Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 16) was provided assistance with nail care when Resident 16 was observed with long untrimmed nails with a brown substance underneath. These findings had the potential for increased infections, shame, discomfort, and feelings of frustration for Resident 16. Findings: A review of Resident 16's admission record indicated Resident 16 was re-admitted to the facility in 2021 with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition of excessive worry, fear, and nervousness that can interfere with daily life), dementia (a progressive state of decline in mental abilities), hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), nail dystrophy (a group of conditions that cause abnormal changes in the structure, appearance, and growth of the nails), and other nail disorders. A review of Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/21/25, indicated that Resident 16 has severe cognitive impairment and needed assistance with personal hygiene and dressing. A review of Resident 16's care plans indicated a care plan titled The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Dementia, Limited ROM [Range of Motion], initiated on 12/13/24 and revised on 2/5/25. The care plan indicated, The resident is totally dependent on staff for personal hygiene and oral care. During a concurrent observation and interview on 2/11/25 at 9:58 a.m. with Resident 16 in her wheelchair by her bedside, Resident 16 was observed with long discolored nails with a brown substance underneath. Resident 16 stated that she would like to get her nails trimmed. During a concurrent observation and interview on 2/14/25 at 8:39 a.m. with the Nursing Assistant (NA 1) and Unit Manager (UM 2) in Resident 16's room, Resident 16 was observed in her wheelchair at her bedside with long discolored nails with a brown substance underneath. NA 1 and UM 2 confirmed that the nails were long and had a brown substance underneath. NA 1 described nails as being 1 centimeter or longer, and she stated that nails could be cleaned with a wooden stick and filed down to the appropriate length. She also stated that she provided nail care whenever she sees that the nails are dirty. In an interview on 2/14/25 at 8:50 a.m. with Certified Nursing Assistant (CNA 2), CNA 2 confirmed that Resident 16 had long nails with a brown substance underneath and she planned on fixing it. She was not able to state the last time Resident 16 received nail care. In an interview on 2/14/25 at 11:21 a.m. the Director of Nursing (DON) stated that residents' nails should be clean and trimmed. DON also agreed that given Resident 16's medical condition her nail care should be more rigorous. The facility's policy on nail care was requested but was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control and preventive practices when: 1. There was no infection control and preventive practices training provided by the Infection Prevention nurse (IP, who specializes in preventing and controlling infections in healthcare settings) during a norovirus outbreak (a very contagious virus that causes stomach inflammation, vomiting, diarrhea, and stomach cramps); 2. Resident 335's urinary catheter (a hollow tube inserted into the bladder (a hollow organ of the lower stomach that holds urine before it leaves the body) drainage bag (a bag that collects urine) was found on the floor; 3. Resident 335's intravenous (IV- a needle or tube inserted into a vein) tubing was not dated; and, 4. Licensed Nurse (LN) placed a dirty pillow under Resident 335's leg. These failures decreased the facility's ability to ensure infection would not spread among residents for a census of 83. Findings: 1. During a review of the facility's infection prevention and control program (IPCP, a set of policies and procedures implemented within a healthcare setting to minimize the spread of infections among patients, staff, and visitors) on 2/14/25 at 10:25 a.m., the facility's antibiotic stewarship program (ASP, a set of practices that ensure antibiotics are used appropriately) was reviewed. During a review of the facility's monthly infection control report: under Healthcare Associated Infection (HAI, infections that develop while receiving medical care), on 2/14/25 at 10:28 a.m., the HAI report indicated, norovirus outbreak line list for the month of December 2024, 15 residents were listed to have gastro-intestinal (G.I.) infection symptoms like nausea (a feeling of sickness or discomfort in the stomach), vomiting, and diarrhea (stools are loose and watery). During a review of the facility's document submitted by the IP nurse to the local health department dated 1/6/25 at 4:42 p.m., the report indicated, gastrointestinal (G.I.) outbreak summary information. The local health department in its response confirmed it had received the norovirus outbreak report submitted by the facility. The facility's training binder was reviewed on 2/14/25 at 10:15 a.m. The review did not show any documentation that preventive practices training and/or in-services about norovirus outbreak was implemented. During a concurrent interview and record review on 2/14/25 at 10:25 a.m., with the IP Nurse, the facility's norovirus outbreak line list for the month of December 2024 and the monthly infection control report were reviewed. The IP nurse confirmed that in the line list, 15 residents have had norovirus-like symptoms of nausea, vomiting and diarrhea. The IP nurse was unable to show proof a norovirus in-service/training was provided during the outbreak to help protect both patients and healthcare workers from the spread of the infectious disease. The IP nurse stated she should have provided and documented the training but she did not. During an interview and record review on 2/14/25 at 11:19 a.m., with the Director of Staff Development (DSD), the monthly infection control report and the facility training binder were reviewed. The DSD confirmed the facility had a norovirus outbreak for the month of December 2024 but there was no norovirus training implemented to ensure the health and safety of the residents. During an interview on 2/14/25 at 11:32 with the Director of Nursing (DON), the DON confirmed the norovirus outbreak and stated when there was an outbreak, an infecton prevention and control training should have been provided to ensure the health and safety of the residents. During a review of the facility's undated policy and procedure (P/P) titled, Infection Control Plan, the P/P indicated, .Work with the in-service director in educating staff on infection control, methods, programs and procedures . During a review of the facility's undated Infection Preventionist position summary: it indicated, the IP is accountable for decreasing the incidence and transmission of infectious disease between patients, staff, visitors and community . Essential duties and responsibilities included: .Authority and responsibility for ensuring appropriate intervention and education occurs with staff, volunteers and medical staff when healthcare infection trends, outbreaks or non-compliance to infection control are identified . 2. A review of Resident 335's admission record indicated admission to the facility in January 2025 with diagnoses which included retention of urine (a condition that prevents urine from leaving the bladder). A review of Reident 335's medical records indicated the following: -An Order Summary Report dated 2/5/25 indicated orders for the provision of urinary catheter with drainage bag. -A care plan initiated on 2/7/25 indicated, The resident has .Catheter due to urinary retention .Position .away from entrance room door .Check tubing for kinks each shift During an observation in room [ROOM NUMBER]-B, on 2/12/25 at 11:40 a.m., Resident 335's urinary catheter drainage bag was found on the floor, on the right side of the bed facing the entrance room door, and not properly hung from the bed rail with use of the drainage bag hook. During a concurrent observation and interview on 02/12/25 at 11:49 a.m. with LN 1, LN 1 agreed to go to Resident 335's room as requested. LN 1 acknowledged that the urinary catheter drainage bag was on the floor. LN 1 confirmed that the drainage bag should not be on the floor, but that the drainage bag hook should be properly hung on the bed rail so that the drainage bag is positioned off the floor. LN 1 stated that by having the drainage bag on the floor could cause a potential infection control issue, and tripping hazard, which could lead to urine being spilled on the floor. An interview on 2/13/25 at 10:30 a.m. in the DSD's office, the DSD provided a copy of the new hire Certified Nursing Assistant (CNA) Skills Checklist which did not include checkoffs for urinary catheter care and catheter drainage bag positioning. DSD stated that it was important for staff to follow infection control prevention practices to avoid a potential illness outbreak between vulnerable residents. DSD provided a copy of the Competency/Procedure LN Checklist with checkoffs being done by the Director of Nursing (DON). The DSD conducted a three-way telephone call with the DON on 2/13/25 at 10:40 a.m. for an interview to discuss the Competency/Procedure LN Checklist. The DON stated that there are no objectives or syllabus (an outline of what is taught) associated with the Competency/Procedure LN Checklist. DON acknowledged that there is no LN checkoffs related to urinary catheter care and urinary catheter drainage bag positioning. 