**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately for one of two residents reviewed for resident assessment (Resident 43). This failure resulted in an inaccurate assessment, potentially leading to a misidentification of Resident 43's care and support needs.Findings:During a review of Resident 43's admission Record (a document that contains demographic and clinical data), it indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included fibromyalgia (a long-term condition that involves widespread body pain) and rhabdomyolysis (condition in which damaged skeletal muscle [the main tissue responsible for body posture and movement] breaks down rapidly).A review of Resident 43's physician order, dated July 30, 2025, indicated Percocet [an opioid that binds to specific receptor in the body to give pain relief] . give 1 tablet by mouth every 4 hours as needed for severe pain.During a concurrent interview and record review, on August 14, 2025, at 10:30 AM, with the MDS Nurse, the MDS reviewed Resident 43's Medication Administration record for the months of July and August 2025. The record indicated that Percocet was administered to Resident 43 on July 30, 2025; July 31, 2025; August 1, 2025; and August 2, 2025. The MDS Nurse confirmed Resident 43 received Percocet for a total of four days during an observation period (also known as look back period is the time just before and including the assessment date to assess and document resident condition and care needed).During further concurrent interview and record review, on August 14, 2025, at 10:35 AM, with the MDS Nurse, the MDS Nurse reviewed and acknowledged Resident 43's MDS admission Assessment, dated August 2, 2025, under Section N, titled Medication, which indicated Resident 43 did not receive any opioids during the observation period (from July 26, 2025 to August 2, 2025). The MDS Nurse stated, I should have coded 'yes' to indicate that resident [Resident 43] received an opioid during the observation period, but I did not.During a concurrent interview and record review, on August 14, 2025, at 10:40 AM, with the MDS Nurse, the MDS Nurse reviewed the facility's policy and procedures (P&P) titled Comprehensive Assessment revised October 2023, which indicated Policy statement. Comprehensive assessments are conducted to assist in developing person - centered care plan. Policy interpretation and implementation. 1. The facility conducts comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. The MDS Nurse stated the facility did not follow the policy. During a concurrent interview and record review on August 14, 2025, at 10:43 AM, with MDS Nurse, the MDS Nurse reviewed the facility's P&P titled Certifying Accuracy of The Resident Assessment revised November 2019, which indicated . Policy interpretation and implementation . 3. The information captured on the assessment reflects the status of resident during the observation ( look back) period for that assessment. The MDS Nurse stated the facility did not follow the policy. During a review of CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2024, it indicated, .item rationale. While assuring that only those medications required to treat the resident's assessed condition are being used, it is important to assess the need to reduce these medications wherever possible and ensure that the medication is the most effective for the resident's assessed condition. Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident food preferences were provided for one of seven residents reviewed for nutrition (Resident 37) when Resident 37 did not receive a fresh fruit cup for breakfast as indicated on meal ticket on August 11, 2025.This failure had the potential to cause nutritional decline and unmet care needs for Resident 37.Findings:During a review of Resident 37's admission Record (contains demographic and medical information), it indicated Resident 37 was admitted to the facility on [DATE], with the diagnoses of osteoarthritis (degeneration of the cartilage in single joint, leading to pain, stiffness and reduced range of motion), metabolic encephalopathy (condition where brain dysfunctions from metabolic imbalances such as nutrient intake or toxin buildup) and dysphagia (difficulty swallowing).During a review of Resident 37's Diet Order dated July 9, 2025, it indicated regular diet (healthy meal plan for individuals without specific medical needs or dietary restrictions, providing adequate nutrients and calories from all major food groups), regular texture (normal diet with no mechanical modification), thin liquid consistency.During a concurrent observation and interview, on August 11, 2025, at 9:19 AM, with Resident 37, in Resident 37's room, Resident 37 was lying in bed. Her breakfast was on her bedside table. Resident 37 stated she liked to eat her breakfast late. Resident 37's breakfast contained a cup of coffee, cup of juice, small bowl of cream of wheat, two pancakes and three slices of bacon, with half of a single strawberry.During a concurrent interview and record review, on August 11, 2025, at 9:20 AM, with Resident 37, Resident 37's meal ticket (a piece of paper indicating allergies, preferences and likes/dislikes) was reviewed. It indicated serves only: coffee, toast, cinnamon, margarine, or any other pastries is ok, bacon 2 sls [slices] fresh fruit cup. Resident 37 stated the facility had forgotten her fresh fruit cup. During an interview on August 14, 2025, at 1:09 PM, with the Dietary Supervisor (DS), the DS stated the single strawberry was a garnish. The DS further stated Resident 37 should have received a fresh fruit cup for breakfast on August 11, 2025.During a concurrent interview and record review, on August 14, 2025, at 1:10 PM, with the DS, the facility's policy and procedure (P&P) titled, Resident Food Preferences dated revised July 2017, was reviewed. The P&P indicated, Individual food preferences will be assessed [checked] upon admission. modification to diet will only be ordered with the resident's . consent . 10. The Food Service Department will offer a variety of foods at each scheduled meal. The DS stated the P&P was not followed.

