**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 12 sampled residents (Resident 18) by failing to: 1. Ensure Resident 18's Depakote (an anticonvulsant used to treat seizure disorder and other psychiatric conditions) medication was encoded as anticonvulsant and reflected in the MDS assessment under Section N (N0415 High-Risk Drug Classes) medication. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 18's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 18 was admitted to the facility on [DATE]. The admission Record indicated, Resident 18's diagnoses included dementia (a progressive state of decline in mental abilities), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] - high blood pressure). During a review of Resident 18's MDS assessment, dated 1/22/2025, the MDS indicated, Resident 18's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 18 was totally dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 18's Order Listing Report (a document containing active orders), dated 2/16/2025, the Order Listing Report indicated, Resident 18 has an active order of Depakote 500 milligrams ([mg] - metric unit of measurement, used for medication dosage/and or amount) by mouth at bedtime (9 p.m.) for mood disorder (a mental health condition that involves a persistent change in person's emotional state) manifested by hostile behavior. During a concurrent interview and record review on 2/15/2025 at 2:21 p.m., with the Minimum Data Set Nurse (MDSN), Resident 18's MDS assessment, dated 1/22/2025 was reviewed. The MDSN stated the MDS assessment was completed inaccurately. The MDSN stated Resident 18 was taking Depakote which is considered as anticonvulsant medication and was not checked on the MDS assessment Section N0415. The MDSN stated per Resident Assessment Instrument ([RAI] - a guide that helps nursing home staff use to assess residents and develop care plans) manual coding of medications should be based on the pharmacological (relating to the use of drugs to treat a condition) classification of the medication not based on the reason it was prescribed. The MDSN stated it was a human error and an oversight on her part by not encoding the Depakote as anticonvulsant medication in the MDS assessment. The MDSN stated accuracy of assessment in the MDS was important because it reflects the care provided by facility staff to the residents. During a review of the facility's policy and procedure (P&P) titled, MDS Assessment, dated 10/15/2021, the P&P indicated, The RAI shall be completed for residents residing in the facility per current RAI manual instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure one out of 12 sampled residents (Resident 28) had four padded side rails on the bed per physician's order. This deficient practice had the potential to result in Resident 28 being injured in the event of a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) Findings: During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), seizures, and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's History and Physical (H&P), dated 6/22/2024, the H&P indicated Resident 28 can make needs known but cannot make medical decisions. During a review of Resident 28's Minimum Data Set ([MDS] a resident assessment tool) dated 12/5/2024, the MDS indicated Resident 28 was dependent on staff for toileting and showering. During a review of Resident 28's care plan, dated 6/20/2024, the care plan indicated Resident 28 required the use of four padded side rails for seizure precautions. The care plan indicated Resident 28 would have padded side rails when in bed. During a concurrent interview and record review on 2/15/2025 at 5:48 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 28's order summary was reviewed. The order summary indicated Resident 28 had a physician's order for four padded side rails to be up when in bed for seizure precautions. During a concurrent observation and interview on 2/15/2025 at 5:50 p.m. with LVN 4 at the bedside of Resident 28, Resident 28 was noted in bed with four unpadded side rails up. LVN 4 stated padded side rails are ordered to decrease the impact and protect from injury during a seizure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one out of 12 sampled residents (Resident 28) was not prescribed Seroquel (an anti-psychotic medication used to treat mental illness) to control dementia (condition where there is a decline in mental abilities and memory) symptoms. This deficient practice put Resident 28 at risk of an adverse reaction (bad outcome) from taking an anti-psychotic without a diagnosis of a mental illness. Findings: During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), seizures, and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's History and Physical (H&P), dated 6/22/2024, the H&P indicated Resident 28 can make needs known but cannot make medical decisions. During a review of Resident 28's Minimum Data Set ([MDS] a resident assessment tool) dated 12/5/2024, the MDS indicated Resident 28 was dependent on staff for toileting and showering. During a concurrent interview and record review with the Director of Staff Development (DSD) on 2/16/2025 at 12:48 p.m., Resident 28's order summary was reviewed. The order summary indicated Resident 28 had a physician's order for Seroquel 25 mg for dementia psychosis. The DSD stated anti-psychotics are given for a psychiatric diagnosis to help manage behavior. The DSD stated Resident 28 does not have a psychiatric diagnosis. The DSD stated Seroquel is not used for dementia. You must be careful giving anti-psychotics to the elderly because they can become very drowsy and it increases their risk for fall. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication, dated July 2022, the P&P indicated the facility will ensure each resident's drug regimen will be free of unnecessary drugs. Doctors orders will contain the appropriate diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that analyzes a sample of blood, urine, or other bodily fluid or tissue) was completed as ordered by the physician for one of 12 sampled residents (Resident 18). This deficient practice had the potential for Resident 18 not receiving necessary medical treatment. Findings: During a review of Resident 18's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 18 was admitted to the facility on [DATE]. The admission Record indicated, Resident 18's diagnoses included dementia (a progressive state of decline in mental abilities), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] - high blood pressure). During a review of Resident 18's MDS assessment, dated 1/22/2025, the MDS indicated, Resident 18's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 18 was totally dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 18's Order Listing Report (a document containing active orders), dated 2/16/2025, the Order Listing Report indicated, Resident 18 has an active order to check the Complete Blood Count ([CBC] - a blood test used to look at overall health conditions and blood disorders), Comprehensive Metabolic panel ([CMP] a test that measures different substances in the blood, and provides important information of your body's chemical balance and how it uses food and energy), Thyroid Stimulating Hormone ([TSH] - a blood test that measures this hormone), Lipid Panel (a blood test that measures the amount of fat in your blood), and hemoglobin A1C (a test that indicates the average level of blood sugar control over the last couple of months, a high number is a sign of poor blood sugar control) on 12/9/2024. During a concurrent interview and record review on 2/15/2024 at 2:31 p.m., with the Director of Nursing (DON), Resident 18's clinical records were reviewed. The DON stated Resident 18's laboratory tests as ordered by the physician on 12/9/2024 was not completed and results were not available. The DON stated Resident 18's physician ordered the laboratory test remotely and did not communicate to the licensed nursing staff. The DON stated it was important for Resident 18's to have a routine blood test to monitor his different diagnoses and clinical condition and to revaluate if the ongoing treatment would continue. During a review of the facility's policy and procedure (P&P) titled, Laboratory and X-ray Services, dated 4/29/2022, the P&P indicated, It is the facility's policy to provide laboratory and x-ray services, as ordered by the physician.

Based on interview and record review, the facility failed to: 1. Maintain and notify the dietary supervisor of the temperature being out of range in one of the walk-in refrigerators during the month of February. This deficient practice had the potential for food spoilage and can cause foodborne pathogens in the residents. Findings: During a review of the Refrigerator Temperature Log, dated February 2025, it indicated the walk-in refrigerator located towards the back of the kitchen for February 2025 had the following temperatures recorded: 44 Fahrenheit ( F- measurement of temperature) on 2/6 at 5:00 a.m. 42 F on 2/8 at 5:30 a.m. 45 F on 2/10 at 5:30 a.m. 45 F on 2/11 at 5:40 a.m. During a concurrent interview and record review on 2/16/2025 at 9:30 a.m. with Kitchen Aide (KA), the Refrigerator Temperature Log for February 2025 was reviewed. KA stated that the individual who arrives the earliest, usually around 5:30 a.m. would check the temperatures of the refrigerator and freezer and record it on the temperature log. KA stated they check it when they first come in because the refrigerator and freezer isn't being opened or closed which could affect the temperatures, so the first temperature taken when then first staff member arrives is the most accurate temperature. KA stated there are several dates in February where the refrigerator exceeded 41 F and there were no comments written the in the column for corrective action/comments and there should have been so the staff could see what was