomes and reduces antibiotic resistance) to optimize antimicrobial (destroy or inhibit the growth of all microorganisms) therapy use by promoting optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity (degree of being very harmful) to the patient and minimal impact on subsequent resistance. Antibiotic orders should be written to include the dose, duration, and indication of therapy. Avoid prolonged use of antibiotics and prophylactic therapy. Keep the duration as short as possible. Based on interview and record review, the facility failed to: a. Ensure two out of three residents (Resident 4 and Resident 10) reviewed for quality of care were monitored for their responses to anticoagulant (prevents the formation of clots and extension of existing clots within the blood) therapy. They were not monitored for adverse effects (any unexpected or dangerous reaction to a drug) and signs of bleeding, such as bruising, hematuria (presence of blood in urine), melena (presence of blood in stool), epistaxis (nosebleed), and coughing up of blood. Resident 4's response to anticoagulant was not evaluated since 4/20/2020. Resident 10's response to anticoagulant therapy was not evaluated since 3/17/2021. This deficient practice placed the residents at risk for unintended complications of bleeding which can be severe or life threatening from taking heparin sodium (anticoagulant) for Resident 4 and Lovenox (anticoagulant) for Resident 10. b. Identify and include the duration (length of time) and indication (reason for use) of erythromycin (an antibiotic medication) eye ointment prescription for one out of one resident (Resident 77). Erythromycin ointment was prescribed last 2/23/2021. This deficient practice had the potential for development of antibiotic resistance (germs develop the ability to defeat the drugs designated to kill them) to Resident 77 due to possible unnecessary or inappropriate antibiotic use. Findings: a. A review of Resident 4's admission Record (face sheet) indicated the resident was admitted on [DATE] with diagnoses that included pneumonia (an infection of the air sacs in one or both the lungs), sepsis (an infection of the blood stream) and chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood). A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/04/2020, indicated the resident had severely impaired cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making. The MDS also indicated the resident was totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 4's Order Summary Report indicated a physician`s order dated 4/20/2020 to administer heparin sodium solution (anticoagulant - prevents the formation of clots and extension of existing clots within the blood) 5000 units/ml (units of measurement), inject 5000 units subcutaneously (situated or lying under the skin) every eight hours for clotting prevention. A review of Resident 4`s Anticoagulant Therapy Care Plan, initiated and revised on 3/12/2020, indicated to administer anticoagulant medication as ordered and to monitor for signs of bleeding like excessive bruising, epistaxis (nosebleed), pallor (unhealthy pale appearance), hematuria (presence of blood in urine), and excessive bleeding from wounds or in the mouth. On 4/7/2021 at 1:50 PM, during a record review of Resident 4`s medical records and a concurrent interview, Registered Nurse (RN 4) stated there was no monitoring for adverse effects (unexpected or dangerous reaction to a drug) anticoagulant therapy such as bleeding, excessive bruising, pallor, and hematuria since heparin sodium was ordered on 4/20/2020. According to RN 4, it is the facility`s nursing protocol to monitor for signs of bleeding when a resident is on anticoagulant therapy because residents are at a higher risk for bleeding due to this medication. On 4/8/2021 at 1:21 PM, during an interview, the Director of Nursing (DON) stated that during the monthly medication regimen review, the pharmacy consultant would review each resident`s medication therapy and should have identified and recommended to monitor for signs of bleeding for residents on anticoagulant therapy. The DON added that they would always follow the guidelines on the requirement to monitor for signs of bleeding for residents on heparin sodium. A review of Consultant Pharmacist`s Medication Regimen Review from 1/1/2021 to 3/3/2021, indicated that there was no pharmacist recommendation to monitor Resident 4 who was on anticoagulant therapy for signs of bleeding. A review of the facility`s policy and procedure titled Medication Regimen Review, updated in 1/2017, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident`s response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevent or minimizes adverse consequences related to medication therapy. Findings are reported to the director of nursing and the attending physician, and if appropriate, the medical director/or administrator. A review of the undated facility-provided medication literature (package insert) for heparin indicated a warning to monitor patient closely for signs of bleeding and discontinue if bleeding occurs. b. A review of Resident 10's admission Record (face sheet) indicated the resident was admitted on [DATE] with diagnoses including heart failure (he heart doesn't pump blood as well as it should), encephalopathy (damage or disease that affects the brain), and gastroesophageal reflux disease ( a digestive disease in which stomach acid or bile irritates the food pipe lining). A review of Resident 10's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/20/2020, indicated