Based on the observation, interview, and record review, the facility failed to maintain an appropriate environment for storing all drugs and biologicals in accordance with accepted professional principles and the facility's policies and procedures for one of two medication rooms (South Station medication room) and one of two treatment cart (Treatment Cart 2) reviewed for medication storage, when: 1. The medication refrigerator inside the South Station medication room was found to be unsanitary on August 12, 2025. 2. Three opened and used ointments tubes were found without documented opened dates inside Treatment Cart 2 on August 13, 2025. These failures had the potential to cause contamination (when something harmful, like dirt, germs, or chemicals, mixes with something clean or safe, making it unsafe to use) and reduce confidence in medication efficacy and safety for 59 highly vulnerable residents. Findings:1. During a concurrent observation and interview, on August 12, 2025, at 3:16 PM, in the South Station medication room, with the Infection Prevention Nurse (IPN), the medication refrigerator was inspected. The IPN used a paper towel to wipe the bottom of the medication refrigerator which revealed moist dust build up. The IPN stated the refrigerator was designated for storing all medications that require refrigeration. The IPN further stated all medication storage areas should have been clean to maintain the efficacy and safety of the medications and prevent contamination.During further concurrent interview and record review, on August 12, 2025, at 4:50 PM, with the IPN, the IPN reviewed the facility's policy and procedure (P&P) titled, Storage of Medication, revised November 2020, which indicated, . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The IPN stated the facility did not have a specific cleaning schedule, but all licensed staff were responsible for keeping the medication refrigerator clean in a sanitary manner, which was not done. The IPN further stated the facility policy was not followed.2. During a concurrent observation and interview, on August 13, 2025, at 9:45 AM, with the Treatment Nurse (TN), the TN inspected the contents inside Treatment Cart 2. The TN found three opened and used ointment tubes without documented opened dates which were as follows:i. Silver sulfadiazine cream (prescription topical medicine used to help prevent and treat wound [a break or opening in the skin] infections)ii. Santyl ointment (prescription topical medicine used to help clean and remove dead tissue from the wound)iii. Mupirocin ointment (prescription topical medicine used to treat bacterial skin infections) During further observation and interview, on August 13, 2025, at 10:00 AM, with the TN, the TN acknowledged that the Silver Sulfadiazine cream, Santyl ointment and Mupirocin ointment were opened and used without documentation of when the tubes were opened.During further concurrent interview and record review, on August 14, 2025, at 2:55 PM, with the TN and the Director of Nurse (DON), both the TN and the DON reviewed the facility's P&P titled, Wound Care revised October 2010, which indicated, Purpose. The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation. 3. Assemble the equipment and supplies as need. Date and initial all bottles and jars upon opening. Both the TN and DON acknowledged their unawareness of the requirement to document the opening date on ointments. The DON stated the facility policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for three residents reviewed for puree diets (Resident 4, 46, and 79) when the incorrect portion size of pureed meatball was served for lunch on August 11, 2025. This failure has the potential to cause unintended weight loss (a noticeable decrease in body weight that occurs without conscious effort, such as dieting or exercising more), and inadequate nutritional needs (a state where the body doesn't receive enough of the essential nutrients it needs to function properly) for medically compromised Residents 4, 46 and 79 on puree diet (a modified diet where regular foods are transformed into a smooth, lump-free consistency, resembling pudding). Findings: During a review of the facility's Meal Distribution Report, it indicated Residents 4, 46, and 79 were on puree diet.During a review of the facility recipe for Meatballs / Marinara menu, it indicated Serve meat with a #8 scoop, topped with 4 oz (1/2 cup) of tomato sauce (1 cup total). An observation of the lunch tray line's puree diet preparation was conducted on August 11, 2025, at 11:57AM, in the kitchen. [NAME] 1 used a #10 (3/8 cup) scoop (a specific size of food dish commonly used in food service and baking) to serve the puree meatball with sauce. [NAME] 1 did not use the #8 scoop. During an interview and record review with the Dietary Supervisor (DS), on August 12, 2025, at 2:43 PM, in the kitchen, the DS stated the cook should have served the puree meatball using two #8 scoops (equaling 1 cup) based on what the recipe indicates. During a concurrent interview and record review, with the DS, on August 12, 2025, at 2:45 PM, the DS reviewed the facility recipe for Meatballs / Marinara menu, which indicated Serve meat with a #8 scoop, topped with 4 oz (1/2 cup) of tomato sauce (1 cup total). The DSS stated the menu was not followed and should have been.

Based on observation, interview, and record review, the facility failed to ensure the recipes were followed for puree (a modified diet where regular foods are transformed into a smooth, lump-free consistency, resembling pudding) diets for three residents reviewed for puree diet (Residents 4, 46, and 79) when the pureed lemon herb chicken, served for lunch on August 12, 2025, was crumbly and not smooth.This failure had the potential to cause choking and dissatisfaction for Residents 4, 46, and 79 who are medically compromised. Findings: During a review of the facility's Meal Distribution Report, it indicated Residents 4, 46, and 79 were on puree diet. During a review of the facility recipe for Lemon Herb Chicken, it indicated, Puree Diets: Place portions of meat needed into a food processor. Process to a fine texture. For every 5 portions. Prepare a slurry with 4 tbsp thickener and 1 cup hot liquid. Mix well with a wire whip. Add 1/2 of the slurry to the chicken. Process for 1 minute; if too dry, and more slurry until meat is pudding consistency.During a concurrent observation and interview on August 12, 2025, at 10:32 AM, with [NAME] 1, in the kitchen, [NAME] 1 was preparing pureed food items for lunch. [NAME] 1 stated she was preparing puree food for three residents (Residents 4, 46, and 79). [NAME] 1 put 6 servings of cooked chicken in the food processor and blended. [NAME] 1 added some chicken broth to the blender and blended further. [NAME] 1 did not check for puree consistency before serving. During a test tray observation and interview on August 12, 2025, at 12:20 PM, with the Dietary Services Supervisor (DSS), at the South Nursing station, the test tray was inspected. The pureed lemon herb chicken was crumbly in consistency. It was not smooth, and lump-free. It did not resemble the consistency of a pudding. The DSS stated Yes, the puree chicken consistency is not of a pudding consistency.During an interview on August 13, 2025, at 10:24 AM, with the Registered Dietician (RD), the RD stated, the recipe for the puree lemon herb chicken was not followed and should have been for residents' on puree diet.During a review of the facility document titled, Dysphagia Diet: Puree IDDSI Level 4, dated 2023, it indicated, Definition: A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky and holds it shape in a plate. The diet requires no biting or chewing. During a review of the facility document titled Menu dated October 2017, it indicated Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the proper and safe infection control practices were followed when:1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene in between Residents 33 and 80's rooms. CNA 1 did not disinfect vital signs machine in between Resident 33 and 80. 