3. A review of Reident 335's admission record indicated diagnoses which included Bacteremia (a condition where bacteria is present in the blood). A review of Resident 335's medical records indicated the following: -An Order Summary Report dated 2/13/25 indicated orders for the provision of Cefazolin (an antibiotic used to treat serious bacterial infections) Sodium 2 gram IV two times a day. -A care plan initiated on 2/7/25 indicated, The resident is on IV medications Cefazolin .The resident will not have any complications related to IV therapy . During a concurrent observation and interview on 2/12/25 at 12:35 p.m. with Unit Manager (UM) in Resident 335's room, UM was observed hanging Resident 335's IV medication Cefazolin. UM stated that Resident 335 has this medication scheduled to receive at 12 noon and at 12 midnight every day. UM spiked the new medication bag with the previously hung IV tubing noted on IV pole. UM hung the IV medication with the tubing, gave medication to Resident 335's IV site for infusion, and was prepared to leave the room. UM did not notice that the previous IV tubing did not have a label. UM did not use a new IV tubing for infusion, and did not label the IV tubing with the current date and time when hung. UM acknowledged that the IV tubing was not labeled with a date and time, and stated that no label was required for IV tubing per facility policy. During an interview on 2/13/25 at 10:30 a.m. in the Director of Staff Development's (DSD) office, the DSD provided a copy of the Competency/Procedure LN Checklist with checkoffs being done by the Director of Nursing (DON). The DSD did a three-way telephone call with the DON on 2/13/25 at 10:40 a.m. for an interview to discuss the Competency/Procedure LN Checklist. The DON stated that there are no objectives of what was taught associated with the Competency/Procedure LN Checklist. DON acknowledged that there is no LN checkoffs related to IV tubing or IV tubing labeling. 4. During a concurrent observation and interview on 2/12/25 at 12:53 p.m. with LN 1 in Resident 335's room, it was noted that bed A (the roommate) was not occupied, the resident was discharged earlier in day, bed room area was not cleaned yet; as observation indicated that no linen was on bed, container of sanitizing wipes with discharged resident's name was left on dresser, and room area was not prepared for the next potential admission. LN 1 was observed taking a dirty pillow from bed A, placed a clean pillow case on the dirty pillow, and then positioned that pillow under Resident 335's right leg. LN 1 did not clean or sanitize the pillow before use on Resident 335. LN 1 acknowledged that the pillow was taken from bed A, and stated that bed A room area had been cleaned by housekeeping, and that the pillow used from bed A was clean. During an interview on 02/12/25 at 12:56 p.m. with Housekeeper (HK) in room [ROOM NUMBER]-A. HK stated that bed A had not been cleaned by housekeeping yet. HK stated that when a resident is discharged , the CNA strips the bed and remove a resident's personal items so that housekeeping can do a deep cleaning (terminal cleaning) of the bed, chair, wheelchair, dresser, floors, walls, and curtains. HK acknowledged that discharged resident's container of sanitizing wipes were left on dresser, and stated anything that the CNA forgot to remove, housekeeping would remove as part of the deep cleaning process. An interview on 2/13/25 at 10:30 a.m. in the Director of Staff Development's (DSD) office, the DSD provided a copy of the new hire CNA Skills Checklist which did not include checkoffs for cleaning items/pillows before resident use. DSD stated that it was important for staff to follow infection control prevention practices to avoid a potential illness outbreak between vulnerable residents. DSD provided a copy of the Competency/Procedure LN Checklist with checkoffs being done by the Director of Nursing (DON). The DSD did a three-way telephone call with the DON on 2/13/25 at 10:40 a.m. for an interview to discuss the Competency/Procedure LN Checklist. The DON stated that there are no objectives or syllabus (an outline of what is taught) associated with the Competency/Procedure LN Checklist. DON acknowledged that there is no LN checkoffs related to cleaning items/pillows before resident use. A follow up interview on 2/14/25 at 8:50 a.m. in the DON's office, the DON stated that the expectation of an LN is to follow infection control prevention practices by making sure that labels are placed on IV tubing with date and time hung, that dirty items/pillows are cleaned before use on a resident, and that urinary catheter drainage bags are hung properly from resident's bed frame and not touching the floor. DON stated that the facility does not have a urinary catheter policy and procedure (P&P), that had been requested, but that LNs follow the Lippincott Manual of Nursing Practice, Ninth Edition, related to urinary catheter care and catheter drainage bag positioning. An interview on 2/14/25 at 9:25 a.m. in the IP's office, the IP presented the past 4 months of facility's In-Service/Training/Seminar Records for staff which did not include inservices related to cleaning items/pillows before resident use, or urinary catheter care and urinary drainage bag positioning. IPN stated did not know enough about IV tubing to make a comment due to a certification as a LVN. IP stated that it was important for staff to follow infection control prevention practices to keep everyone safe from germs and illness. A review of the facility's Lippincott Manual of Nursing Practice, Ninth Edition, chapter General Procedures and Treatment Modalities, indicated, Maintaining a closed drainage system .2. Maintain unobstructed urine flow .c. Keep the bag off the floor . A review of the facility's Pharmacy Intravenous Therapy Services Manual, dated 10/2020, Section 6, titled: N. I.V. TUBING indicated, .2. I.V. tubings shall be dated and timed when hung . A review of the facility's Infection Control Manual, dated 10/25/24, Section 6, titled, Housekeeping Department, indicated, Procedure for Cleaning .3. Terminal cleaning of a resident room must include: Cleaning . Decontamination .; Cleaning Routines .In certain areas, housekeeping will not be responsible for the care of specific .These items may be the responsibility of the nursing services personnel, . A review of the facility's Infection Control Plan Policy, undated, indicated, .Work with the In-service Director in educating staff on infection control methods, programs and procedures; .

Based on observation, interview and record review, the facility failed to provide an accessible call system for two of six sampled residents (Resident 1, and Resident 6) when Resident 1 and Resident 6's call light buttons were not within their reach. This failure has the potential to result in the residents' not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being. Findings: 1a. A review of Resident 1's clinical record indicated Resident 1 was admitted April of 2022 and had diagnoses that included cardiomyopathy (a disorder that affects the heart muscle and causes the heart to lose its ability to pump blood well), and dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities). A review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/10/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 1 had a moderately impaired cognition. A review of Resident 1's MDS Mood Status, dated 1/10/24, indicated Resident 1 would always feel lonely or isolated from those around him. A review of Resident 1's MDS Functional Abilities and Goals, dated 1/10/24, indicated Resident 1 required substantial/maximal assistance with oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/ taking off footwear, and personal hygiene. Resident 1 also required partial/moderate assistance with rolling left or right, toilet transfers, and tub/shower transfers. Resident 1 further required supervision or touching assistance with movement from sitting to lying or lying to sitting position, movement from sitting to standing position, and chair/bed-to-chair transfers. During a concurrent observation and interview on 3/28/24 at 2:05 p.m. with Resident 1, in Resident 1's room, Resident 1 was unable to locate his call light button and stated, I don't know where it [call light button] is. During a concurrent observation and interview on 3/28/24 at 2:21 p.m. with Certified Nurse Assistant (CNA) 1, in Resident 1's room, CNA 1 found Resident 1's call light button inside the top shelf of Resident 1's bedside drawer which was approximately 2 feet away from Resident 1's bed. CNA 1 and stated, .Normally, it [call light button] should be next to him [Resident 1] where he can reach it. When asked if the resident would be able to reach the call light button and use it if he would need help, CNA 1 stated, Probably no, especially if there's an emergency. During an interview on 3/28/24 at 3:18 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) regarding call lights was requested. The DON stated, We [facility] don't have [a] policy for call light .That's [call light use] a regulation, so we [facility] don't need a policy for it [call light use]. 1b. A review of Resident 6's clinical record indicated Resident 6 was admitted November of 2023 and had diagnoses that included atherosclerosis of native arteries (hardening of arteries from plaque building up gradually causing slowed or blocked blood flow), and dementia. A review of Resident 6's MDS Cognitive Patterns, dated 2/29/24, indicated Resident 6 had a BIMS score of 3 out of 15 which indicated Resident 6 had a severely impaired cognition. A review of Resident 1's MDS Mood Status, dated 2/29/24, indicated Resident 1 would sometimes feel lonely or isolated from those around her. A review of Resident 6's MDS Functional Abilities and Goals, dated 2/29/24, indicated Resident 6 was dependent with toileting hygiene, and shower/bathing. Resident 6 also required substantial/maximal assistance with lower body dressing and putting on/ taking off footwear. Resident 6 further required partial/moderate assistance with oral hygiene, upper body dressing, personal hygiene, rolling left or right, movement from sitting to lying or lying to sitting position, movement from sitting to standing position, doing chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. During a concurrent observation 3/28/24 at 3:34 p.m. in Resident 1's room, Resident 6 was observed being assisted with care and being fixed in bed after returning in the facility by CNA 2. During a concurrent observation and interview on 3/28/24 at 3:41 p.m. with Resident 6, in Resident 6's room, Resident 6 stated she did not know where her call light button was located. Resident 6's call light button was then found on the bottom of her bed, touching the floor. During a concurrent observation and interview on 3/28/24 at 3:46 p.m. with CNA 4, in Resident 6's room, CNA 4 confirmed that Resident 6's call light button was on the bottom of Resident 6's bed, touching the floor. CNA 4 stated, The call light [button] should be next to her [Resident 6] so she [Resident 6] can call for help when she needs to .She [Resident 6] won ' t be able to reach it [call light button] if it's on the floor . During an interview on 3/28/24 at 3:51 p.m. with the Unit Manger (UM), the UM stated, .the call light [button] should be [placed] where they [residents] can reach it [call light button] .It [placing call light button within resident's reach] is our protocol .So they [residents] can use the call light [button] whenever they [residents] need help, and especially if there's an emergency. A review of the facility's P&P titled, RESIDENT RIGHTS, revised 03/2017, indicated, Safe Environment .[residents] have the right to a safe .and homelike environment. A review of the Centers for Medicare & Medicaid Services document titled, .Physical Environment, undated, indicated, The call system [call light] must be accessible to residents while in their bed or other sleeping accommodations within the resident ' s room. (https://qsep.cms.gov/data/352/PhysicalEnvironment.pdf)