Resident 10 was able to make self understood and understand others. The MDS also indicated the resident was totally dependent on staff for dressing, toilet use, personal hygiene, and bathing. A review of Resident 10's Order Summary Report indicated a physician`s order dated 11/11/2020 to administer Lovenox Solution (anticoagulant - prevents the formation of clots and extension of existing clots within the blood) 40 mg/0.4 ml (mg/ml are units of measurement), inject 0.4 ml subcutaneously (situated or lying under the skin) one time a day for deep vein thrombosis (DVT - a serious condition that occurs when a blood clot forms in a vein located deep inside your body) prophylaxis (measures taken for disease prevention). On 4/07/21 at 1:50 PM, during a review of Resident 10`s Medication Administration Record (MAR) and a concurrent interview with Registered Nurse 4 (RN 4), there was no monitoring for adverse effects of anticoagulant therapy documented on 3/17/2021. RN 4 stated that indeed there was no documentation of the monitoring for adverse effect of the anticoagulant therapy. RN 4 added that the nurse assigned should have monitored Resident 10 for any signs of bleeding because the resident had a high risk for bleeding because of the anticoagulant therapy. A review of the facility`s policy and procedure titled Medication Regimen Review, updated in 1/2017, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident`s response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevent or minimizes adverse consequences related to medication therapy. Findings are reported to the director of nursing and the attending physician, and if appropriate, the medical director/or administrator. A review of the undated facility-provided medication literature (package insert) for Lovenox indicated that concerns related to adverse effects (unexpected or dangerous reaction to a drug) included but not limited to bleeding, and patients should be monitored closely for signs or symptoms of bleeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Adequately monitor for specific target behaviors for the use of Depakote Sprinkles Capsule (medication is used to treat seizure [sudden, uncontrolled electrical disturbance in the brain] disorders and certain psychiatric [mental illness] conditions) for one out of five sampled residents (Resident 3) selected for unnecessary medications review. 2. Document specific behavioral concerns prior to starting Seroquel (an antipsychotic medication used to manage abnormal condition of the mind described as involving a loss of contact with reality), thus providing an inadequate indication for its use. The facility also failed to monitor the resident for a more specific and observable behavior, for one out of five sampled residents (Resident 82) selected for unnecessary medications review. These deficient practices had the potential to result in inconsistent monitoring and placed the residents at risk for receiving unnecessary medication and unrecognized adverse reactions. Findings: a. A review of Resident 3's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension), unspecified dementia (general term for severe loss of memory, language, problem-solving and other thinking abilities), and unspecified psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/26/2020, indicated the resident had the ability to sometimes self understood and has the ability to sometimes understand others. The MDS also indicated the resident needed total assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 3's Order Summary Report dated 3/18/2021, indicated to administer Depakote Sprinkles Capsule (medication used to treat seizure [sudden, uncontrolled electrical disturbance in the brain] disorders and certain psychiatric [mental illness] conditions) Delayed Release Sprinkle 125 milligrams (mg - a unit of measurement) two capsules via gastrostomy tube (G-tube - surgically placed device used to give direct access for feeding) two times a day for severe anxiety (feeling of worry, nervousness, and unease) and agitation manifested by spitting and pulling out of tube. A review of Resident 3's Medication Administration Records (MAR) indicated the resident received Depakote Sprinkles Capsule 250 mg from 3/18/2021 to 4/7/2021. During a concurrent interview and record review, on 4/7/2021 at 2:09 PM, Minimum Data Set Coordinator 1 (MDS 1) confirmed there was no documented evidence about the behavior monitoring on Resident 3's use of Depakote. MDS 1 stated Resident 3's specific behavior should have been monitored before each Depakote medication administration to make sure whether Depakote was indicated. During an interview, on 4/8/2021 at 9:20 AM, the Director of Nursing (DON) stated the licensed nurse who was administering the Depakote should have monitored the specific behavior before medication administration. The DON also stated it was important to know whether the medication is effective or not for the resident. A review of the facility's policy and procedures titled Psychoactive Medications, dated 11/2016, indicated it is the policy of this facility that residents on psychoactive medication (substances that can alter the consciousness, mood, and thoughts of those who use them)/chemical (given to control behavior) restraints are assessed at least quarterly for the effectiveness of interventions and/or chemical restraints and that residents on chemical restraints have psychoactive drugs reduced as indicated based on their comprehensive assessment. For residents with