2. CNA 2 did not perform hand hygiene before and after perineal care (cleaning the genital and anal areas) and did not utilize personal protective equipment (PPE - clothing and gear designed to protect you from hazards at work or during certain activities) in isolation room (room used to keep germs from spreading) for Resident 11. 3. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene nor don gloves after medication preparation and before medication administration in an isolation room for Resident 7. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 54 vulnerable residents whose health conditions are already highly compromised.1. During a review of Resident 80’s “admission Record” (contains demographic and medical information), it indicated Resident 80 was admitted to the facility on [DATE], with the diagnoses of presence of right artificial knee joint (right knee implant) and aftercare following joint replacement surgery. During a review of Resident 80’s “Order Summary Report”, it indicated a physician order for “Enhanced barrier precautions (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) during high contact (things that are touched often by many people) resident care activities secondary to Right knee surgical site” dated August 9, 2025. During an observation on August 12, 2025, at 3:45 PM, Certified Nursing Assistant (CNA 1) exited Resident 33’s room, pushing the vital signs machine (medical device used to measure a patient’s vital signs such as temperature, pulse, blood pressure, and oxygen reading). Without performing hand hygiene (cleaning hands to remove or reduce harmful microorganism, such as washing hands or using alcohol-based rub) nor disinfecting the vital signs machine, CNA 1 entered Resident 80’s room, and donned (put on) a gown. During an interview on August 12, 2025, at 3:48 PM, with CNA 1, CNA 1 stated she did not perform hand hygiene after leaving Resident 33’s room and before entering Resident 80’s room. During a follow up interview on August 12, 2025, at 3:49 PM, with CNA 1, CNA 1 stated she did not disinfect the vital signs machine after using it on Resident 33 and before using it on Resident 80. During a concurrent interview and record review on August 14, 2025, at 1:03 PM, with the Infection Preventionist Nurse (IPN), the facility’s policy and procedure (P&P) titled, “Handwashing/Hand Hygiene”, revised October 2023, was reviewed. The P&P indicated, “This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections… 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections … Indications for Hand Hygiene … 1. Hand Hygiene is indicated: … d. after touching a resident … e. after touching the resident’s environment…” The IPN stated the P&P was not followed. During a concurrent interview and record review on August 14, 2025, at 1:04 PM, with the IPN, the facility’s P&P titled, “Cleaning and Disinfection of Environmental Surfaces” revised June 2009, was reviewed. The P&P indicated, “Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities… c. Non-critical items are those that come in contact with intact skin but not mucous membranes… (2) Most non-critical items can be decontaminated where they are used…” The IPN stated the P&P was not followed. 2. During a review of Resident 11’s clinical record, the face sheet indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (a bacteria enters the part of body that affects urine), and immunodeficiency (a decreased ability to fight infections and other diseases). During a review of Resident 11’s “Order Summary Report,” dated July 29, 2025, it indicated, “…Enhanced barrier precaution high contact resident care activities secondary to abscess (collection of pus – a liquid, usually yellowish or whitish, that appears when your body is trying to fight off an infection or when a wound isn’t healing properly) to lumbar (five bones in the lower back of the human body) every shift.” During a concurrent observation and interview on August 11, 2025, at 11:13 AM, inside Resident 11’s room, CNA 2 was preparing to perform perineal care for Resident 11. CNA 2 did not perform hand hygiene nor wear PPE upon entering the resident’s room and proceeded to close the door and begin with care. In the middle of starting care, the IPN entered the room and instructed CNA 2 to put on PPE. CNA 2 then donned his gloves and gown and continued rendering care to Resident 11. During a follow-up observation and interview on August 11, 2025, with CNA 2, at 11:22 AM, in Resident 11’s room, CNA 2 and the IPN transferred Resident 11 into a wheelchair. CNA 2 took off the PPE, and without performing hand hygiene, pushed Resident 11’s wheelchair to the common area outside of the room. CNA 2 stated he did perform hand hygiene before providing perineal care for Resident 11. CNA 2 also stated he did not put on PPE before performing perineal care and only wore it after being instructed by the IPN. During further interview, CNA 2 stated after he removed his PPE, he also did not perform hand hygiene. CNA 2 also stated he should have performed hand hygiene and applied PPE to prevent cross-contamination. During a concurrent interview and record review on August 13, 2025, at 1:00 PM, with the IPN, the facility’s P&P titled, “Enhanced Barrier Precautions” revised March 2024 was reviewed. The P&P indicated “…2. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) [germs that resist antibiotic treatments] to residents.” The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:08 PM, with the IPN, the facility’s P&P titled, “Handwashing/Hand Hygiene,” revised October 2023, was reviewed. The P&P indicated, “…1. Hand hygiene is indicated: a. immediately before touching a resident. c. after contact with blood, body fluids, or contaminated surface .” The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:24 PM, with the Director of Nursing (DON), the P&P titled, “Enhanced Barrier Precautions” revised March 2024 was reviewed. The P&P indicated “…2. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) [germs that resist antibiotic treatments] to residents.” The DON stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:26 PM, with the DON, the P&P titled, “Handwashing/Hand Hygiene,” revised October 2023, was reviewed. The P&P indicated, “…1. Hand hygiene is indicated: a. immediately before touching a resident. c. after contact with blood, body fluids, or contaminated surface .” The DON stated the facility did not follow the P&P. 3. During a review of Resident 7’s clinical record, the face sheet indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including sepsis (an infection that causes the body to damage its organs), urinary tract infection, and immunodeficiency due to drugs. During a review of Resident 7’s “Order Summary Report,” dated July 25, 2025, it indicated, “…Enhanced barrier precaution during high contact resident care activities secondary to foley catheter (a tube that collects urine into a bag) every shift…” During an observation on August 12, 2025, at 12:32 PM, with LVN 1, in front of Resident 7’s room, LVN 1 was preparing Resident 7’s medications for administration. LVN 1 unlocked the medication cart and retrieved a bubble pack (medication packaging) containing Resident 7’s medication. LVN 1 dispensed one tablet from the bubble pack into a medication cup. LVN 1 did not perform hand hygiene before entering Resident 7’s room to administer the medications. During an interview on August 12, 2025, at 12:35 PM, with LVN 1, LVN 1 stated she did not perform hand hygiene after preparing medications and before medication administration. LVN 1 further stated she should have to prevent the spread of MDROs and ensure resident safety. During a concurrent interview and record review on August 13, 2025, at 1:00 PM, with the IPN, the facility’s P&P titled, “Enhanced Barrier Precautions” revised March 2024, was reviewed. The P&P indicated “…2. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) [germs that resist antibiotic treatments] to residents.” The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:06 PM, with the IPN, the facility’s P&P titled, “Administering Medications,” revised April 2019, was reviewed. The P&P indicated, …25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable… The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:08 PM, with the IPN, the facility’s P&P titled, “Handwashing/Hand Hygiene,” revised October 2023, was reviewed. The P&P indicated, “…1. Hand hygiene is indicated: a. immediately before touching a resident. c. after contact with blood, body fluids, or contaminated surface .” The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:24 PM, with the DON, the facility’s P&P titled, “Administering Medications,” revised April 2019, was reviewed. The P&P indicated, …25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable… The DON stated the facility did not follow the P&P.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and facility policy review, the facility failed to transmit discharge Minimum Data Set (MDS) assessments for 2 (Resident #16 and Resident #40) of 3 sampled residents reviewed for resident assessment. Findings included: A facility policy titled MDS Completion and Submission Timeframes, dated July 2017, indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy indicated, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/2023, indicated, Discharge assessment refers to an assessment required on resident discharge from the facility. 1. An admission Record revealed the facility admitted Resident #16 on 12/12/2023. According to the admission Record, the resident discharged from the facility on 01/17/2024. The discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2024, revealed Resident #16 discharged home on [DATE]. 2. An admission Record revealed the facility admitted Resident #40 on 01/10/2024. According to the admission Record, the resident discharged from the facility on 01/3/2024. The discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/30/2024, revealed Resident #40 discharged home on [DATE]. In an interview on 06/05/2024 at 10:54 AM, the MDS Nurse stated Resident #16's discharge MDS with an ARD of 01/17/2024 and Resident #40's discharge MDS with an ARD of 01/30/2024 had not been transmitted. The MDS Nurse stated the discharge MDS should have been transmitted within 14 days of the ARD. In an interview on 06/05/2024 at 12:47 PM, the Director of Nursing stated her expectation was that MDS assessments should be submitted in a timely manner following the RAI manual guidelines. In an interview on 06/06/2024 at 8:22 AM, the Administrator stated his expectation was that MDS assessments were completed and transmitted in the required timeframe.

Based on observation, interview, record review, and facility policy review, the facility failed to provide conduct an assessment and monitor the provision of a nebulizer treatment for 1 (Resident #165) of 1 sampled resident reviewed for respiratory care. Findings included: A facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised in 10/2010, indicated, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The policy specified, Documentation The following information should be recorded in the resident's medical record. 1. The name, title and initials of the person administering the treatment. 2. The date, time and length of treatment (treatment administration record). 3. The type and amount of medication administered (medication administration record). 4. The type and source of gas. 5. Pulse, respiratory rate and lung sounds before and after treatment. 6. Pulse during treatment. 7. Amount and characteristics of sputum production. 8. The resident's tolerance of the treatment. 9. Any adverse effects of the medication and/or treatment and physician notification, if applicable. An admission Record indicated the facility admitted Resident #165 on 05/23/2024. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia (insufficient oxygen level), chronic pulmonary edema (fluid accumulates in lung tissue), and acute on chronic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2024, revealed Resident #165 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required oxygen therapy. Resident #165's care plan, initiated on 06/03/2024 indicated the resident had altered respiratory status and difficulty breathing related to pulmonary edema and acute respiratory failure with hypoxia. Interventions directed staff to administer medications/puffers as ordered and monitor for effectiveness and side effects. Resident #165's Order Summary Report, with active orders as of 06/05/2024, revealed an order dated 05/23/2024, for Xopenex nebulization solution 0.63 milligrams (mg) per 3 milliliters (ml) with instructions for the resident to inhale 3 ml via nebulizer every six hours for respiratory failure. Resident #165's medication administration record for June 2024, revealed no evidence to indicate the resident's pulse, respiratory rate, or lung sound before or after their nebulizer treatment, the resident's pulse during treatment, or the resident's tolerance to the treatment. Resident #165's treatment administration record for June 2024, revealed no evidence to indicate the resident's pulse, respiratory rate, or lung sound before or after their nebulizer treatment, the resident's pulse during treatment, or the resident's tolerance to the treatment. Resident #165's Progress Notes, for the timeframe 05/06/2024 to 06/05/2024, revealed no evidence to indicate the resident's pulse, respiratory rate, or lung sound before or after their nebulizer treatment, the resident's pulse during treatment, or the resident's tolerance to the treatment. On 06/05/2024 at 12:39 PM, the surveyor observed as Resident #165 sat on the side of their bed. The resident stated they had not received their nebulizer treatment yet; however, the nebulizer mask and medication cup were on top of a tissue box in the resident's room. According to Resident #165, the nurse placed the medication in the cup and turned the machine on, but did not stay in their room during the entire treatment. Resident #165 stated they turned off the nebulizer machine when it was done. Resident #165 stated the nurse did not listen to their lungs before or after they received their nebulizer treatment. During an interview on 06/05/2024 at 12:26 PM, Licensed Vocational Nurse (LVN) #1 stated after a resident finished their nebulizer treatment, the nurse should have the resident rinse their mouth and check the resident's oxygen saturation and respirations, but she did not think it would be documented anywhere. During an interview on 06/05/2024 at 3:33 PM, LVN #3 stated Resident #165 put on and took off their nebulizer mask and turned the machine off when they were done. LVN #3 stated she did not check the resident's lung sounds or vital signs when she administered the resident their nebulizer treatment and could not recall anywhere that she was supposed to document it. During an interview on 06/06/2024 at 8:45 AM, the Director of Nursing stated the nurse should document if a resident did not receive their full nebulizer treatment and the nurse should assess the resident's oxygen saturation, respiration, and lung sounds before, during, and after a treatment. During an interview on 06/06/2024 at 9:04 AM, the Administrator stated the resident should be assessed during a nebulizer treatment as per the facility protocol.