Based on observation, interview and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of 19 sampled residents (Resident 573) when nursing staff administered the wrong narcotic (pain) medication to Resident 573. This failure had the potential for worsening their clinical condition. Findings: During a concurrent observation, interview and record review on 1/23/24 at 10:48 a.m. with the Director of Nursing (DON) at the Natoma nursing station, the First Dose Narcotic Emergency box (E-kit) was observed with a white plastic tie indicating it had been opened by nursing staff. Inside the narcotic medication E-kit were three E-kit logs (a document completed by nursing staff whenever a medication is removed from the emergency supply). The latest entry into the kit was documented on 1/16/24, for one tablet of Oxycodone (a narcotic pain medication to treat moderate to severe pain) 5 mg (milligram, a unit of measurement), one tablet as needed for pain, for Resident 573. A review of the E-kit inventory list from pharmacy indicated there were eight tablets of Oxycodone IR (immediate release) 5 mg stocked and there were currently eight tablets of Oxycodone IR in the E-kit. The DON confirmed there were still eight tablets of Oxycodone IR in the E-kit. A medication reconciliation of the E-kit was done with the DON, which revealed one missing Oxycodone/APAP (acetaminophen) 5/325 mg tablet. The DON verified there should be eight tablets of Oxycodone/APAP 5/325 mg but there were only seven tablets in the E-kit. The DON stated, I'm sure [the nurse] gave the tablet that has the Tylenol [acetaminophen] instead of the Oxycodone IR. The nurse should have done the five medication rights [the right: patient, drug, time, dose and correct route] and done it more than once. The DON verified Resident 573's Physician Orders, dated 1/2024, indicated an order with a start date of 1/15/24 for Oxycodone 5 mg, one tablet, by mouth every four hours as needed for moderate to severe pain. The DON acknowledged, The doctor ordered the Oxycodone IR 5 mg, not the Oxycodone with Tylenol [acetaminophen]. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated March 2018, the P&P stipulated, Medications are administered as prescribed with good nursing principles and practices .Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .Prior to administration, the medication and dosage .on the resident's medication administration record (MAR) is compared with the label.

Based on observation, interview and record review, the facility's consultant pharmacist (CP) failed to identify drug-related issues for one of 19 sampled residents (Resident 57), when the CP failed to identify the lack of target behavior monitoring and inadequate indication for use of antipsychotic medications. These failures had the potential for unsafe medication use. Findings: A review of Resident 57's medical record (MR) indicated Resident 57 was admitted to the facility in March 2022 with diagnoses including dementia (a condition characterized by memory loss) with psychotic disturbance, psychotic disorder with delusions (a mental disorder characterized by a disconnection from reality) and mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function). A review of Resident 57's MR indicated the following physician's orders: - Divalproex (a mood stabilizer used to treat certain psychiatric conditions) DR (delayed release) 125 milligrams (mg, a unit of measurement), take 1 tablet twice a day for mood disorder manifested by mood swings and verbal outbursts, ordered 10/3/23 - Quetiapine (antipsychotic medication that treats several kinds of mental health conditions) 25 mg, take ½ tab (12.5 mg) twice daily for psychotic disorder manifested by refusing needed care, ordered 10/4/23 During a concurrent interview and record review on 1/24/24 at 3:58 p.m. with Licensed Nurse 1 (LN 1), Resident 57's physician's orders were reviewed. When asked if the indication for Resident 57's divalproex was appropriate she stated, I don't see anything regarding verbal outbursts. I'm not sure what [divalproex sodium] is used for off the top of my head. When asked if the indication for Resident 57's quetiapine was appropriate she stated, I don't know if I would describe [refusing care] as a psychotic disorder, I'm not sure. LN 1 confirmed there was no target behavior monitoring related to the use of divalproex and quetiapine for Resident 57. During a concurrent interview and record review on 1/24/24 at 4:20 p.m. with the Director of Nursing (DON), Resident 57's MR was reviewed. The DON confirmed there was no target behavior monitoring for quetiapine. During a concurrent interview and record review on 1/25/24 at 3:17 p.m. with CP, Resident 57's MR was reviewed. When asked if mood swings and verbal outbursts were appropriate indications for the use of divalproex CP stated, It can be an indication for use, but there isn't any documentation of the mood swings or angry outbursts in his chart. A lot of these target behaviors are hard to quantify. When asked if refusing care is an appropriate indication for the use of quetiapine the CP stated, That's not my favorite indication, I admit that. Nursing staff likes to use that because it's easy to track. I can recommend some more target behaviors. The CP confirmed there was no monitoring for target behaviors related to the use of quetiapine for Resident 57. When asked if he provided a recommendation for monitoring a target behavior for quetiapine he stated, No, usually I'll make recommendations to add the monitoring if I don't see that monitoring there. I must have missed this one. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review (Monthly Report), dated March 2018, the P&P indicated, The consultant pharmacist identifies irregularities through a variety of sources including: Medication Administration Records (MARs) . progress notes of prescriber, nurses and/or consultants . behavior monitoring information . and from interviewing, assessing, and/or observing the resident. The consultant pharmacist's evaluation includes . documented objective findings support each medication order . indication for use and therapeutic goals are consistent with . clinical practice guidelines . Response to drug therapy are evaluated to assure the appropriateness of the medication regimen.

Based on observation, interview and record review the facility failed to ensure one of 19 sampled residents (Resident 57) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 57 received psychotropic medications without adequate indication for use and was not being appropriately monitored. This failure resulted in unnecessary medications for the resident, which had the potential for increased risks and exposure of side effects associated with psychotropic medications such as sedation, falls, abnormal involuntary movements, and memory loss. Findings: A review of Resident 57's medical record (MR) indicated Resident 57 was admitted to the facility in March 2022 with diagnoses including dementia (a condition characterized by memory loss) with psychotic disturbance (a mental disorder characterized by a disconnection from reality), and psychotic disorder with delusions and mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function). During a review of Resident 57's MR indicated the following orders: - Ordered on 10/3/23 divalproex sodium (a mood stabilizer used to treat certain psychiatric conditions) DR (delayed release) 125 milligram (mg, a unit of measurement) tab, take ½ tab (12.5 mg) oral twice a day for mood disorder manifested by mood swings, verbal outburst. - Ordered on 10/4/23 quetiapine fumarate (an antipsychotic medication that treats several kinds of mental health conditions) 25 mg tab, take ½ tab (12.5 mg) oral twice daily for psychotic disorder manifested by refusing needed care. A review of Section E (Behavior) of the Minimum Data Set (MDS, an assessment tool), undated, indicated Resident 57 did not exhibit behavioral disturbances; including delusions, verbal behavioral symptoms directed at others, or rejection of care. During an observation on 1/24/24 at 2:15 p.m. in Resident 57's room, Resident 57 was observed lying in bed, under the covers, facing the wall in no apparent distress. During an interview on 1/24/24 at 2:17 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 described Resident 57, He's energetic and empathetic, talks to other residents and engages in conversations. He's helpful during care, he hasn't had outbursts; one time he was frustrated because he couldn't use the bathroom, but he couldn't verbalize it. CNA 1 denied Resident 57 had episodes of psychosis or refusing care. During an interview on 1/24/24 at 2:23 p.m. with Licensed Nurse (LN) 2, LN 2 described Resident 57, He's super relaxed .cooperative, able to communicate his needs .if he doesn't want to do something, then he won't do it and he'll verbalize it. He might initially refuse medications, but if you give him some time and come back, he will take his medications. LN 2 denied Resident 57 had episodes of psychosis and stated, He doesn't lose touch with reality when angry. During a concurrent interview and record review on 1/24/24 at 3:58 p.m. with LN 2, Resident 57's MR was reviewed. LN 2 confirmed there was no monitoring for divalproex sodium or quetiapine fumarate target behaviors. LN 2 confirmed there