behavioral problems, not on psychoactive medications, the interdisciplinary team (IDT - a group of health care professionals from different fields who coordinate resident care) will develop appropriate strategies to intervene with the behaviors and document the interventions and rationale in the clinical record. The IDT will check the physician orders for the medication, including the name of the medication, dose, route, times and behaviors for which the medication is being administered. The order shall also include monitoring requirement for the behavior. b. A review of Resident 82's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE], was and readmitted on [DATE] with diagnoses that included acute respiratory failure (condition when not enough oxygen passes from the lungs to the blood) with hypoxia (low oxygen in the tissues), end stage renal disease (ESRD - stage when the kidneys can no longer support the body's needs of removing waste and excess water from the body), and Stage IV pressure sore (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) on the sacral region (located at the base of the spine and connected to the pelvis). A review of Resident 82's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/18/21, indicated the resident was cognitively intact and required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility, transfers, ambulation (walking) in the room and in the corridor, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident did not exhibit any behavioral symptoms. On 4/5/21 at 9:46 AM, during an observation, Resident 82 was awake, alert, and calm on his bed. Resident 82 was open to answering questions. On 4/7/21 at 8:33 AM, during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated Resident 82 had an order to receive Seroquel 25 milligrams (mg - unit of measurement) by mouth (PO) at bedtime (QHS) for mood disorder (a state in which one's general emotional state or mood is distorted or inconsistent with one's circumstances and interferes with one's ability to function) manifested by mood swings. RN 2 stated there was a physician's order, dated 3/31/21, for Resident 82 to have a psychiatry consult for insomnia (a sleep disorder in which one has trouble falling and/or staying asleep) and lack of appetite. RN 2 stated on 4/2/21, Psychiatric Medical Doctor 1 (PMD 1) came to see Resident 82, which was when he prescribed the Seroquel. RN 2 stated the resident was previously on Restoril (a medication used to treat insomnia) 7.5 mg PO as needed (PRN) QHS for insomnia for 14 days, ordered on 3/8/21. RN 2 stated, when monitoring for the behavior of mood swings, she would know when the resident was exhibiting the behavior when the nurses would tell her the resident was refusing care, but after a while, he would be okay with receiving care. On 4/7/21 at 9:29 AM, during a concurrent interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated since the resident was getting his Seroquel at night, he did not have to monitor for any behaviors during the day shift. LVN 1 stated the only things he monitored the resident for was drowsiness, dry mouth, and increased agitation. When asked if the resident had a behavior of refusing care, LVN 1 stated the resident refused his morning and afternoon blood sugar checks (a procedure that measures the amount of sugar, or glucose, in the blood) but allowed him to do the one in the evening. LVN 1 stated the resident did not like to be poked. On 4/7/21 at 4:14 PM, during a concurrent interview and record review, Licensed Vocational Nurse 2 (LVN 2) stated she was familiar with Resident 82 and had worked with him a couple of times. LVN 2 stated she most recently administered medications to him on 4/5/21. LVN 2 reviewed the Medication Administration Record (MAR - a report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for Resident 82 and stated that the behavior indication for Seroquel was mood disorder manifested by mood swings. LVN 2 stated the physician's order was to monitor the behavior for every shift. When asked what she looked for in a mood swing behavior, LVN 2 stated she would look for a behavior that was opposite of combative, wherein the resident followed instructions and listened to the nurses. LVN 2 stated, in other words, being compliant and then being combative. LVN 2 stated the resident would go from being compliant by following instructions and being in a good mood, and then switching to being combative, aggressive, or being rude. LVN 2 stated she had not personally experienced the resident having any mood swings. LVN 2 stated the resident has been very compliant with her and very easy going during the times she worked with him. On 4/7/21 at 4:20 PM, during a concurrent interview and record review, the Director of Nursing (DON) stated Resident 82 had a recent diagnosis of mood disorder because, according to the nurses and when they had done their clinical review, the resident had been having unpredictable behavior lately. The DON stated that was the reason his primary care physician referred him for a psychiatric consult. The DON stated PMD 1 came to see the resident on 4/2/21 and had started him on a low dose of Seroquel at bedtime. The DON stated she had seen his behavior go up and down, meaning he got easily frustrated and refusing treatments, but the next day he would be fine again. The DON stated when a resident has a new behavior, they monitor it closely, and they discuss with the physician if a medication is really needed or not. When asked to provide documentation regarding