Based on observation, interview, record review, and facility policy review, the facility failed to monitor the dialysis fistula for 1 (Resident #165) of 1 sampled resident reviewed for dialysis. Findings included: A facility policy titled, Hemodialysis Catheters - Access and Care of, revised in 02/2023, specified under the section titled, Care of AVFs [arteriovenous fistula] and AVGs [arteriovenous graft], 3. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 4. To prevent infection and/or clotting: a. Keep access site clean at all times. b. Do not use the access site arm to take blood samples, administer IV [intravenous] fluids or give injections. c. Needle access for hemodialysis should be rotated. d. Check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing routine care and at regular intervals. e. Do not use the access arm to take blood pressure. f. Advise the resident not to sleep on, wear tight jewelry or lift heavy objects with the access arm. g. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. h. Check patency of the site at regular intervals. Palpate the site to feel the 'thrill,' or use a stethoscope to hear the 'whoosh' or 'bruit' of blood flow through the access. An admission Record indicated the facility admitted Resident #165 on 05/23/2024. According to the admission Record, the resident had a medical history that included a diagnosis of end stage renal disease with dependence on renal dialysis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2024, revealed Resident #165 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received dialysis. Resident #165's care plan, initiated 06/01/2024, indicated the resident required hemodialysis due to end stage renal disease and was at risk for bleeding at the access site, weight fluctuation, fluid overload, and hypotension. Interventions directed staff to observe the access/shunt/catheter site for signs or symptoms of complication (i.e., redness, pain, bleeding, unusual bruising, pus/drainage, absent thrill/bruit over graft site, complaints of coldness/numbness of hand/arm or chest pain) and report abnormal finding to physician. Resident #165's Order Summary Report, with active orders as of 06/05/2024, revealed an order dated 05/23/2024 that directed staff to check the resident's left arm fistula site dressing every shift, leave intact for four to six hours following dialysis., change if soiled or fallen off. If bleeding was noted from dialysis access site, immediately apply pressure to site to stop bleeding. If bleeding did not subside, call the physician, and initiate emergency medical services immediately. There was also another order dated 05/23/2024, that directed staff to monitor the resident's left arm AV fistula site for bleeding, redness, discharge, swelling, pain and notify the physician every shift. There was not an order to check the thrill and bruit of the resident's dialysis access site. The Dialysis Communication Report, for Resident #165. dated 05/24/2024, revealed no documentation of the status of the resident's access site to indicate if there was redness, edema, or drainage, and there was no documentation that the resident's shunt was checked for thrill and bruit prior to dialysis. T The Dialysis Communication Report, for Resident #165 dated 05/27/2024, revealed no documentation of the status of the resident's access site to indicate if there was redness, edema, or drainage, and there was no documentation that the resident's shunt was checked for thrill and bruit prior to dialysis. The Dialysis Communication Report, for Resident #165 dated 05/29/2024, revealed no documentation of the status of the resident's access site to indicate if there was redness, edema, or drainage, and there was no documentation that the resident's shunt was checked for thrill and bruit prior to dialysis. The Dialysis Communication Report, for Resident #165 dated 05/31/2024, revealed no documentation of the status of the resident's access site to indicate if there was redness, edema, or drainage, and there was no documentation that the resident's shunt was checked for thrill and bruit prior to dialysis. The Dialysis Communication Report, for Resident #165 dated 06/04/2024, revealed no documentation of the status of the resident's access site to indicate if there was redness, edema, or drainage, and there was no documentation that the resident's shunt was checked for thrill and bruit prior to dialysis. Resident #165's medication administration record and treatment administration record for June 2024, revealed no documentation the thrill and bruit of the resident's access site was assessed. During an interview on 06/05/2024 at 10:04 AM, Resident #165 stated the staff had never felt or listened to their fistula and stated maybe they did not know and needed to be educated. During an interview on 06/05/2024 at 12:26 PM, Licensed Vocational Nurse (LVN) #1 stated that when a resident returned from dialysis, she checked their skin to make sure there were no new areas of concern and checked the access site. LVN #1 stated she would also check the thrill and bruit of the fistula if the resident had one and it should be documented on the dialysis communication form. LVN #1 stated Resident #165 returned from dialysis after her shift ended so she had not checked the resident's access site before. LVN #1 stated she did not check the thrill or bruit prior to the resident going to dialysis. During a follow-up interview on 06/05/2024 at 2:26 PM, LVN #1 reviewed Resident #165's Dialysis Communication Report dated 06/04/2024, and confirmed that she signed the report. LVN #1 stated she did check the thrill and bruit but forgot to mark it on the form. LVN #1 stated she did not know why the resident would say it was not done because she did it. LVN #1 stated she forgot that she had done it the previous day when she was asked about it in a previous interview. During an interview on 06/05/2024 at 3:33 PM, LVN #3 stated that when a resident came back from dialysis, she would check the resident's skin, check the access site, check for thrill and bruit, and document it on the communication form. After review of the Resident #165's Dialysis Communication Report dated 05/29/2024, LVN #3 confirmed that it was her signature and that the thrill and bruit were not documented. LVN #3 stated she must have forgotten. LVN #3 stated she knew they needed orders for care of the access site and monitoring, but was unsure what all the orders were needed for a dialysis resident. During a telephone interview on 06/06/2024 at 8:24 AM, LVN #4 stated that when a resident returned from dialysis, she checked their access site and checked for thrill and bruit. LVN #4 stated this all should be documented on the communications form. LVN #4 acknowledged she must have forgotten to document her assessment. During an interview on 06/06/2024 at 8:45 AM, the Director of Nursing (DON) stated that when a resident returned from dialysis, the nurse should collect the binder (that held the communication forms), check the resident's vital signs, check the dressing to the access site and monitor the resident for bleeding but leave the dressing on the resident for four to six hours and then remove it, and assess for the thrill and bruit. The DON stated the nurses should document their assessment on the communication form, sign the post dialysis sheet, and return it to the binder. During an interview on 06/06/2024 at 9:04 AM, the Administrator stated he expected the nurses to follow the dialysis protocol and complete the necessary documentation.