done to correct the issue. KA stated that the individual who took the temperature that is out of range need to report it to the dietary supervisor and they are the ones who would fill out the column corrective action/comments. KA further stated it is important for food to be stored at the appropriate temperature because if not the food can go bad and can make the food unsafe to eat. During a concurrent interview and record review on 2/16/2025 at 9:43 a.m. with the Dietary Supervisor (DS), the Refrigerator Temperature Log for February 2025 was reviewed. FSM stated he or the maintenance supervisor would fill out the column titled corrective action/comments after they addressed the temperature being out of range. DS stated he was not notified about the temperature being out of range and it is unknown if there were any corrective actions taken to address the temperatures on the dates it was out of range. During a review of the Refrigerator Temperature Log dated February 2025, it indicated to maintain the refrigerator temperature at 40 F or below during stable times and to complete corrective action column if temperatures are not in proper ranges.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure a change of condition Preadmission Screening & Resident Review (PASARR) was submitted to the Department of Health Care Services (DHCS) to ensure the resident was re-evaluated for one of one sampled resident (Resident 40) This deficient practice had the potential to cause harm due to not receiving care and services in the most appropriate setting for the resident's needs. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE]. Resident 40's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality.), anxiety disorder (persistent and excessive worry that interferes with daily activities), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.). During a review of Resident 40's History and Physical (H&P), dated 10/16/2023, the H&P indicated Resident 40 could make needs known but could not make medical decisions. During a review of Resident 40's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated Resident 40 had a Brief Interview for Mental Status(BIMS) of 4 (0-7 - suggested severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment).The MDS section I active diagnoses included dementia, anxiety disorder, depression, and psychotic disorder. During a review of Resident 40's physician order summary report (MD orders), MD orders indicated Resident 40 had an active order dated 10/17/2023 for Seroquel oral tablet 12.5mg enterally two times a day for psychosis. During an interview on 2/23/2024 at 12:40 p.m. with MDS Coordinator , the MDS coordinator stated PASRR's are done before admission, readmission and if there is a change in condition, new mental health diagnosis. The MDS coordinator stated the PASRR is an evaluation to make sure the residents are place at the appropriate facility. The MDS coordinator stated for a positive PASSR II the state gives recommendations for treatments and services needed. The MDS coordinator stated if not resubmitted the resident could possible not get the services they may need. The MDS coordinator stated Resident 40 now had a new diagnosis of psychosis and is taking Seroquel (an anti-psychotic mediation). The MDS coordinator stated that the PASSR should have been resubmitted for Resident 40 and was not. During a review of the facility's policy and procedure (P&P) titled, PASRR, dated 7/16/2021, the P&P indicated, Referral for level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experience a significant change. Examples of such changes include but are not limited to: A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASARR Level II evaluation and determination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Provide pharmaceutical services that met the needs one of six sampled residents (Resident 101). Resident 101 did not receive medication at the scheduled time and with food as ordered by the physician. This deficient practice had the potential for avoidable physical harm related to residents not receiving their medications on time, or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered. Findings: During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 101's diagnoses included gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and gastric ulcer (Stomach ulcers (gastric ulcers) are open sores that develop on the lining of the stomach). During a review of Resident 101's History and Physical (H&P), dated 2/8/2024, the H&P indicated Resident 101 had the capacity to understand and make decisions. During a review of Resident 101's Medication Administration Record (MAR), dated 2/1/2024-2/29/2024, the MAR indicated the medication order for pantoprazole sodium (generic name for Protonix, medication used to treat certain conditions in which there is too much acid in the stomach) oral tablet delayed release 40mg 1 tab two times a day for gastric ulcer, due at 7:30 