Resident 82's observed behaviors prior to being prescribed Seroquel, the DON reviewed the resident's medical record. The DON stated there was a progress note, dated 3/31/21, indicating the resident's wife was requesting a psychiatrist visit, but it had more to do with the resident's inability to sleep. The DON stated the resident's physician was documenting more on the resident's poor PO intake and the fluctuation of the resident's PO intake. The DON stated that during their clinical review it was always mentioned that the resident had up and down behavior, and that sometimes he refused treatments. When asked if there were any IDT notes, physician's progress notes, or nurses' notes addressing these behaviors, the DON searched through the resident's medical records. The DON stated she did not find anything in the resident's medical records addressing that behavior. The DON stated their notes were more concentrated on the resident's food intake and insomnia. On 4/7/21 at 4:43 PM, during an interview in the presence of the DON, when asked why Resident 82 was started on Seroquel, PMD 1 stated that they had tried Restoril, Remeron, and Trazodone, but the resident still was not able to sleep. PMD 1 stated the resident felt like his mind was racing, and that was why he had a mood disorder. A review of the facility's policy and procedure titled, Psychoactive Medications, revised in November 2016, indicated that for residents with behavioral problems, not on psychoactive medications, the IDT will develop appropriate strategies to intervene with the behaviors and document the interventions and rationale in the clinical record and/or care plan as indicated based on their professional judgment. When asked for a more specific policy and procedure addressing antipsychotic medications, the facility was not able to provide one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Physician's Discharge Summary (a clinical report prepared by the physician at the conclusion of a resident's stay) was completed for one out of three sampled residents (Resident 89) investigated addressing closed records. This deficient practice had the potential for ineffective management of Resident 89's medical records. Findings: A review of the admission Record (face sheet) indicated Resident 89 was admitted to the facility on [DATE], with diagnoses that included respiratory failure (condition when not enough oxygen passes from the lungs to the blood) and chronic obstructive pulmonary disease (COPD - a group of progressive lung disorders characterized by increasing breathlessness). A review of Resident 89's Physician's Discharge Summary (a clinical report prepared by the physician at the conclusion of a resident's stay) indicated the resident expired (passed away) at the facility on [DATE]. The Physician's Discharge Summary did not indicate the physician's signature, the date of signing, and the discharge diagnoses. On [DATE] at 1:20 p.m., during an interview with Registered Nurse 4 (RN 4), she stated the Physician's Discharge Summary should have been completed by the physician within 30 days after discharge; if not, the staff should have reminded the physician to come in and complete the documents. On [DATE] at 4:00 p.m., during an interview with Medical Record Director (MR 1), she stated the Physician's Discharge Summary should have been documented thoroughly by the discharging physician at the time of discharge; however, it was not done. MR 1 stated that when it comes to like this, medical records department should have followed up and had the physician complete the form. A review of the facility's policy and procedures titled Patient's Health Records, , dated 03/2016, indicated all health records of discharged patients shall be completed and filed within 30 days after discharge date and such records shall be kept for a minimum of seven years.

Based on observation, interview, and record review, the facility failed to ensure availability of the State Long Term Care Ombudsman Program (resident advocacy group) by not posting the sign (notice) in the resident dining room and the employee lounge. This deficient practice had the potential to deprive the residents of assistance from resident advocacy groups should unresolved issues arise in the facility. Findings: During a Resident Council Meeting, on 4/6/21 at 10 AM, three residents stated they were not aware of where the Ombudsman (resident advocacy group) contact information was. During a concurrent observation and interview, on 4/6/21 at 12:03 PM, the Director of Nursing (DON) confirmed there were no posted Ombudsman signs (notices) in the employee lounge and in the resident dining room. The DON stated there should be one posting in each location. The DON stated the dining room was used as a storage room and was reopened for resident use last week. The DON stated she would replace the Ombudsman posting in the resident dining room that day. During a concurrent observation and interview, on 4/8/21 at 2:58 PM, the Administrator (ADM) confirmed there was no Ombudsman posting in the employee lounge and the posting in the resident dining room was not put back. ADM stated there should be one in the lobby, in the resident dining room which also has a phone, and in the hallway in subacute (area of the facility that cares for residents on respiratory support). A review of the California Health and Safety Code 1422.6, effective 1/1/2001, indicated facility notice should be posted in a conspicuous location in at least 4 areas of the facility- a location accessible