Based on interview, record review, and facility policy review, the facility failed to ensure ordered medication was available in the facility for 1 (Resident #32) of 6sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Orders and Receipt Record, revised in 04/2007, revealed no evidence related to receiving medications in a timely manner from the pharmacy. An admission Record indicated the facility admitted Resident #32 on 05/15/2024. According to the admission Record, the resident had a medical history that included a diagnosis of paraplegia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of05/18/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had moisture associated skin damage (MASD). Resident #32's care plan, initiated on 05/16/2024 indicated the resident had impaired skin integrity present upon admission as evidenced by skin discoloration. Interventions directed staff to administer treatments as ordered and monitor for effectiveness. Resident #32's Order Summary Report, with active orders as of 06/05/2024, revealed an order dated 05/28/2024, for nystatin-triamcinolone cream with instructions for the cream to be applied to the resident's coccyx extending to the left and right buttocks every day shift for fungal MASD for 21 days until finished. Resident #32's treatment administration record (TAR) for June 2024, revealed for the dated 06/01/2024 to 06/05/2024, the staff documented a 9, which indicated Other /See Nurses Notes, for the administration of the nystatin-triamcinolone cream. Resident #32's Progress Notes, dated 05/29/2024 at 9:41 AM, 06/01/2024 at 11:26 AM, 06/02/2024 at 1:03 PM, 06/03/2024 at 10:40 AM, 06/04/2024 at 3:43 PM, and 06/05/2024 at 9:50 AM, revealed staff documented the resident's nystatin-triamcinolone cream was pending delivery from pharmacy. During an interview on 06/05/2024 at 11:28 AM, Licensed Vocational Nurse (LVN) #6 stated if he did not have a medication available to do a treatment, he would call the pharmacy to find out the delay and notify the physician. LVN #6 stated the resident should not go longer than a day without the treatment. LVN #6 stated the physician should be notified and it would be documented on the TAR or a progress note. During a follow-up interview on 06/05/2024 at 12:00 PM, LVN #6 stated he faxed the order for the nystatin-triamcinolone cream for Resident #32 the previous week to the pharmacy, but did not work over the weekend and did not follow up on it on Monday, 06/03/2024 or Tuesday, 06/04/2024. During an interview on 06/05/2024 at 12:26 PM, LVN #1 stated if a medication was not available, she would contact the physician to ask for an alternative that could be used until that medication became available. LVN #1 stated the facility should receive the medication within 24 hours. She stated if a medication was not available for a treatment to be provided, the pharmacy and physician should be notified, and it should be documented on the medication administration record, TAR, or a progress note. During an interview on 06/06/2024 at 8:24 AM, LVN #4 stated she would follow up with the pharmacy for medications that were not available and notify the physician. During an interview on 06/06/2024 at 8:45 AM, the Director of Nursing (DON) stated if a medication was not available for a treatment, the nurse should notify the physician to get it changed if needed. The DON stated LVN #6 should have followed up with the pharmacy about Resident #32's nystatin-triamcinolone cream and then notified the physician for an alternative. During an interview on 06/06/2024 at 9:04 AM, the Administrator stated if a medication was not available the nurse should follow up with the physician to see if that particular medication was needed or if an alternative could be used, but he expected the staff to get the medication. The Administrator stated the resident should not have to wait, and it should be followed up on right away.

Based on observation, interview, record review, and facility policy review, the facility failed to store nebulizer equipment for 1 (Resident #165) of 1 sampled resident reviewed for respiratory care. Findings included: A facility policy titled, Prevention of Infection Respiratory Equipment, revised in 11/2011, specified, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 1. Obtain equipment 2. Wash Hands. 3. Take care not to contaminate internal nebulizer tubes. 4. Store the circuit in plastic bag, marked with date and resident's name and replace tubing and plastic bag once a week. An admission Record indicated the facility admitted Resident #165 on 05/23/2024. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia (insufficient oxygen level), chronic pulmonary edema (fluid accumulates in lung tissue), and acute on chronic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2024, revealed Resident #165 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required oxygen therapy. Resident #165's care plan, initiated on 06/03/2024 indicated the resident had altered respiratory status and difficulty breathing related to pulmonary edema and acute respiratory failure with hypoxia. Interventions directed staff to administer medications/puffers as ordered and monitor for effectiveness and side effects. Resident #165's Order Summary Report, with active orders as of 06/05/2024, revealed an order dated 05/23/2024, for Xopenex nebulization solution 0.63 milligrams (mg) per 3 milliliters (ml) with instructions for the resident to inhale 3 ml via nebulizer every six hours for respiratory failure. On 06/03/2024 at 10:21 AM, the surveyor observed a nebulizer machine on Resident #165's nightstand with the mask and medication cup lying on top of the nightstand with fluid in the