were no progress notes indicating Resident 57 was experiencing delusions, verbal outbursts or refusing care prior to receiving psychotropic medications. During an observation on 1/24/24 at 4:15 p.m. Resident 57 was observed in his room lying in bed, on his back, under the covers with his eyes closed in no apparent distress. During a concurrent interview and record review on 1/24/24 at 4:20 p.m. with the Director of Nursing (DON), the DON confirmed there were no progress notes indicating Resident 57 was experiencing delusions, verbal outbursts, or refusal of care. The DON verified there were no orders for monitoring the target behaviors related to divalproex sodium or quetiapine fumarate. When asked if there were any non-pharmacological (non-drug) interventions attempted before initiating these psychotropic medications the DON stated, No, I don't see any notes. During a concurrent observation and interview on 1/25/24 at 9:06 a.m. in Resident 57's room, Resident 57 was sitting up in his wheelchair by the side of the bed, appropriately groomed, with his tray table in front of him. Resident 57 engaged appropriately in conversation and stated he enjoys playing bingo with other residents. During a concurrent interview and record review on 1/25/24 at 10:25 a.m., Resident 57's medical record was reviewed with the facility's Consultant Pharmacist (CP). The CP stated he reviews a resident's medical record when reviewing the use of psychotropic medications. The CP stated, There would normally be a progress note documenting what they [physicians and nursing staff] are seeing and why the physician wants to use that specific medication and if they [nursing staff] are tracking that behavior. The CP confirmed there was no documentation of Resident 57's mood swings, angry outbursts or refusal of care and there were no orders for monitoring the target behaviors related to the use of divalproex sodium or quetiapine fumarate. During a concurrent interview and record review on 1/25/24 at 11:08 a.m. Resident 57's MDS, Section E, dated 9/28/23, was reviewed with the DON. The DON confirmed Resident 57 did not exhibit behavioral disturbances; including delusions, verbal behavioral symptoms directed at others, or rejection of care. During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Medication Use, dated September 2012, the P&P indicated, Psychotherapeutic medications are only considered for use after alternative methods have been tried unsuccessfully .Residents on psychotherapeutic medications will be monitored for appropriate use, effectiveness .Routinely, the licensed nurse will evaluate the resident for overall effectiveness of the psychotherapeutic medication and record side effects noted. The Interdisciplinary Team will review the report and recommendations will be documented in the resident's health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 31) was free of a significant medication errors when Resident 31's budesonide/formoterol inhaler (a medication to treat asthma, swelling of the airways making it difficult to breathe) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) was continuously given after it had expired. This deficient practice resulted in Resident 31 receiving expired medication and had the potential for worsening Resident 31's medical conditions. Findings: A review Resident 31's medical record indicated she was admitted to the facility in 11/2023 with diagnoses that included COPD and asthma. A review of Resident 31's medical record indicated a physician's order, dated [DATE], for budesonide/formoterol 80/4.5 microgram (mcg, a unit of measurement) inhaler, administer 2 puffs twice daily for COPD. During a concurrent observation and interview on [DATE] at 2:07 p.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed Resident 31's budesonide/formoterol inhaler had been expired since [DATE]. LN 1 verified Resident 31 has been continuously receiving the inhaler past its expiration date. LN 1 agreed residents should not be administered an expired medication and stated, The [expired] medication will lose its efficacy. I usually check the expiration dates, but I missed this one. During a concurrent interview and record review on [DATE] at 10:48 a.m. with LN 1 and LN 3, Resident 31's Medication Administration Records (MAR) dated [DATE] through [DATE] were reviewed. LN 1 and LN 3 confirmed Resident 31 had received the expired budesonide/formoterol inhaler 25 times in [DATE] times in [DATE] and 38 times in [DATE]. During an interview on [DATE] at 11:52 p.m. with the Director of Nursing (DON), when questioned why the nursing staff would continuously administer an expired medication the DON stated, I don't know what is going on. If the nurse was actually giving it [the medication], it would have already been gone. The nurse should inform the doctor that the resident has been receiving an expired medication. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated [DATE], the P&P indicated, Outdated . medications . are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer and administer pneumococcal vaccine (immunization against pneumonia [an inflammatory condition of the lung]) to one of five sampled residents (Resident 27). This failure placed Resident 27 at an increased risk for illness that the vaccine could have prevented or decreased the severity of symptoms. Findings: A review of Resident 27's Face Sheet indicated Resident 27 was admitted to the facility in Fall of 2019. During a concurrent interview and record review on 1/26/23 at 1:39 p.m. with the Infection Preventionist (IP), Resident 27's vaccination records were reviewed and indicated Resident 27 received a Pneumococcal Polysaccharide Vaccine (PPSV23) on 8/22/15, (before turning [AGE] years old) and a Pneumococcal 13-valent Conjugate Vaccine (PCV 13) on 10/18/19, (after turning [AGE] years old). The IP confirmed Resident 27's records and acknowledged Resident 27 needed to be reassessed for vaccine eligibility based on age and CDC (Centers for Disease Control, the national public health agency) guidelines. The IP also confirmed there was no documented evidence that indicated the vaccine was offered. A review of CDC guidelines for Pneumococcal vaccinations titled, Pneumococcal Vaccine Timing for Adults, published on 3/15/23, indicated for adults who received the PCV 13 at any age and the PPSV23 prior to turning [AGE] years old, the Pneumococcal 20-valent Conjugate Vaccine (PCV20) or PPSV23 should be administered in at least 5 years from the last administration of the PPSV23 or in at least one year after administration of PCV13. A review of Resident 27's vaccination records and the CDC guidelines indicated Resident 27 qualified to receive either the PPSV23 or the PCV20 starting as of 10/18/20. In an interview on 1/26/24 at 1:54 p.m. the Director of Nursing (DON) stated he expected vaccinations to be offered per the CDC guidelines. The DON also stated if consents or declination responses were not received from the resident representatives, he expected facility staff to follow up within 30 days. A review of the facility's policy titled, Pneumococcal Vaccine, effective date 12/22/16, indicated, It is the policy of [facility's name] to provide pneumococcal vaccine to residents in accordance with CDC recommendations and physicians orders .

Based on observation, interview, and record review, the facility failed to: 1. Ensure emergency medications (E-kit) were replaced timely for a census of 77 residents; and 2. Dispose of medications in accordance with facility policy and procedure. These failures had the potential for emergency medications to be unavailable when needed, the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions, and the potential for diversion of medications. Findings: 1. During a concurrent observation and interview on 1/23/24 at 10:38 a.m. in the Mill station medication storage room with the Director of Nursing (DON), the First Dose Oral Medications E-kit was observed with a white plastic tie indicating it had been opened by nursing staff. Inside the oral medication E-kit were two E-kit logs (a document completed by nursing staff whenever a medication is removed from the emergency supply), with the earliest entry into the kit documented on 1/13/24. The DON confirmed the E-kit had been opened and stated, E-kits need to be replaced 72 hours after opening. During a concurrent observation and interview on 1/23/24 at 10:48 a.m. of the Natoma station medication cart with the DON, the First Dose Narcotic E-Kit was observed with a white tag indicating the E-kit had been opened by nursing staff. Inside the narcotic E-kit were logs indicating medications were removed on three separate occasions: twice on 1/12/24 and once on 1/16/24. The DON confirmed the E-kit had been opened and E-kits need to be replaced 72 hours after opening. During a review of the facility's policy and procedure (P&P) titled, Emergency Pharmacy Service and Emergency Kits, dated March 2018, the P&P indicated, .Opened kits are replaced with sealed kits within 72 hours of opening. 2. During an observation and interview on 1/23/24 at 9:50 a.m. in the Central Supply medication room with the DON, the DON stated each medication cart had a drug destruction container with a red lid. The DON stated whenever medications were dropped or refused by a resident, nursing staff were expected to immediately place it in the drug destruction container. During a concurrent observation and interview on 1/23/24 at 1:55 p.m. of the Sutter station medication cart with Licensed Nurse (LN) 2, a small paper cup with 12 unidentified pills was observed in the top drawer of the medication cart. LN 2 stated the medications were doses that were refused by residents and she had placed them in the cup to save herself time from having to go back and forth to the drug disposal container. During an interview on 1/24/24 at 11:39 a.m. with the DON, when asked how medications are disposed of the DON stated, [The LN] Shouldn't be doing that [placing the medications in a paper cup], those should go directly into the drug buster, that's what they're for. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated March 2018, the P&P indicated, .Once removed from the packaging . the refused medications are destroyed at the medication cart per facility procedures.