to the public, a location for employee breaks, next to telephone for resident use, and a location for communal functions for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 77's admission Record (face sheet) indicated the resident was admitted on [DATE] and was readmitted on [DATE], with diagnoses including traumatic brain injury and functional quadriplegia (unable to move limbs due to disability or weakness). A review of Resident 77's Minimum Data Set (MDS - an assessment and care screening tool) dated 3/17/21 indicated the resident had intact cognition, was able to make self understood, and was able to understand others. The tool indicated the resident needed extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 77's Physician Order dated 2/23/21 indicated to apply a small amount of erythromycin ointment (an antibiotic ointment used to treat eye infections) into both eyes at bedtime. A review of Resident 77's Medication Administration Records (MAR) indicated the resident received doses of, and had refusals of erythromycin ointment in the months of 02/2021 and 03/2021. During a concurrent interview and record review, on 04/6/2021 at 2:01 PM, Minimum Data Set Coordinator (MDS 1) stated there was no care plan found for Resident 77 addressing the use of erythromycin eye ointment. MDS 1 stated that if Resident 77 is receiving medication currently, then there should be an active care plan. A review of the facility's policy and procedures titled Care Plan Alerts, revised in 11/2016, indicated it is the policy of the facility to use care plan alerts to effectively manage documentation by identifying potential issues and stable conditions that are not currently affecting the resident and/or are stable. Based on observation, interview, and record review, the facility did not ensure the development and/or implementation of a comprehensive person-centered care plan (written guide that organizes information about the resident's care) with measurable objectives and time frames, and person-centered interventions for three out of 19 residents (Residents 3, 31 and 77) reviewed under the area of care planning. 1. For Resident 3, the facility failed to implement the monitoring of behavior for the use of Depakote Sprinkles Capsule (medication is used to treat seizure [sudden, uncontrolled electrical disturbance in the brain] disorders and certain psychiatric [mental illness] conditions). 2. For Resident 31, the facility failed to develop a care plan addressing the use of heparin sodium (anticoagulant- prevents the formation of clots and extension of existing clots within the blood). 3. For Resident 77, the facility failed to develop a care plan addressing the use of erythromycin (medication used for eye infections). These deficient practices had the potential to result in inconsistent implementation of the care plans that may lead to a delay in or lack of delivery of care and services for Resident 3, Resident 31, and Resident 77. Findings: a. A review of Resident 3's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension), unspecified dementia (general term for severe loss of memory, language, problem-solving and other thinking abilities), and unspecified psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/26/2020, indicated the resident had the ability to sometimes self understood and has the ability to sometimes understand others. The MDS also indicated the resident needed total assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 3's Order Summary Report dated 3/18/2021, indicated to administer Depakote Sprinkles Capsule (medication used to treat seizure [sudden, uncontrolled electrical disturbance in the brain] disorders and certain psychiatric [mental illness] conditions) Delayed Release Sprinkle 125 milligrams (mg - a unit of measurement) two capsules via gastrostomy tube (G-tube - surgically placed device used to give direct access for feeding) two times a day for severe anxiety (feeling of worry, nervousness, and unease) and agitation manifested by spitting and pulling out of tube. A review of Resident 3's Medication Administration Records (MAR) indicated the resident received Depakote Sprinkles Capsule 250 mg from 3/18/2021 to 4/7/2021. The MAR for the months of 3/2021 and 4/2021 did not indicate Resident 3's behaviors on the use of Depakote Sprinkles Capsules were monitored. A review of Resident 3's Care Plan (written guide that organizes information about the resident's care), revised on 3/17/2021, indicated the resident was on antianxiety (medications to reduce anxiety) medications and Depakote Sprinkles. The care plan goal indicated the resident will show decreased episodes of anxiety through the review date. The interventions included to administer Depakote Sprinkles 125 mg, two capsules via G-tube two times a day for severe anxiety and agitation manifested by spitting and pulling out the tube, and to monitor for behaviors. During a concurrent interview and record review, on 4/8/2021 at 9:01 AM, Minimum Data Set Coordinator (MDS 1) confirmed Resident 3's care plan intervention for monitoring behavior was not followed by the licensed nurses who administered Depakote medication. MDS 1 stated the licensed nurses should have monitored the behavior before each Depakote medication administration. MDS 1 also stated the care plans are pathways for resident's care. During an interview, on 4/8/2021 at 9:20 AM, the Director of Nursing (DON) stated, the licensed nurse who was administering the Depakote medication should have been monitoring the behavior before administration, as seen in the care plan. The DON also stated, the role of the care plan is to guide the caregivers to provide resident's care. A review of the facility's policy and procedures titled Psychoactive Medications, dated 11/2016, indicated it is the policy of this facility that residents on psychoactive medication (substances that can alter the consciousness, mood, and thoughts of those who use them)/chemical (given to control behavior) restraints are assessed at least quarterly for the effectiveness of interventions and/or chemical restraints and that residents on chemical restraints have psychoactive drugs reduced as indicated based on their comprehensive assessment. For residents with behavioral problems, not on psychoactive medications, the interdisciplinary team (IDT - a group of health care professionals from different fields who coordinate resident care) will develop appropriate strategies to intervene with the behaviors and document the interventions and rationale in the clinical record. A review of the facility's policy and procedures titled Care Plan Alerts, revised in 11/2016, indicated it is the policy of the facility to use care plan alerts to effectively manage documentation by identifying potential issues and stable conditions that are not currently affecting the resident and/or are stable. b. A review of Resident 31's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included acute respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), diabetes mellitus (a condition in which blood sugar is high), obesity (excessive body fat), transient ischemic attack (temporary blockage of blood flow to the brain), and cerebral infarction (damage to brain tissue). A review of Resident 31's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 2/19/2021, indicated the resident sometimes understood others and sometimes was able to make self understood. The MDS also indicated the resident needed total assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 31's Order Summary Report dated 11/16/2020, indicated to administer heparin sodium (anticoagulant- prevents the formation of clots and extension of existing clots within the blood) solution 5000 units/milliliter (ml - a unit of measurement) inject 1 ml subcutaneously (situated or lying under the skin) every 12 hours for deep vein thrombosis (DVT- blood clots in deep veins of the body) prophylaxis (action taken to prevent disease). A review of Resident 31's Medication Administration Records (MAR) indicated the resident received heparin sodium 5000 units/ml from 11/1/2020 to 4/7/2021. During an interview and a concurrent review of Resident 31's Care Plans (written guide that organizes information about the resident's care), on 4/7/2021 at 3:58 PM, Minimum Data Set Coordinator (MDS 1) confirmed there was no documented evidence that a care plan was developed on anticoagulant or heparin use. MDS 1 stated the care plan for heparin should have been developed. MDS 1 also stated care plans are important in resident's care and the effectiveness of interventions should have been measured. During an interview, on 4/8/2021 at 9:27 AM, the Director of Nursing (DON) stated, the licensed nurses should have developed care plan on heparin use upon receiving the medication order. The DON also stated the role of care plan is to guide resident's care. A review of the facility's policy and procedures titled Care Plan Alerts, revised in 11/2016, indicated it is the policy of the facility to use care plan alerts to effectively manage documentation by identifying potential issues and stable conditions that are not currently affecting the resident and/or are stable.

Based on observation, interview, and record review, the facility failed to: 1. Ensure that nine bags of bread inside the refrigerator were labeled with the date of delivery. 2. Ensure that the scoops were not left inside of two bins in the dry storage area. These deficient practices had the potential to cause foodborne illnesses (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) for 43 out of 88 residents in the facility who were on oral feeding. Findings: On 4/5/21 at 8:03 AM, during the initial tour of the kitchen, observed nine bags of bagels and english muffins inside the refrigerator with no dates on them. The Dietary Supervisor (DS) stated the bags of bread were delivered on 4/2/21, and the staff who put them inside the refrigerator should have labeled them with the dates of delivery on them. On 4/5/21 at 8:15 AM, during a concurrent observation and interview, in the dry storage area, observed a bin of white rice and a bin of beans with the scoops sitting inside each bin. The DS stated there was usually a clear plastic container next to the bins where the scoops were supposed to be placed after each use. The DS stated the scoops should not have been inside the bins. On 4/6/21 at 4:25 PM, during a follow-up interview, the DS stated that food inside the refrigerator needed to be labeled with the date of delivery because staff needed to throw away any food that had been there for more than three days. The DS also stated the dry food container scoops should have been washed and cleaned after each use and not kept inside the bins because they could be contaminated. A review of the facility's undated policy and procedure titled, Labeling and Dating of Foods, indicated food delivered to the facility needs to be marked with a received date. A review of the facility's undated policy and procedure titled, Ingredient Bins, indicated scoops used in bins must not be left in the bin. If scoops are used, they are to be kept in a protected container/cover, conveniently located near the bins.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 76's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included acute and chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), dependence on ventilator (an appliance for artificial respiration), urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder or urethra]), unspecified dementia (disease that include decline in memory, language, problem-solving and other thinking skills), and pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 3/16/2021, indicated the resident rarely/never made self understood and rarely/never understood others. The MDS also indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed total assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). During an observation, on 4/5/21 at 10:51 AM, observed Resident 76 on bed and his urinary drainage tubing (tube that helps drain urine from the bladder) touching the floor. During a concurrent observation and interview, on 4/5/2021 at 11:05 AM, Certified Nursing Assistant 1 (CNA 1) confirmed that Resident 76's urinary drainage tubing was touching the floor. CNA 1 stated the resident's urinary drainage catheter tubing should not touch the floor as it is important for infection control. During an interview, on 4/7/2021 at 1:03 PM, the Director of Nursing (DON) stated Resident 76's urinary drainage tubing should not touch the floor as it was necessary for infection control. The DON also stated the licensed nurses and certified nursing assistants are responsible in making sure the urinary drainage tubing does not touch the floor. A review of the facility's policies and procedures titled Catheter Care, Indwelling, reviewed on 11/2016, indicated it is the policy of this facility to provide catheter care to reduce the risk of infections. A review of the Centers for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, updated in 7/2019, indicated floors can become rapidly recontaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. Based on observation, interview, and record review, the facility failed to implement infection control practices for two out of 19 residents (Resident 47 and Resident 76) reviewed under the care area of infection control. 1. For Resident 47, the facility failed to ensure contact time (kill time - how long a disinfectant needs to stay wet on a surface in order to be effective) of one minute as indicated in the manufacturer`s direction for use is followed when using the Micro-Kill One Germicidal Alcohol Wipes (disinfectant) in cleaning an overbed table for use in setting up supplies for wound care treatment. This deficient practice had the potential to result in increasing the risk of spreading infection to residents and staff members. 2. For Resident 76, the facility failed to ensure the urinary drainage tubing (tube that helps drain urine from the bladder) was not touching the floor. This deficient practice had the potential to develop repeated urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder or urethra]) for Resident 76. Findings: a. A review of Resident 47's admission Record (face sheet) indicated the resident was originally admitted on [DATE], and was readmitted on [DATE] with diagnoses including persistent vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness), diabetes mellitus (an impairment in the way the body regulates and uses sugar [glucose] as a fuel), and pressure ulcer (also called pressure injuries and decubitus ulcers - injuries to skin and underlying tissue resulting from prolonged pressure on the skin). A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 2/25/2021, indicated Resident 47 was on a persistent vegetative state with no discernible consciousness. The MDS indicated the resident was totally dependent on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). On 04/06/2021 at 10:53 a.m., during an observation and interview, observed Licensed Vocational Nurse 6 (LVN 6) prepare the supplies for Resident 47's wound care treatment. Observed LVN 6 clean an overbed table and wipe the surface with Micro-Kill One Germicidal Alcohol Wipes (disinfectant) for 30 seconds. When LVN 6 was finished with cleaning for 30 seconds, he/she then started placing Resident 47`s wound care treatment supplies on a drape (barrier) on top of the overbed table. LVN 6 then proceeded to do wound care treatment on Resident 47. Immediately after the wound care treatment observation, during an interview, asked LVN 6 about the manufacturer`s direction for the disinfectant use. LVN 6 responded that as a matter of fact he was not aware of the wet/kill time for the disinfectant, and upon closely looking at the label and reading the directions for use, LVN 6 stated that he should have waited for one minute as indicated in the label for the disinfectant to effectively kill bacteria and viruses on the overbed table surface. According to LVN 6, by not waiting for the one minute kill time, it inadvertently poses a risk for the spread of bacteria to Resident 47. A review of the undated facility-provided Micro-Kill One Germicidal Alcohol Wipes manufacturer`s directions for use indicated that Micro-Kill One Germicidal Alcohol Wipes are an effective chemical agent that deactivates or destroys viruses and kills bacteria on hard non-porous surfaces (solid surfaces where liquid and air cannot move through), when treated surfaces are allowed to remain wet for 1 minute and allow surfaces to dry.