medication cup; the mask was not stored in a plastic bag. Resident #165 stated they used the machine a couple of times a day and had already used it that morning. On 06/04/2024 at 2:10 PM, the surveyor observed Resident #165's nebulizer mask and medication cup were connected to the machine with tubing, and they were lying on top of the nightstand, not stored in a plastic bag. On 06/05/2024 at 10:04 AM, the surveyor observed Resident #165's nebulizer mask and medication cup were connected to the nebulizer machine by tubing and was lying on top of a tissue box on the nightstand, not stored in a plastic bag. On 06/05/2024 at 12:39 PM, the surveyor observed as Resident #165 sat on the side of their bed. The resident stated they had not received their nebulizer treatment yet; however, the nebulizer mask and medication cup were on top of a tissue box, not stored in a plastic bag. During an interview on 06/05/2024 at 12:26 PM, Licensed Vocational Nurse (LVN) #1 stated respiratory equipment should be stored in a plastic bag when not in use. During an interview on 06/05/2024 at 1:04 PM, Certified Nursing Assistant (CNA) #2 stated respiratory equipment should be stored in a plastic bag when not being used. CNA #2 entered Resident #165's room and confirmed the resident's nebulizer mask was not stored in a plastic bag and there was not a bag available in the resident's room to store it in. On 06/05/2024 at 2:26 PM, LVN #1 confirmed Resident #165's nebulizer equipment was not stored in a plastic. During an interview on 06/05/2024 at 3:33 PM, LVN #3 stated nebulizer equipment should be stored in a plastic bag when not in use. During an interview on 06/06/2024 at 8:24 PM, LVN #4 stated nebulizer equipment should be stored in a bag when dry. During an interview on 06/06/20224 at 8:45 AM, the Director of Nursing stated respiratory equipment should be stored in a plastic bag when not in use. During an interview on 06/06/2024 at 9:04 AM, the Administrator stated respiratory equipment should be cleansed and stored appropriately according to the facility protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services in the skin conditions for one resident (Resident 52) reviewed for pressure ulcers (an open wound on the skin caused by a long period of constant pressure). This failure had the potential to cause inaccuracy in identifying Resident 52's care and support needs. Findings: During a review of Resident 52's admission Record (a document that contains demographic and clinical data), it indicated Resident 52 was admitted to the facility on [DATE], with diagnoses which included cellulitis (a deep infection of the skin caused by bacteria) of right lower limb and type 2 diabetes mellitus (a chronic, metabolic disease characterized by elevated blood sugar level) with foot ulcer (an open sore or wound). During a concurrent interview and record review, with the Treatment Nurse (TN), on January 6, 2023, at 10:30 AM, the TN reviewed Resident 52's Electronic Health Record (EHR) which indicated an admission body assessment was conducted for Resident 52 on November 30, 2022. Further review indicated Resident 52 was assessed with diabetic foot ulcer on her right foot. The TN stated, I remembered, I did the resident admission body assessment, the patient [Resident 52] did not have any pressure injury. During further interview and record review, with TN, on January 6, 2023, at 10:40 AM, the TN reviewed Resident 52's EHR which indicated a weekly body assessment was conducted for Resident 52 on December 7, 2022. Further review indicated Resident 52 was assessed with diabetic foot ulcer on her right foot. The TN stated there were no other skin condition was observed during Resident 52's weekly skin assessment. During a concurrent record review and interview, with the Minimum Data Set Nurse (MDS Nurse), on January 6, 2023, at 2:21 PM, the MDS Nurse reviewed Resident 52's EHR, and was not able to find any documentation that Resident 52 had pressure ulcer. The MDS Nurse acknowledged that there was no other skin condition recorded on Resident 52's EHR besides the diabetic ulcer on her right foor. During further interview and record review, with the MDS Nurse, on January 6, 2023, at 2:30 PM, the MDS Nurse reviewed Resident 52's MDS admission Assessment ( a comprehensive assessment for a resident that must be completed within 14 days after admission), dated December 10, 2022, which indicated under Section M titled Skin Conditions, that Resident 52 was coded to have an unhealed unstageable (unable to see the bottom of the sore to know how deep is the sore) or deep tissue injury (can be dark purple or maroon-colored areas on or under the skin) pressure ulcer. The MDS Nurse stated Resident 52 did not have any unstageable nor deep tissue injury. The MDS Nurse further stated, It was coded in error. During a concurrent interview and record review, with MDS Nurse, on January 6, 2023, at 2:35 PM, the MDS Nurse reviewed the facility's policy and procedures titled Comprehensive Assessment, revised March 2022, which indicated . Comprehensive assessment are conducted to assist in developing person - centered care plan .8 . a. the resident's overall clinical status is not accurately represented (i.e. miscoded) on the erroneous assessment and/or result in an inappropriate plan of care . The MDS Nurse stated the facility did not follow the policy. During a review of CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2019, indicated .Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer risk assessments. 2. Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident. 3. Examine the resident and determine whether any ulcers, scars, or non-removable dressings/devices are present .