Based on observation, interview, and record review, the facility failed to ensure: 1. Medication refrigerator temperatures were monitored twice daily; 2. An opened multi-dose biological was dated with an open and discard date to ensure it was not used beyond the discard date; 3. Single resident over-the-counter (OTC) products and prescription medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and 4. Expired medications were available for resident use. The deficient practices had the potential for residents to receive unsafe or ineffective medications or biologicals from inadequate temperature monitoring and storage, medications with unsafe and reduced potency from being used past their discard date, and incorrect medications from inadequate labeling. Findings: 1. During a concurrent observation, interview and record review on 1/23/24 at 10:10 a.m., in the Sutter nursing station medication room, with the Director of Nursing (DON), the Medication Refrigerator Daily Temperature Records dated 11/1/23 through 1/23/24 were reviewed. The DON confirmed the logs were incomplete and nursing staff did not monitor and record the temperature on 21 shifts between the reviewed dates and stated, Temperatures are taken twice a day, on each shift. During a concurrent observation and interview on 1/23/24 at 11:09 a.m., in the Natoma nursing station medication room with the DON, the Medication Refrigerator Daily Temperature Records from 11/1/23 through 1/23/24 were reviewed. The DON confirmed nursing staff did not monitor and record temperatures on 41 shifts between the review dates and reiterated temperatures are to be taken twice a day. A review of the facility's Medication Refrigerator Daily Temperature Records indicated, Refrigerator temperature to be monitored and documented on every shift to maintain a desired refrigerator temperature . 2. During a concurrent observation and interview on 1/23/24 at 11:09 a.m. in the Natoma station medication room, with the DON, an opened multi-dose vial of tuberculin (a combination of proteins that are used in the diagnosis of tuberculosis) was observed without an open date. The DON confirmed the vial did not have an open date and stated the vial needed to be discarded 30 days once opened. A review of the manufacturer's packaging for tuberculin indicated, Short exp. [expiration] date, discard 30 days after opening. A review of the facility's policy and procedure (P&P), titled, Medication Labels, the P&P stipulated, Each prescription medication label includes .expiration date of the medication . 3. During a concurrent observation and interview on 1/23/24 at 1:28 p.m. at the Sutter station medication cart, with Licensed Nurse (LN) 2, LN 2 confirmed there were: - Four OTC eye drops (artificial tears) that did not have a pharmacy label or resident specific identification on the individual containers; - One OTC eye ointment (lacrilube) that did not have a pharmacy label or resident specific identification on the container; and, - Two prescription inhalers placed in the incorrect containers without pharmacy labels or resident specific identification on the individual inhalers. LN 2 confirmed the OTC and prescription medications did not have resident specific information or opened dates on the medication containers. She stated the medication should have at least the resident's name and opened date. LN 2 stated, If it's [resident's medication] not labeled with the resident's name it could be given to another resident and that would cause an issue. During a review of the facility's P&P titled, Medication Labels, the P&P stipulated, If a label does not fit directly onto the product, e.g., eye drops, .the resident's name, at least, must be maintained directly on the actual product container .Each prescription medication label includes .Resident's name .expiration date of medication . 4. During a concurrent observation and interview on 1/23/24 at 1:28 p.m. at the Sutter station medication cart, with LN 2, LN 2 confirmed the following: - One lacrilube eye ointment had an expiration date of 1/19/24; and, - Two inhalers (Serevent 50 mcg [microgram, a unit of measurement] Diskus and Fluticasone Propionate/Salmeterol Diskus 500/50 mcg inhaler) were placed in the incorrect box. The open dates were illegible and there was no resident specific identification on the inhalers. LN 2 confirmed the open dates on the inhalers were illegible stating, I can't read that, it's too hard to read. LN 2 stated, The opened date needs to be written on the inhalers because you're supposed to use it within 30 days of opening them. During a concurrent observation and interview on 1/23/24 at 2:07 p.m. at the Mill station medication cart, with LN 1, LN 1 confirmed the following: - Two Spiriva Respimat inhalers did not have resident specific labels or opened dates; - Resident 31's Budesonide/Formoterol Fumarate Dihydrate inhaler did not have a resident specific label on the container and expired on 11/26/23; - One bottle of restful legs homeopathic tablets expired on 12/2023; and, - One Fluticasone Propionate/Salmeterol Diskus inhaler did not have a resident specific label or an open date. LN 1 confirmed the medications needed an open date because some medications need to be discarded after 30 days and agreed the medications needed to be labeled with resident specific labels for identification purposes. LN 1 confirmed Resident 31's medication had expired on 11/26/23 and the resident had continued to receive the expired medication. LN 1 stated residents should not be receiving expired medications since the medication will lose its efficacy. During a review of the facility's P&P titled, Medication Storage in the Facility, the P&P stipulates, Outdated .medications .are immediately removed from stock, disposed of .and reordered from the pharmacy .

Based on observation, interview, and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when Dietary Aide (DA) 1 and DA 2 were unable to demonstrate and verbalize the procedure for verifying sanitizer strength for contact surfaces to ensure effective sanitation. This failure had a potential to result in ineffective sanitation and cause food borne illness in a high-risk population of 75 out of 75 residents who consumed food from the kitchen. Findings: During an initial kitchen tour observation and concurrent interview on 1/23/24, at 9:47 a.m., Dietary Aide (DA) 1 was sanitizing resident meal carts using a solution from a red bucket (the bucket is used as a standard of practice to contain sanitizer solution). The surveyor asked DA 1 to verbalize the procedure for testing the concentration of the sanitizer using the test strip. She stated she would dip the test strip in the sanitizer for one minute and the concentration should be at 150-200 ppm (parts per million-a unit to measure concentration). DA 1 demonstrated the procedure. She dipped the test strip dipped in the sanitizer for 16 seconds and the result was 150 ppm. A concurrent review of the test strip instruction on the test strip box with DA 1, it stated the test strip should immerse in the sanitizer for 10 seconds. During a follow up observation and concurrent interview with DA 2 on 1/24/23, at 9:01 a.m., DA 2 was sanitizing patient meal carts using the sanitizer solution in the red bucket. DA 2 demonstrated testing the sanitizer concentration in the red bucket by dipping the test strip in the solution for 12 seconds. She stated the sanitizer concentration should be at 100 ppm. The test strip indicated the strength of the solution was 150 ppm. DA 2 changed her answer and stated the concentration should be at 150 ppm. During a follow up interview with the RD on 1/25/24, at 12:23 p.m., the RD stated the kitchen staff should have the knowledge to properly test and prepare the sanitizer solution with the correct concentration. A review of departmental policy and procedure, titled Quaternary Ammonium Log Policy, dated 2018, it read, .the concentration will be tested at least every shift or when the solution is cloudy .the solution will be replaced when the reading is below 200 ppm . During a review of employee files of DA 1 and DA 2 on 1/24/24, at 4:01 p.m., it indicated DA 1 had a date of hire (DOH) of 10/20/97, and DA 2 had a DOH of 9/25/23. Neither DA 1 or DA 2 had current performance evaluations. A review of undated department document, titled Job Description: Diet Aide 1, it indicated, .Job Duties .Responsible to keep carts clean and sanitized .to maintain proper food handling practices .maintaining proper sanitation and safety standards .proper chemical use . An interview and concurrent review with the Nutrition Supervisor (NS) on 1/25/24, at 8:42 a.m. was conducted. A review of departmental documents, completed by the NS, titled Verification of Job Competency Demonstration, for DA 1 (completed on 7/20/20) and DA 2 (completed on 10/27/23), indicated DA 1 and DA 2 demonstrated competency in the preparation, testing and recording of sanitizer solution concentration results. The NS confirmed the most recent competency for DA 1 was done on 7/20/20. She stated she did not perform staff competency checks yearly. A review of department document, titled Personal Management, dated 2018, indicated, .Responsibilities of FNS (Food and Nutrition Services) Director .food & Nutrition service .supervision, staff training and in-servicing .All Food & Nutrition Service employees shall receive a competency check and a written review by the FNS Director on an annual basis . A review of department in-service document, titled Chemical Sanitizer, completed on 11/16/23, it indicated DA 1 and DA 2 attended the in-service. A review of departmental documents, completed by the RD, titled Sanitation and Food Safety Checklist, completed on 12/8/23, 11/10/23, and 10/2/23 indicated a satisfactory rating in the area of Sanitizing solution test kit present, used, recorded, is within desired range per direction.

Based on interview and record review, the facility failed to offer and provide updated COVID-19 (Coronavirus Disease, an infection affecting the lungs) vaccinations to four out of five sampled residents (Resident 4, Resident 17, Resident 27, and Resident 43). This failure placed Resident 4, Resident 17, Resident 27, Resident 43 at an increased risk for illness that the vaccine could have prevented or decreased the severity of symptoms. Findings: A review of Resident 4's Face Sheet document indicated Resident 4 was admitted to the facility in summer of 2023. A review of Resident 4's vaccination record indicated Resident 4's latest COVID-19 vaccine was administered on 9/11/22. A review of Resident 17's Face Sheet document indicated Resident 17 was readmitted to the facility in winter of 2023. A review of Resident 17's vaccination record indicated Resident 17's latest COVID-19 vaccine was administered on 2/26/21. Vaccination record also indicated that resident was at the facility with initial admission from Summer of 2023 to December of 2023. A review of Resident 27's Face Sheet document indicated Resident 27 was admitted to the facility in Fall of 2019. A review of Resident 27's vaccination record indicated resident 27's latest COVID-19 vaccine was administered on 11/17/22. A review of Resident 43's Face Sheet document indicated Resident 43 was admitted to the facility in spring of 2021. A review of Resident 43's vaccination record indicated Resident 43's latest COVID-19 vaccine was administered on 11/17/22. During a concurrent interview and record review on 1/26/24 at 1:39 p.m. with the Infection Preventionist (IP), Resident 4's, Resident 17's, Resident 27's, Resident 43's vaccination records were reviewed. The IP confirmed all four residents did not have a current 2023-2024 COVID vaccine and the IP did not have documented evidence the vaccine was offered. The IP also provided and discussed COVID-19 test results which indicated Resident 17 tested COVID-19 positive on 11/29/23, and Resident 4 tested COVID-19 positive on 12/2/23. The IP added Resident 17 consented to the COVID-19 vaccination today and will be getting it shortly. The IP provided Resident 59's vaccination record and confirmed Resident 59 was current with the COVID-19 vaccination and received the vaccine at the facility. A review of Resident 59's (additional sample resident) Face Sheet document indicated Resident 59 was admitted to the facility early in 2020. A review of Resident 59's vaccination record indicated Resident 59's latest COVID-19 vaccine was administered at the facility on 11/10/23., which confirmed the availability of the newer COVID-19 vaccines in November of 2023 when Resident 4, Resident 17, Resident 27, Resident 43 were at the facility and before Resident 4 and Resident 17 tested positive for COVID-19. In an interview on 1/26/24 at 1:54 p.m. the Director of Nursing (DON) stated he expected vaccines to be offered per CDC guidelines. The DON also stated if consents or declination responses were not received from the resident representatives, he expected facility staff to follow up within 30 days. A review of CDC guidelines for COVID-19 vaccinations, titled Stay Up to Date with Vaccines, updated 1/18/24, indicated, People aged 12 years and older who got COVID-19 vaccines before September 12, 2023, should get 1 updated [listed 3 brand names of vaccines] COVID-19 vaccine. A review of the facility's policy titled, COVID Vaccine, effective date 1/26/24, indicated, The Covid-19 vaccine is, generally, offered to all residents on admission and when new vaccine is available.

Based on interview and record review, the facility failed to develop a water management plan to address potential Legionella contamination (a pathogenic microorganism that tends to colonize water systems and capable of causing pneumonia). This failure decreased facility's potential for early detection, prevention, and mitigation of Legionella-associated infections for a census of 77 residents. Findings During a concurrent interview and record review on 1/25/24 at 11:30 a.m. with the Infection Preventionist (IP), the facility's infection control policies and practices were reviewed. The IP stated she wasn't sure about water testing for Legionella and if the facility has a water management plan to address potential contamination. In a follow-up interview on 1/26/24 at 1:39 p.m., the IP stated, It [water management plan] doesn't exist. In an interview on 1/26/24 at 1:54 p.m. the Director of Nursing (DON) confirmed he expected the facility to have a water management plan addressing potential Legionella contamination. In an interview on 1/26/24 at 3:25 p.m. the Facility's Administrator (Admin) confirmed the facility did not have a water management plan to address the potential for a Legionella contamination, and the facility relied on the municipal water testing data. The Admin also confirmed there was no in-facility testing nor were related water management services completed. Facility's Policies and Procedures (P&P) addressing water management and Legionella control were requested but were not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure services met professional standards for one resident (Resident 1) of two sampled residents when: 1. The physician ordered sodium polystyrene sulfonate (SPS, a medication used to treat high levels of potassium) to treat Resident 1's high ammonia level; 2. The Licensed Nurse 1 (LN 1) obtained a telephone order from the physician and did not include the prescriber's name, the time the medication should be given, and the indication for the medication; and, 3. The LN 1 administered the medication without knowledge of what it was for. This failure decreased the facility's potential to administer medications safely to residents. Findings: 1. A review of a face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including a kidney cyst (a pouch of fluid on the kidney). A review of a Minimum Data Set (MDS, an assessment tool), dated 3/31/23, indicated Resident 1 had moderate memory problems. A review of Resident 1's clinical record indicated the following: · A lab result. dated 3/27/23, indicated a high ammonia level of 42 mcmol/L (micromoles per liter, a unit of measure); a normal range for ammonia was between 9- 35 mcmol/L. · A medication administration record (MAR), dated March 2023, indicated Resident 1 was administered the SPS on 3/28/23. · A lab result, dated 4/3/23, indicated a higher ammonia level of 58 mcmol/L. · An MAR dated April 2023 indicated Resident 1 was administered the SPS on 4/4/23 and 4/5/23. In an interview on 4/20/23 at 2:40 p.m., the Physician stated he mistakenly ordered the SPS for Resident 1. The Physician confirmed the SPS lowered potassium, not ammonia, and stated Resident 1 should not have been given it. 2. A review of Resident 1's written physician's order dated 3/28/23 at indicated, Give [SPS] 30 gm (gm: grams, a unit of measurement) PO [orally] +1 . The order did not indicate the time the medication was to be given, it did not clearly indicate the frequency it was to be given, nor did it indicate the reason the medication was to be given. A review of Resident 1's written physician's orders, dated 4/4/23 indicated, Give [SPS] 30 gm orally once a day for two days (2 doses). The order did not indicate it was received via the telephone, the name of the licensed staff who received the order, the physician's name, the time the medication was to be given, or the reason the medication was ordered. A review of Resident 1's MAR dated March 2023 and April 2023 did not indicate the reason the SPS was to be given. In an interview on 4/20/23 at 2:15 p.m., the LN 1 confirmed she received a telephone order from the Physician who ordered SPS 30 gm by mouth for two days. The LN 1 verified she had not clarified the order with the Physician. In an interview on 4/21/23 at 3 p.m., the Director of Nurses (DON) confirmed the LN 1 did not indicate the prescriber's name, the time the medication should be given, and the indication of the SPS on Resident 1's chart. The DON also stated it was expected of a licensed nurse to include the following information when an order is received over the telephone: the name of the drug, the indication for the drug, the frequency it should be given, the dose to be given, the prescriber's name, and the licensed nurse's name who received the order. 3. A review of Resident 1's clinical record indicated the following: · A lab result dated 3/27/23 indicated a normal potassium level of 4.1 mmol/L (millimoles per liter, a unit of measure); a normal range for potassium was between 3.6- 5.1 mmol/L. · A lab result dated 4/3/23 indicated a normal potassium level of 4 mmol/L. · A lab result, dated 4/6/23, indicated a low potassium level of 3.2 mmol/L. · A physician's order dated 4/7/23 for potassium chloride extended release meq (milliequivalent, a unit of measure) table; give one table oral once a day every day for three days. A review of the Food & Drug Administration's informational data on SPS, revised December 2010, indicated, [SPS] is indicated for the treatment of hyperkalemia [high potassium level] .Serious potassium deficiency can occur from therapy with [SPS] .Early clinical signs of severe hypokalemia include a pattern of irritable confusion and delayed though processes . In an interview on 4/20/23 at 2:15 p.m., LN 1 stated she presumed Resident 1's order for SPS was correct since it came directly from the physician. The LN 1 was unable to state the indication for SPS in Resident 1's case. In an interview on 4/21/23 at 3 p.m., the DON stated the nurse giving a medication must know the indication for giving it so if the order has an error, it could be clarified with the prescriber. A review of the facility's policy titled Medication Orders, dated March 2018, indicated, Any dose or order that appears inappropriate considering the resident's .condition .or diagnosis is verified with the attending physician .Each medication is documented in the resident's medical record with the date and signature of the person receiving the order .is recorded on the physician's order sheet or the telephone order sheet if it is a verbal order, and on the MAR .All drug orders shall be written, dated .The name, quantity or specific duration of therapy, dosage and time or frequency of administration of the drug, and the route of administration if other than oral shall be specific .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to prevent Resident 1 from eloping from the facility. This failure had the potential to result in serious injury or death for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage (blood between the brain and the outermost covering) without loss of consciousness. Resident 1's Quarterly MDS (Minimum Data Set-an assessment tool), dated 10/28/22 documented Resident 1 as having clear speech, usually able to understand others and usually able to make self-understood and his Brief Interview for Mental Status (BIMS) summary score as a 1 (severe impairment). The MDS described Resident 1 as no having delirium or behavioral symptoms. MDS also described Resident 1 as needing extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toilet use and personal hygiene. Review of Resident 1's Elopement Risk Tool, dated 8/26/22, indicated resident as not being an elopement risk. Review of a progress note, dated 10/20/22 at 8:42 a.m. indicated on 10/19/22 Resident attempting to get out of bed unassisted. Resident 1 assisted in his wheelchair and place at the nurses station. No agitation. No restlessness. Resident calm. (sic) 2210 (10:10 p.m.) @2230 (11:30 p.m.), resident no longer sitting at nurses station in his wheelchair. Complete facility searched and outside surrounding area by staff. Unable to locate resident. Police notified. Staff continues to search for resident on foot and by car .@2335, Police notified staff that resident has been located sitting on the ground across the street. Resident assessed by fire paramedics and released to facility. In an interview with the Director of Nurses, (DON) on 10/28/22 at 10:39 a.m., he stated Resident 1 was sitting in his wheelchair in front of the nurse's station. Around 10:30 p.m. Resident 1 was no longer sitting at the station. Staff searched for the resident and around 11:30 p.m. local police department found Resident 1 sitting on the ground directly across from the facility. Resident 1 stated he had fallen and was assessed with no injuries and brought back to the facility. Review of the facility's policy Elopement effective date 9/12 indicated, To protect residents from injury who wander and/or attempt to elope from the facility.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for a census of 66 when: 1. A container of hardboiled eggs was unlabeled and undated; 2. A 5 lb (pounds, a unit of measurement) container of ready-made tuna salad was expired; 3. A bag of frozen dinner rolls was opened and undated; and, 4. Two containers of dried goods were stored past their expiration dates. These failures had the potential to cause/spread foodborne illnesses. Findings: 1. During a concurrent observation of the facility's refrigerators and interview with the cook, on 11/15/21 at 8:20 a.m., an unlabeled and undated container with approximately 12 hard-boiled eggs was in the refrigerator. The [NAME] (CK) stated she had opened the package of hard-boiled eggs that morning, had forgotten to label the container, and confirmed it should have been labeled. In an interview, on 11/15/21 at 12:18 p.m., the Food Services Supervisor (FSS) stated she expected all opened refrigerated foods were labeled with an open date. A review of the facility's policy titled, Labeling and Dating of Foods, dated 2020, stipulated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . 2. During a concurrent observation and interview, on 11/15/21 at 8:25 a.m., a 5 lb container of ready-made tuna salad opened on 10/27/21, with a use by date of 11/11/21 was in the refrigerator. The CK agreed it was expired and should have been discarded. In an interview, on 11/15/21 at 8:33 a.m., the FSS stated the ready-made tuna salad was safe for use until its expiration date. The FSS confirmed the tuna salad was expired and should have been discarded. A review of the facility's guideline titled, Refrigerated Storage Guide, dated 2019, indicated the maximum refrigeration time for the tuna salad was 3 days. 3. During a concurrent observation of the facility's freezers, and interview, on 11/15/21 at 8:38 a.m., an opened and unlabeled bag of approximately 30 frozen dinner rolls was in the freezer. The DM confirmed it was not labeled and dated, and stated it should have been. A review of the facility's policy titled, Procedure for Refrigerated Storage, dated 2018, stipulated, Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. 4. During a concurrent observation and interview, on 11/15/21 at 8:55 a.m., a container of approximately 3 lbs of dried black eyed peas with an open date of 1/16/19 was on a shelf in the dry storage area. A container of approximately a 1/2 lb of dried small white beans labeled with an open date of 9/13/20 was also on the shelf. The FSS stated opened dried beans were stored for 1 year. The DM confirmed the beans were past their storage date and should have been discarded. A review of the facility's guideline titled, Dry Goods Storage Guidelines, dated 2018, indicated opened dried beans were to be stored 1 year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop comprehensive person-centered care plans for two of seventeen sampled residents (Resident 47 and Resident 51) when there was no comprehensive person-centered care plan for: 1. Resident 47's dementia (brain disease or injury marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) diagnosis; and, 2. Resident 51's anxiety (a nervous disorder characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks, and interfere with daily living) diagnosis. These failures had the potential to result in Resident 47 and Resident 51 not receiving necessary care and services to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Findings: 1. Resident 47 was re-admitted to the facility in late 2020 with multiple diagnoses, which included dementia. Resident 47's Minimum Data Sheet (MDS - an assessment tool), dated 10/11/21, indicated a Brief Interview for Mental Status (BIMS -a cognitive assessment tool) score of 4/15 indicating a very severe cognitive impairment. The MDS also indicated Resident 47 was assessed with dementia. During a concurrent observation and interview on 11/15/21, at 9:44 a.m., Resident 47 was lying in bed, looked alert, with flat affect. When asked if she was doing okay, Resident 47 stated, Yes. Resident 47 was not able to provide a meaningful conversation further. A review of Resident 47's medical record indicated no documented evidence of a care plan for dementia. During a concurrent interview and record review, on 11/17/21, at 12 p.m., with Licensed Nurse (LN) 6, Resident 47's medical record indicated no documented evidence of a care plan for dementia. LN 6 stated, [I] couldn't find a specific care plan for dementia . During a concurrent interview and record review on 11/17/21, at 1:30 p.m., with LN 4, Resident 47's medical record indicated no documented evidence of a care plan for dementia. LN 4 stated, No care plan for dementia . During a concurrent interview and record review, on 11/17/21, at 2:30 p.m., the Director of Nursing (DON) confirmed no care plan for dementia was done, but was revised on 11/17/21 at 1:52 p.m. When asked regarding the care plan, the DON stated, LNs should have done the care plan . The DON acknowledged and confirmed it was a deficiency. 2. According to the Resident Face Sheet, Resident 51 was admitted in the Fall of 2021 with diagnoses including an anxiety disorder. A review of Resident 51's clinical record included the following documents: An MDS, dated [DATE], described the resident as having no memory impairment, scoring 15 out of 15 possible points on the BIMS. The MDS also indicated the resident had an anxiety disorder. A MAR (Medication Administration Record), dated 11/21, indicated the resident had an order, dated 11/2/21, for alprazolam (an antianxiety medication), 0.25 mg (milligram, a unit of measurement) tablet, 1 tablet every 8 hours as needed for anxiety M/B (manifested by) the inability to relax for 14 days. According to the MAR, the medication was administered 15 times during the month. The MAR also indicated nursing monitored the resident's number of episodes of anxiety, and Resident 51 had 21 episodes during the month. In an interview, on 11/18/21 at 9:43 a.m., LN 4 confirmed Resident 51's diagnosis of anxiety and stated if she was receiving medication for the anxiety, she should have had a care plan. LN 4 confirmed there was no care plan for the resident's anxiety. In an interview, on 11/18/21 at 11:02 a.m., the DON stated there should have been an anxiety care plan in place for the resident. During a review of facility's policy and procedure (P&P) titled, CARE PLANNING/INTERDISCIPLINARY TEAM CARE PLANNING CONFERENCE, dated September 2012, the P&P indicated, To assure that all residents care needs are identified .those needs are care planned with corresponding .objectives and . interventions .All residents will have a comprehensive care plan to meet their individual needs .

Based on observation, interview, and record review, the facility failed to accurately and safely provide or obtain pharmaceutical services when medications were obtained from the pharmacy without the proper expiration dates and expired medications were not removed and destroyed according to facility policy. These failures increased the potential for administration of expired medications to residents. Findings: During a concurrent inspection of Medication Storage Room A and interview with Licensed Nurse (LN) 1 and 5, on 11/15/21 at 11:55 a.m., an expired vial of insulin (medication used to treat high sugar level in blood) was available with an open date of 10/13/21 (vials must be discarded 28 days after being opened per product box), a used box of oral fluticasone and salmeterol inhalation powder (combination of two medications used to help with breathing) with an incorrect expiration date of 5/1/22 (discard 1 month after removal from foil patch [first use] per product box), a used bottle of atropine eye drop (medication used to relieve pain caused by swelling and inflammation of the eye or to treat drooling) was dispensed by the pharmacy on 3/26/21 with a short expiration date label indicating to discard 60 days after opening with no written open date on the label. LN 1 and 5 both confirmed the insulin vial was expired, the oral inhalation powder had the wrong expiration date on the label, and the eye drops did not have an open date label and were possibly expired. During a phone interview with the facility's Consultant Pharmacist (CP) on 11/16/21 at 11:04 a.m., the CP stated the pharmacy should supply the correct expiration dates for eye drops, oral inhalers, and insulin products and the facility nurses should follow the facility's pharmacy policies. During an interview with Director of Nursing (DON) on 11/16/21 at 11:45 a.m. the DON acknowledged that expired medications had not been removed from the medication storage cart by licensed nursing staff in accordance with facility policy. The DON stated the staff needed more training and in-house services to know what expiration date to use for insulin, eyedrops, and oral inhalers. A review of the facility policy titled, Medication Administration, IIB-1 Specific Procedures for All Medications, effective date March 2018, indicated, .check expiration date on package/container. When opening a multi-dose container of a drug whose expiration date shortens on opening, place the date on the container. A review of facility policy titled, Section I: General Policies and Procedures, effective March 2018, indicated, .Outdated, contaminated or deteriorated medications .are immediately removed from the stock, disposed of according to procedures for medication disposal .The facility must label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and expiration date .drugs shall not be kept in stock after the expiration date on the label . A review of pharmacy policy titled, Dating of Containers When Opened, effective March 2018, indicated, Some medications require the container to be dated when opened and discarded a number of days after opening as defined by the manufacturer. In some instances the facility's pharmacy will put the expiration date of medications on the prescription label to correspond with the (new) expiration date as if the container was opened. This date will be based on the dispensing date of the medication and be XX day after dispensing .Eye Drops dispensed by the facility's pharmacy will automatically have the shortened expiration date put on the label on the eye drop container. There is no need to put a date opened on eye drops dispensed by the facility's pharmacy.

Based on observation, interview, and record review, the facility failed to implement their medication storage policies and procedures when: 1. The medication storage room's door was left opened and the medication refrigerator inside the medication storage room was unlocked. The controlled medications in the medication refrigerator were accessible to unauthorized individuals with the potential for drug diversion; and, 2. Expired medications were not removed and destroyed according to facility policy. These failures increased the potential for administration of expired medications to residents and access by unauthorized personnel to controlled medications. Findings: 1. During a concurrent observation and interview with Licensed Nurse (LN) 5 on 11/15/21 at 11:45 a.m., Medication Room A was observed unlocked with the door wide open. The medication refrigerator in Medication Room A was observed unlocked with four controlled medications (medications with potential for abuse and addiction) stored inside the refrigerator. During an interview with LN 5 on 11/15/21 at 11:55 a.m., LN 5 confirmed that the medication storage room and the medication refrigerator doors were not locked by one of the nurses after the morning medication pass. LN 5 also confirmed that controlled medications were stored in the medication refrigerator and accessible to others. During a phone interview with the facility's Consultant Pharmacist (CP) on 11/16/21 at 11:20 a.m., the CP stated the medication room and the medication refrigerator doors should be closed and locked. During an interview with the Director of Nursing (DON) on 11/16/21 at 11:40 a.m., the DON acknowledged that the doors should be closed and locked all the time. The DON also noted that the nurses did not see the sign on the refrigerator door that said .refrigerator door LOCKED at all TIMES . A review of the facility policy titled, Medication Storage in the Facility, effective date March 2018, indicated, .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access .Schedule II and V controlled medications are stored separately from other medications in a separate area under double lock. A review of facility policy titled, Section I: General Policies and Procedures, effective March 2018, indicated, .In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to keys. 2. During a concurrent inspection of Medication Storage Room A and interview with Licensed Nurse (LN) 1 and 5, on 11/15/21 at 11:55 a.m., an expired vial of insulin (medication used to treat high sugar level in blood) was available with an open date of 10/13/21 (vials must be discarded 28 days after being opened per product box), a used box of oral fluticasone and salmeterol inhalation powder (combination of two medications used to help with breathing) with an incorrect expiration date of 5/1/22 (discard 1 month after removal from foil patch [first use] per product box), a used bottle of atropine eye drop (medication used to relieve pain caused by swelling and inflammation of the eye or to treat drooling) was dispensed by the pharmacy on 3/26/2021 with a short expiration date label indicating to discard 60 days after opening with no written open date on the label. LN 1 and 5 both confirmed the insulin vial was expired, the oral inhalation powder had the wrong expiration date on the label, and the eye drops did not have an open date label and were possibly expired. During a phone interview with facility's Consultant Pharmacist (CP) on 11/16/21 at 11:04 a.m., the CP stated that the pharmacy should supply the correct expiration dates for eye drops, oral inhalers, and insulin products and the facility nurses should follow the facility's pharmacy policies. During an interview with Director of Nurses (DON) on 11/16/21 at 11:45 a.m. the DON acknowledged that expired medications had not been removed from the medication storage cart by licensed nursing staff in accordance with facility policy. The DON stated the staff needed more training and in-house services to know what expiration date to use for insulin, eyedrops, and oral inhalers. A review of the facility policy titled, Medication Administration, IIB-1 Specific Procedures for All Medications effective date March 2018, indicated, .check expiration date on package/container. When opening a multi-dose container of a drug whose expiration date shortens on opening, place the date on the container. A review of facility policy titled, Section I: General Policies and Procedures, effective March 2018, indicated, .Outdated, contaminated or deteriorated medications .are immediately removed from the stock, disposed of according to procedures for medication disposal .The facility must label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for two of seventeen sampled residents (Resident 47 and Resident 51) when: 1. Resident 47's medical record did not contain a physician order for hospice (palliative - end of life) services and a comprehensive person-centered care plan for dementia (brain disease or injury marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) diagnosis; and, 2. Resident 51's medical record did not contain a comprehensive person-centered care plan for anxiety (a nervous disorder characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks, and interfere with daily living) diagnosis. These failures decreased the potential for Resident 47 and Resident 51 receiving necessary care and services. Findings: 1. Resident 47 was re-admitted to the facility in late 2020 with multiple diagnoses, which included dementia and an encounter for palliative care. Resident 47's Minimum Data Sheet (MDS - an assessment tool), dated 10/11/21, indicated a Brief Interview for Mental Status (BIMS -a cognitive assessment tool) score of 4/15 indicating a very severe cognitive impairment. The MDS also indicated Resident 47 was assessed with dementia. During a concurrent observation and interview on 11/15/21, at 9:44 a.m., Resident 47 was lying in bed, looked alert, with flat affect. When asked if she's doing okay, Resident 47 stated, Yes. Resident 47 was not able to provide a meaningful conversation further. During a review of Resident 47's medical record, indicated no documented evidence of a physician order for hospice services and a care plan for dementia. During a concurrent interview and record review, on 11/17/21, at 12 p.m., with Licensed Nurse (LN) 6, Resident 47's medical record indicated no documented evidence of a care plan for dementia. LN 6 stated, [I] couldn't find a specific care plan for dementia [in resident's medical record]. During a concurrent interview and record review on 11/17/21, at 1:30 p.m., with LN 4, Resident 47's medical record indicated no documented evidence of a care plan for dementia. LN 4 stated, No care plan for dementia . During a concurrent interview and record review on 11/17/21, at 2:30 p.m., the Director of Nursing (DON) confirmed no care plan for dementia was done. During a concurrent interview and record review, on 11/17/21, at 5:09 p.m., with LN 5 and Medical Records Director (MRD), LN 5 and MRD acknowledged and confirmed Resident 47's medical record indicated no documented evidence of a physician order for hospice services. LN 5 and MRD stated, Yes, there is no physician order for [Resident 47]. The MRD and LN 5 acknowledged there should have been a facility physician order for hospice services in the medical record. 2. According to the Resident Face Sheet, Resident 51 was admitted in the Fall of 2021 with diagnoses including an anxiety disorder. A review of Resident 51's clinical record included the following documents: A MDS, dated [DATE], described the resident as having no memory impairment, scoring 15/15 points on the BIMS. The MDS also indicated the resident had an anxiety disorder. A MAR (Medication Administration Record), dated 11/21, indicated the resident had an order, dated 11/2/21, for alprazolam (an antianxiety medication), 0.25 mg (milligram, a unit of measurement) tablet, 1 tablet every 8 hours as needed for anxiety M/B (manifested by) the inability to relax for 14 days. In an interview, on 11/18/21 at 9:43 a.m., LN 4 confirmed Resident 51's diagnosis of anxiety and stated if she was receiving medication for the anxiety, she should have a care plan. LN 4 confirmed there was no care plan for the resident's anxiety. In an interview, on 11/18/21 at 11:02 a.m., the DON stated there should have been an anxiety care plan in place for the resident. During a review of a facility's document titled, HEALTH INFORMATION MANAGEMENT GUIDELINES, dated 2015, indicated, .Initiate, facilitate and promote the attainment of high quality content of clinical records in accordance with .appropriate regulations .Assure conformance to statutes, regulations and standards .as they apply to clinical record information .