a.m. During an interview on 2/23/2024 at 12:18 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the medication Protonix was due at 7:30am, it was given at 8:45am. LVN 1 stated medication should have been given without food, resident ate around 8 a.m. LVN 1 stated if medications are given late there could potentially be a contraindication with another medication. LVN 1 stated it is important to follow physician orders. During an interview on 2/23/2024 at 1:30 p.m. with Director on Nursing (DON), the DON stated medications should be given one hour before to one hour after scheduled administration time. The DON stated that if medication is given with food and order stated without food the medication could potentially decrease the efficiency of the medication. DON stated should follow physician orders. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Guidelines, dated 12/5/2023, the P&P indicated, Medications shall be administered within 60minutes of scheduled time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure a two multi-dose vials of heparin were labeled with the dates when the vials were opened. These deficient practices had the potential for unintentional medication administration of possibly expired medication for the residents. Findings: During a concurrent observation and interview on [DATE] at 11:41 a.m. with Licensed Vocational Nurse (LVN) 3 at the med cart station, two opened multi-dose heparin vials were not labeled with the open date on them. LVN 3 stated you can not tell when the vial was opened. LVN3 stated a multi-dose medication should be labeled with the open date as soon as it is opened. LVN 3 stated by know knowing the expiration date there is a potential risk that the medication is expired. LVN 3 stated if the medication is given after the expiration date it can potentially cause an adverse reaction, the strength could be diminished and not help the resident. During an interview on [DATE] at 1:30 p.m. with Director on Nursing (DON), the DON stated a multi-dose medication should be labeled with the date opened. DON stated there is potential for contamination. DON stated that if not labeled you cannot ensure medication is safe to administer. DON stated policy stated label medication with the date opened. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Guidelines, dated [DATE], the P&P indicated, When a multidose container is opened, the date opened is recorded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure the quarterly Minimum Data Set ([MDS], a standardized assessment and care planning tool) was submitted to Centers for Medicare and Medicaid Services (CMS) within 14days after completion for three of three sampled residents (Residents 9, 11, and 25) This deficient practice resulted in data not being transmitted to CMS regarding resident's current assessment. Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 9's diagnoses included congestive heart failure (chronic condition where the heart does not pump blood effectively), osteoarthritis (a progressive joint disease, in which the tissues in the joint break down over time), and hypothyroidism (the thyroid doesn't create and release enough thyroid hormone into your bloodstream). During a review of Resident 9's History and Physical (H&P), dated 10/9/2023, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.), and sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep. This can prevent your body from getting enough oxygen). During a review of Resident 25's H&P, dated 4/15/2022, the H&P indicated Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE]. Resident 25's diagnoses included type 2 diabetes mellitus (abnormal blood sugar), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Resident 11's H&P, dated 10/16/2023, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a concurrent interview and record review on 2/22/2024 at 1:17 p.m. with MDS Coordinator, the clinical MDS-export ready list was reviewed. Export ready list indicated, Resident 9's transmission should have been submitted by 2/10/2024, Resident 11's transmissions should have been submitted by 2/13/2024, and Resident 25's transmission should have been submitted by 2/19/2024. The MDS coordinator stated that no these have not been submitted to CMS yet. The MDS coordinator stated by following guidelines once MDS assessment is complete it needs to be transmitted within 14 days of completion. MDS coordinator stated that it is transmitted to CMS so Medicare and insurances will know the status of the resident. During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set Assessment, dated 9/1/2022, the P&P indicated, The MDS shall be completed in accordance with the required time frames set forth by the Center of Medicare and Medicaid Services (CMS). The completed MDS records shall be encoded and transmitted to the State repository in accordance with Center of Medicare and Medicaid Services (CMS) established record specifications and time frames.

Based on observation, interview, and record review, the facility failed to ensure food items were labeled and expired food was discarded in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food) for 43 out of the 46 residents in the facility by failing to: 1. Ensuring 10 packs of frozen vegetables in Freezer 1, 2 opened 1-gallon milk cartons, a storage bin of lemons and green onions in Refrigerator 2, and [NAME] and Basmati [NAME] stored in the dry storage room were labeled. 2. Discarding 2 large storage bins of expired jasmine rice (1) and basmati rice (1), 1 large storage bin of pasta noodles, 3 small packs of lasagna pasta noodles in a Ziploc bag, 1 large storage bin of dried split peas and a large box of graham crackers in the dry storage room. 3. Ensuring the dishwasher and sink sanitization levels were within adequate recommended perimeters for 43 residents. These deficient practices had the potential to result in pathogen (germs) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) leading to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 2/20/24 at 8:38 AM in the kitchen with Dietary [NAME] (DC 1), DC 1 observed frozen vegetables from Freezer 1; along with milk, lemons, and green onions from Refrigerator 2 were not labeled. DC 1 stated all food items in the kitchen have labels with an opened date and use by date. DC 1 stated frozen vegetables, milk, lemons, green onions, [NAME] rice and Basmati rice should have been labeled. DC 1 stated the risk of not labeling food can cause residents to become sick. During a concurrent observation and interview on 2/20/24 at 9:01 AM in the kitchen with DC 1, DC 1 observed expired pasta noodles, jasmine rice, basmati rice, dried peas and graham crackers on the shelf in the dry storage room. DC 1 stated the kitchen's protocol was the first in, first out method. DC 1 stated all expired foods should be discarded by or on the used by date. DC 1 stated the risk of not discarding expired food could result in residents to become very sick. During a concurrent observation and interview on 2/20/24 at 9:23 AM in the kitchen with DC 1, DC used sanitization strips to test the kitchen's dishwasher and sink levels. DC 1 stated the dishwasher strips and sink strips were not reading at the recommended levels. DC 1 stated dishwasher strips and sink strips were expired. DC 1 stated the risk of using expired strips to check sanitization levels could result in contamination due to inadequate readings when disinfecting and washing dishes. During an interview on 2/21/24 at 11:17 AM in the kitchen with Dietary Supervisor (DS 1), DS 1 stated all expired foods were discarded and unlabeled food were labeled as of 2/21/24. DS 1 also stated new dishwasher and sink strips were ordered and to be received that day. DS 1 stated the risk of having unlabeled and expired food could result in the residents becoming sick. DS 1 stated Residents can get sick, food can turn, dishes can harbor bacteria if not sanitized correctly. We are cooking for the elderly and since they are more sensitive, their bodies may not be able to handle it. During a review of the facility's policy and procedure, titled Storage of Food and Supplies, dated in 2020, indicated labels should be visible and the arrangement of food items should permit rotation of supplies so that oldest items will be used first. All food will be dated month, day, year. During a review of the facility's policy and procedure, titled Dishwashing, dated in 2018, indicated the dish machine is to be serviced on a regular basis by a technician to ensure accurate measurements of sanitizing agents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 9's diagnoses included congestive heart failure (chronic condition where the heart does not pump blood effectively), osteoarthritis (a progressive joint disease, in which the tissues in the joint break down over time), and hypothyroidism (the thyroid doesn't create and release enough thyroid hormone into your bloodstream). During a review of Resident 9's History and Physical (H&P), dated 10/9/2023, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set ([MDS] - a standardized assessment and care planning tool) dated 1/13/2024, indicated Resident 9's BIMS - (brief interview for mental status) was 14 (13-15 - indicates cognitive intactness). MDS indicated resident required substantial/maximal assistance with rolling left to right. During an observation on 2/22/2024 at 9:20 a.m. in Resident 9's room with the TN 1, TN 1 was observed performing wound care treatment on Resident 9. TN 1 performed hand hygiene properly and cleaned wound with proper technique. TN 1 opened new cotton swab and applied gentamycin ointment from a small cup to Resident 9's wound, with the same cotton swab went back into the same cup to apply more gentamycin cream, applied to wound, added gauze to the gentamycin cup and with the same cotton swab swirled gauze in the gentamycin cream cup and applied to Resident 9's wound. TN 1 performed hand hygiene and placed clean dressing on wound. During an interview on 2/22/24 at 9:50 a.m. with TN 1, TN 1 stated with Resident 9's used a clean cotton swab, and the gentamycin was in a little cup, I applied medicine on the cotton swab and applied it to the wound. TN 1 further stated I used the same cotton swab twice. During an interview on 2/23/2024 at 12:11 p.m. with Infection Prevention Nurse (IPN), the IPN stated when you are doing wound care you should use a clean cotton swab every time you touch the wound. The IPN stated if you use the same cotton swab in the wound and getting the medication you could cross contaminate. The IPN stated you could potentially slow down the healing process, spread the infection, get sepsis, or have to go to the hospital. Based on observation, interview and record review, the facility failed to: 1. Ensure proper infection control techniques were performed during wound care treatment for two of two sampled residents (Resident 26 and Resident 9). This deficient practice had the potential to result in contamination of the residents' wounds and placed the residents at risk for infection. Findings: a. During a review of Resident 26's admission record indicated Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including muscle wasting and atrophy (the wasting (thinning) or loss of muscle tissue), dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). During a review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated January 18, 2018, indicated Resident 1 was severely cognitively impaired (process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and required dependent assistance with transfer, dressing, and toilet use. During observation on 2/22/24 at 1:34 p.m. in Resident 26's room with Treatment Nurse (TN 1), TN 1 was observed performing wound care treatment on Resident 26. TN 1 applied Santyl ointment inside of Resident 26's wound with a cotton swab (a long q-tip). TN 1 then re-used the same cotton swab to apply the remainder of the Santyl medication in the medication cup to the wound. Lastly, TN 1 was observed applying hydrogel ointment (an ointment used to heal dead and infected tissue) inside of Resident 26's wound with same cotton swab used for applying Santyl ointment. During an interview on 2/22/24 at 2:40 p.m. with TN 1, TN 1 stated Resident 26's wound is chronic and refuses to heal. TN 1 stated cotton swabs are to be changed after applying ointment. TN 1 stated after applying Santyl ointment with a cotton swab, The wound is 'clean' to me. TN 1 stated the risk of not changing cotton swabs during wound care treatment can carry the burden of spreading germs and can be an infection control issue.

Based on observation, interview, and record review, the facility failed to ensure unexpired medications were kept in 1 of 2 oral emergency kits ([E-Kit], box which contain a small quantity of medications that can be dispensed when pharmacy services are not available). This deficient practice had the potential for medication errors including missed medication doses and exposure to expired, deteriorated medications with decreased potency to 49 out of 49 residents in the facility. Findings: During a concurrent observation of the facility's medication storage (storage 2) on the second floor and interview on 3/05/23 at 12:04 p.m. with Licensed Vocational Nurse (LVN 5), the following were found in the E-Kit: 6 individually packaged compazine ([prochlorperazine], anti-nausea) 5 milligrams ([mg], unit of measurement) tablets with expiration date of 12/2022 4 individually packaged catapress ([clonidine HCL], treats high blood pressure) 0.1 mg. tablets with expiration date of 1/2023 4 individually packaged potassium chloride ([KCL], mineral supplement that is used to prevent or treat low levels of potassium caused by disease) extended release 750 mg. (10 [mEq], measurement use for electrolytes) capsules with expiration date of 1/2023 7 individually packaged cipro ([ciprofloxacin], antibiotic) 250 mg. tablets with expiration date of 2/2023 LVN 5 stated the E-Kit should not have expired medications and risks of having expired medications included poisoning, adverse reactions, ineffectiveness and could lead to the inability to provide emergency medication to the facility residents. LVN 5 also stated the date should be checked on the E-kits, however, was not sure why there were expired medications inside the E-kit. During an interview with Pharmacist (PHARM 1) on 3/8/2023 at 10:01 a.m., PHARM 1 stated that the last time the E-kit was replaced was on 2/25/2023 and did not recall medications being expired. PHARM 1 also stated expiration dates were indicative that the medication was 90% less effective, would be less effective in treating the patient and could cause undesired outcomes. During a review of the facility's policy and procedure (P/P) titled, Destruction of Non-Returnable Medications/ Expired Medications dated 2/9/2009, the P/P indicated the purpose was to promote the safety of medications dispensed and/or stored for administration on site by eliminating discontinued or expired medications on a regular basis. The P/P also indicated the licensed nurse would inspect all medication for the expiration date and/or currency of prescription during medication pass, inventory and reorder all medications that are outdated through the facility contracted pharmacy.

Based on interview and record review, the facility failed ensure arbitration agreements specifically provided for the selection of a venue that was convenient for residents and/or representatives. This deficient practice had the potential for facility residents to be uninformed and negatively affect the ability to resolve any disputes which can cause psychosocial harm to the residents that sign the agreement. Findings: During a review of the facility's undated Arbitration Agreement (an agreement between the facility and resident where they would resolve any disputes through a neutral person rather than through court), the agreement indicated there was no selection of a convenient venue a selection of a neutral arbitrator by the two parties but no mention of a selection of a convenient venue. During a concurrent interview and record review of the agreement with the Director of Nursing (DON) on 3/7/2023 at 2:41 p.m., the DON stated the agreement did not have the selection of a venue and therefore residents would not be informed of their right to be able to select a convenient venue. During a review of the facility's policy and procedure (P&P), titled Arbitration, dated 1/27/2020, the P&P indicated the facility must ensure that the agreement provided for the selection of a venue that was convenient to both parties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow Infection Control Prevention and Control policy and procedures during wound care for two of five Residents (Residents 22 and 23) by failing to: 1. Ensure Registered Nurse (RN 1) performed hand hygiene (cleaning hands by handwashing or using alcohol-based sanitizer) after doffing (taking off) soiled gloves and donning (putting on) new gloves 2. Ensure RN 1 followed contact time (amount of time a disinfectant needed to sit on a surface to effectively kill germs) according to manufacturer's guidelines to disinfect scissors used to cut wound dressing and allowed disinfectant to dry before use. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria from one place to another), infection and skin irritation for Residents 22 and 23. Findings: 1. During a review of Resident 23's admission Record (Face Sheet), the Face Sheet indicated the Resident 23 was admitted to the facility 9/15/2021 and was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), Parkinson's disease (disorder of the central nervous system), Type II Diabetes Mellitus (process in which the body process blood sugar), chronic pancreatitis (permanent damage from inflammation), prostatic hyperplasia (prostate gland enlargement) and stage 3 pressure ulcer ([PU], full thickness tissue loss) on the sacrum. During a record review of Residents 23's History and Physical (H&P) dated 12/9/2022, the H&P indicated Resident 23 was mildly confused. During a review of Residents 23's Minimum Data Set ([MDS], a standardized care screening and assessment tool) dated 12/15/2022, the MDS indicated Resident 23 needed extensive assistance or was totally dependent on staff for activities of daily living (ADL) such as bed mobility, transfers, locomotion and toilet use. The MDS also indicated the resident had an unhealed stage 3 PU. During an observation on 3/7/2023 at 8:30 a.m. of Resident 23's wound care treatment, RN 1 removed soiled dressing, soiled gloves, and donned new gloves without conducting hand hygiene. RN 1 used Cavi Wipes (surface disinfectant) to disinfect scissors, immediately used the scissors to cut gauze without waiting for proper contact and drying time, then proceeded to place the gauze on the Resident 23's sacral PU. During a concurrent interview and record review on 3/7/2023 at 1:40 p.m. with RN 1, RN 1 stated, hand hygiene should be done after removing soiled gloves. RN 1 stated she used Cavi Wipes to wipe down scissors and did not wait for the scissors to dry which could cause skin irritation and infection for the resident. RN 1 also stated contact time was one minute according to manufacturer's guidelines and drying time was two to five minutes. During a record review of the facility's policy and procedure (P&P) titled, Infection Control dated 9/16/2020, the P/P indicated, to prevent the spread of infection through hand washing and the use of aseptic (free from contamination caused by harmful bacteria and viruses) practices. The P/P also indicated hand hygiene should be performed after removing gloves and before every procedure During a record review of facility's P&P titled, Licensed Treatment Nurse dated 12/8/2010, the P/P indicated the purpose of the job position was to provide primary skin care to residents and to follow infection control procedures in the care of wounds. 2. During a review of Resident 22's Face Sheet, the Face Sheet indicated Resident 22 was admitted on [DATE] with diagnoses including stage 4 PU on the sacrum Alzheimer's disease and dysphagia. During a review of Resident 22's H&P dated 12/9/2022, the H&P indicated Resident 22 was nonverbal and did not have the capacity to understand and make decisions. During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22 was totally dependent on staff for ADL's. During an observation on 3/7/2023 at 8:50 a.m. of Resident 22's wound care RN 1 cleansed the resident's wound, removed her gloves, and donned new gloves without performing hand hygiene. RN 1 also wiped her scissors with disinfectant wipes but immediately used the scissors to cut the resident's dressing. During an interview on 3/7/2023 at 1:44 p.m. with RN 1, RN 1 stated she should wash hands changing gloves, and she can cause residents to have infections if hand hygiene was not performed. RN 1 also stated, surfaces could still be contaminated and can cause infection for the resident if the proper contact time was not followed. During a review of the undated manufacturer's guide, titled, Cavi Wipes Technical Bulletin, the guide indicated a one-minute kill time was required to effectively clean and disinfect surfaces. During a review of the facility's P&P titled, Infection Control, dated 9/16/2020, the P&P indicated hand hygiene needed to be performed after removing gloves and before every procedure.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. A container of juice attached to the juice dispenser in the kitchen was not dated after being opened. 2. Several food items were not dated, labeled, and sealed after opening in, the walk-in refrigerator. A bag of thawed and open bacon was in an unsealed box with no open date or used by date. Boxes of meat beef, and chicken was stored above containers of juices (cranberry and orange) in the walk-in refrigerator. 3. A bag of block cheese with no label, in the walk-in refrigerator. These deficient practices had the potential lead to contamination and foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 44 out of 49 residents who received food and juices from the kitchen. Findings: 1. During the initial tour of the kitchen and inspection on 3/5/23 at 9:30 a.m. the following Rerasia/Bevolution Juice containers were observed opened and undated: a. One three-gallon bag-n-box orange juice b. One three-gallon bag-n-box apple c. Two juice boxes on the bottom shelf unlabeled and undated. During an interview on 3/6/23 at 9:04 a.m. the Dietary Manager (DM) stated he did not know when the boxes were opened. The DM stated all food containers should be dated to indicate when it was opened. The DM stated he had no instruction from the company on the opened and unlabeled juices. 2. During an observation and interview with the DM on 3/6/23 at 8:43 a.m., there was one bag of thawed bacon opened with no open date or used by date and exposed to the walk-in refrigerator environment. The DM stated dietary staff must have used the bacon for breakfast and forgot to seal the bag closed. During a concurrent observation and interview with the DM on 3/6/23 at 9 a.m. DM stated he did not know who placed the boxes of meat above the juice containers. The DM stated he will in-service the kitchen staff on how to place meat products. During an observation and interview on 3/7/23 at 11:46 a.m., [NAME] 1 stated the food placed in the walk-in refrigerator should have instructions on storage temperatures for each type of product, as indicated on the refrigerator storage label in front of the walk-in refrigerator door. A review of the facility's policy and procedure (P&P) titled Thawing of Meats dated 2018, indicated to allow 2 to 3 days to defrost, depending on the quantity and total weight of meat. It indicated to label defrosting meat with pull and use buy date, use a drip pan under food being thawed so dripping did not contaminate other food. The P&P indicated to thaw meat on the bottom shelf below prepared, ready-to-eat foods. 3. During an observation on 3/6/23 at 8:40 a.m., there was a bag on block cheese with no label, in the walk-in refrigerator. During a concurrent observation and interview on 3/6/23 at 8:45 a.m., The DM removed two block cheeses from the walk-in refrigerator and stated opened and unlabeled cheeses had the potential to lead to foodborne illness throughout the facility. A review of the facility P&P titled Labeling and dating of food dated 2020, indicated all food items in the refrigerator and freezer need to be labeled and dated. The P&P indicated newly opened food items will be closed and labeled with an open date and used by the manufacturer's guidelines, all prepared foods will be covered, labeled, and dated, items could be dated individually or in bulk and stored on a try with masking tape if used for meal services.