Based on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of infections and other infectious diseases when four employees was not screened for Covid-19 (a highly infectious disease caused by the SARS-CoV-2 virus] symptoms and exposure upon entering the facility on January 4, 2023. This failure had the potential to cause harm to the 50 residents residing within the facility by causing cross contamination (the transfer of bacteria or viruses from one person to another) of the environment and increasing the risk of exposure and spread of the COVID-19 virus within the facility. Findings: During a concurrent interview and record review, with the Infection Preventionist Nurse (IPN), on January 5, 2023, at 9:11 AM, the IPN reviewed the facility provided list of employees and confirmed the following employees have worked on January 4, 2023: a. Certified Nursing Assistant (CNA 1) b. Certified Nursing Assistant (CNA 2) c. Physical Therapy Assistant (PTA) d. Housekeeper (HKP) During a further interview and record review, with the IPN, on January 5, 2023, at 12:10 PM, the IPN reviewed a facility document titled, Facility Screening for Employees or Ancillary Staff (screening log which includes temperature check and signs or symptoms of COVID-19) dated January 4, 2023, indicated CNA 1, CNA 2, PTA, and HKP were not screened for COVID-19 symptoms before entering the facility. The IPN stated upon entering the facility, all employees were expected to be screened for signs and symptoms of COVID-19, and to answer the screening log questions accurately. During a concurrent interview and record review, with the IPN, on January 5, 2023, at 12:55 PM, the IPN reviewed the facility's undated policy and procedure titled Coronavirus (COVID-19) Employee Screening, which indicated, Employee Screening . Prompt identification and isolation of potentially infectious individuals is a critical step in protecting employees, visitors, and others at the facility . Screening process for an employee below . Start of Shift . 2. The employee's temperature will be check utilizing a digital or temporal thermometer . 3. If an employee's temperature is 100.4 or above, the employee will be sent home and no permitted to be in the building or work his or her shift . The IPN stated that facility did not follow the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the policy and procedure for position change alarm (device place in the bed or wheelchair to alert staff when the person gets out from bed or wheelchair), for three of three residents (Residents 4, 5 and 7) reviewed for falls when position change alarms were used for Residents 4, 5, and 7 without a physician's order. This failure placed Residents 4, 5 and 7 at risk for decreased mobility, sleep disturbances, and agitation in response to the sound of the alarm. Findings: 1. During a review of Resident 4's admission Record (contains demographic and medical information), it indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included dementia (condition that affects the way the person's brain is working), seizures (convulsions), and anxiety (feeling of fear, dread and uneasiness). During a concurrent observation and interview, with the Infection Preventionist Nurse (IPN), on January 5, 2023, at 8:23 AM, inside Resident 4's room, a position change alarm was observed on Resident 4's left bed rail. The IPN stated Resident 4 had a position change alarm because she was at risk for falls. She further stated position change alarms needed to be ordered by a physician. During a concurrent interview and record review with the Director of Nursing (DON), on January 6, 2023, at 8:58 AM, the DON reviewed Resident 4's Order Summary Report, (report that show current physician's orders), dated January 4, 2023, and was not able to find a physician order for Resident 4's use of position change alarm. The DON stated there was no order for it. 2. During a review of Resident 5's admission Record, it indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included dementia, anxiety, and psychosis (mental disorder characterized by a disconnection from reality). During a concurrent observation and interview, with the IPN, on January 5, 2023, at 8:33 AM, inside Resident 5's room, a position change alarm was observed on Resident 5's left bed rail. The IPN stated Resident 5 had a position change alarm because she was at risk for falls. The IPN further stated position change alarms needed to be ordered by a physician. During a concurrent interview and record review, with the DON, on January 6, 2023, at 9:10 AM, the DON reviewed Resident 5's Order Summary Report, dated January 4, 2023, and was not able to find a physician order for Resident 5's use of position change alarm. The DON stated there was no order for it. 3. During a review of Resident 7's admission Record, it indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included dementia, schizophrenia (mental disorder in which people interpret reality abnormally) and bipolar disorder (mental illness that causes extreme mood swings). During a concurrent observation and interview, with the IPN, on January 5, 2023, at 8:33 AM, inside Resident 7's room, a position change alarm was observed on Resident 7's left bed rail. The IPN stated Resident 7 had a position change alarm because he recently had a fall. The IPN further stated position change alarms needed to be ordered by a physician. During a concurrent interview and record review, with the DON, on January 6, 2023, at 9:14 AM, the DON reviewed Resident 7's Order Summary Report, dated January 4, 2023, and was not able to find a physician order for Resident 7's use of position change alarm. The DON stated there was not order for it. During a concurrent interview and record review, with the DON, on January 6, 2023, at 9:16 AM, the DON reviewed the facility's undated policy and procedure (P&P) titled, Alarms, use of Position Change Alarm, which indicated, . Is the policy of the facility use the least restrictive method of ensuring resident safety and to provide the highest degree of resident independence possible . 2.To establish activity patterns and routines, use of an alarm will be included on the care plan as a nursing intervention and reviewed quarterly and as necessary by the IDT [Interdisciplinary Team]. A physician order should include checking placement and functioning of the device. The DON stated the facility did not follow the policy.

Based on interview and record review the facility failed to follow facility's Policy and Procedure when the Licensed Vocational Nurse (LVN1) failed to notify the primary physician prior to administering medication not within physician order's (MD) parameters for one of the three sampled Residents (Resident 1). They failed to ensure that Resident 1 receives treatment in accordance with professional standards of practice. This failure had the potential to place a clinically compromised Residents (Resident 1) health and safety at risk. When not following the medication order correctly prescribed by the physician. Findings: During review of Resident 1s admission Record (general demographics), admitted to facility on , July 14,2022 with diagnosis (DX) diabetes type II (body doesn't produce insulin), hypertension (high blood pressure), cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, chronic obstructive pulmonary disease (difficulty or discomfort in breathing), acute pulmonary edema (excess fluid in the lungs), bronchitis (Inflammation of the lining of bronchial tubes, which carry air in and out of the lungs), lupus erythematosus (autoimmune disease in which the immune systems attacks its own tissues, causes widespread inflammation and tissue damage in the affected organs), generalized anxiety disorder ( a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), During record review on August 4, 2022, at 3:50 PM of Resident 1s Medication Administration Record (MAR) indicates, Tuesday July 19,2022, at 0850 Alprazolam Tablet 0.5 mg was given by LVN1. Order to give 1 tablet as needed for anxiety, verbalization of anxiousness for 14 days. Give at bedtime as needed. During concurrent interview and record review with the Assistant Director of Nursing (ADON), on August 4,2022, at 5:10 PM, the ADON confirmed that LVN1 administered medication at 8:50 AM for anxiety and no documentation that LVN1 notified MD prior to administering medication outside MD's order parameters. When ADON asked if the facility followed the doctors order prior to administering the medication, ADON1 stated that LVN1 should have notified MD prior to administering. Also, when ADON asked if facility followed doctor's order as written, ADON stated that LVN1 did not. During a record review of July 19,2022, Medical Records of R1, there were no documentation and physician notification. During a review of the facility's policy and procedure titled, Administering Medications, revised April 2019, was reviewed. The policy and procedure indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame.