Based on record review, interview, and facility policy review, the facility failed to ensure a psychotropic medication was addressed on the comprehensive care plan for 1 (Resident #5) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. An admission Record indicated the facility admitted Resident #5 on 11/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, anxiety disorder, and insomnia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses of anxiety disorder, depression, and insomnia. The MDS revealed the resident received an antidepressant medication during the assessment's seven-day lookback period. Resident #5's Order Summary Report, with active orders as of 03/19/2025, contained an order dated 11/11/2024 for duloxetine hydrochloride 30 milligrams (mg), with instructions to give two capsules by mouth one time a day related to anxiety disorder. The Order Summary Report also contained an order dated 02/19/2025 for trazodone hydrochloride 100 mg, with instructions to give one table by mouth at bedtime related to major depressive disorder. Resident #5's Care Plan Report included a problem statement revised on 11/22/2024, that indicated the resident used antidepressant medication (trazodone) related to insomnia. The Care Plan Report revealed a problem statement revised 11/22/2024, that indicated the used anti-anxiety medications (buspirone) related to anxiety disorder. Further review revealed the Care Plan Report did not address duloxetine hydrochloride. During an interview on 03/18/2025 at 12:21 PM, Licensed Vocational Nurse (LVN) #1 stated the floor nurses were responsible for the care plans. LVN #1 stated the nurses also updated and revised the care plans with any changes. LVN #1 stated Resident #5 received duloxetine for depression. LVN #1 reviewed Resident #5's care plan and stated, The duloxetine is not addressed on [Resident #5's] care plan. During an interview on 03/20/2025 at 8:16 AM, LVN #2 stated the care plans should match the physician orders. LVN #2 stated the care plans were there to let staff know how to implement the resident's care. During an interview on 03/20/2025 at 8:56 AM, LVN #3 stated if the nurse obtained a new medication order they would address the order on the care plan and put interventions on the care plan. LVN #3 stated the admission nurse was responsible for addressing the care plan. LVN #3 stated the nurse who admitted Resident #5 back from the hospital in November (2024) would have been responsible to ensure the medications were addressed on the care plan. LVN #3 stated she did not know why the duloxetine would not be on the care plan. LVN #3 stated the duloxetine was an antidepressant, so it was important that it was on the care plan for behaviors and monitoring. LVN #3 stated the duloxetine was not addressed on Resident #5's care plan. During an interview on 03/20/2025 at 10:34 AM, the Director of Nursing (DON) stated the admission nurse would initiate the baseline care plan and complete the nursing part. The DON stated the nurse would initiate the psychotropic medication nursing related care plan, then social services would complete the care plan specific to the medication and behaviors. The DON stated she expected the specific medication to be addressed on the care plan. The DON stated the duloxetine had been on the care plan previously and should have been on the care plan. During an interview on 03/20/2025 at 10:51 AM, the Director of Social Services (DSS) stated nursing was responsible for initiating the care plan, then the interdisciplinary team (IDT) team between nursing and social services was responsible for making sure the medication was on the care plan. During an interview on 03/20/2025 at 11:00 AM, the Administrator stated the IDT team was responsible for the comprehensive care plan. The Administrator stated she expected for the duloxetine to have been on the care plan for Resident #5. The Administrator stated the trazodone and duloxetine were the same classification but had different uses, so the duloxetine should have been on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses administered medications in accordance with professional standards of practice for one of three sampled residents (Resident 1), when Resident 1 received medications that were not prescribed for her on 8/20/24. This failure resulted in Resident 1 receiving medication not prescribed for her which had the potential to place Resident 1 at risk for adverse drug effects (an injury resulting from medical intervention related to a drug that includes medication errors). Findings: During a review of Resident 1's admission Record (AR) (document containing resident demographic information and medical diagnosis), dated 09/4/24, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included but are not limited to .TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (chronic condition that affects the way the body processes blood sugar) .HYPO-OSMOLALITY AND HYPONATREMIA (having low levels of electrolytes (including sodium), proteins and nutrients) . During a review of Resident 1's admission MDS assessment, dated 8/26/24, the admission MDS assessment indicated, Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation, and memory recall) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During a concurrent interview and record review on 9/4/24 at 4:00 p.m., with Licensed Vocational Nurse LVN) 1, Residents 1 ' s Medication Order Summary Report dated 9/4/24 was reviewed. LVN 1 stated Resident 1 ' s Physician orders did not include pantoprazole 40 mg 1 tablet, carvedilol 6.25mg 1 tablet, potassium phosphate 500 mg 0.5 tablet, amlodipine 5 mg 1 tablet, memantine 5 mg 1 tablet, pioglitazone 30 mg 1 tablet. LVN 1 stated she failed to verify the right patient prior to administering pantoprazole 40 mg 1 tablet , carvedilol 6.25mg 1 tablet, potassium phosphate 500 mg 0.5 tablet, amlodipine 5 mg 1 tablet, memantine 5 mg 1 tablet, pioglitazone 30 mg 1 tablet. LVN 1 stated she assumed it was the right person by the picture provided in the medication administration software. LVN 1 stated she did not follow doctor ' s directions for medication administration and did not follow facility policies. LVN 1 stated it is the responsibility of the nurse to provide medications per the physician order and verify the correct patient during medication administration. LVN 1 stated she was taught to verify the correct patient prior to medication dosage administration but she did not follow her training and provided the medication without confirmation. LVN 1 stated it is the expectation of all nursing staff to follow doctor ' s orders, and to ensure the correct resident is given the correct medication. LVN 1 stated giving a resident the wrong medication can put resident at risk for adverse reactions which can include but not limited to possible death. During a concurrent interview and record review on 9/4/24 at 5 p.m., with the Director of Nurses (DON), Resident 1 ' s Medication Order Summary report dated 9/4/24 was reviewed. DON validated the following medications were given to the resident in error: pantoprazole 40 mg 1 tablet , carvedilol 6.25mg 1 tablet, potassium phosphate 500 mg 0.5 tablet, amlodipine 5 mg 1 tablet, memantine 5 mg 1 tablet, pioglitazone 30 mg 1 tablet. DON stated it is the expectation of nursing staff to provide medications according to doctors ' orders and according to plan of care. The DON stated LVN 1 failed to provide the correct medications for Resident 1. The DON stated LVN 1 failed to follow the facility ' s Administration Medications policy and procedure. The DON stated when LVN 1 administered Resident 1 ' s medication she did not follow the five rights of medication administration the right patient, the right drug, the right time, the right dose, and the right route. A review of the facility policy and procedure, titled, Administering Medications, dated April 2019, indicated .Medications are administered in accordance with prescriber orders, including any required time frame .Medications errors are documented, reported and reviewed by the QAPI .if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose . During a review of a professional reference The Agency for Healthcare Research and Quality (AHRQ), retrieved from https://psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events titled To Prevent Adverse Medication Errors, dated 9/7/2019 indicated, .Adverse drugs events are one of the most common preventable adverse events in all settings of care .ensuring safety at each stage of the pathway, namely, prescribing, transcribing, dispensing, and administration, was required . During a review of a professional reference titled Lippincott Manual of Nursing Practice (11th ed.), dated 2018, indicated, Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician ' s orders that should have been questioned or not followed, such as orders containing medication dosage errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for two of two sampled residents (Resident 2 and Resident 26) when Resident 2 and Resident 26's urinary catheter (tube inserted into the bladder through the urethra, to drain freely into a connected bag) bags were not placed in a dignity bag (a bag the catheter drainage bag into to shield the resident's urine from view) and were visible from the hall outside the resident's room. This failure violated Resident 2 and Resident 26's need for urinary catheterization to remain private to ensure their dignity and respect. Findings: During a review of Resident 2's admission Record (AR), dated 03/27/24, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis which included Dementia (impaired thinking, remembering or reasoning), Type 2 Diabetes Mellitus (high levels of sugar in the blood), Anemia (lower than normal red blood cells), Neuromuscular Dysfunction (nerve and muscle weakness and pain), Hypertensive Heart Disease with Heart Failure (higher than normal blood pressure causing the heart not to function correctly), Dysphagia (swallowing difficulties), Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms (a build up of prostatic tissue against the urethra making it difficult to urinate). During a review of Resident 2's Minimum Data Set (MDS), Section C Brief Interview for Mental Status (BIMS - assessment of cognitive status for memory and judgement [a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview) score dated 6/22/2023, indicated Resident 2's BIMS score was 4 which indicated Resident 2 was severely cognitively impaired. During a review of Resident 26's admission Record (AR), dated 01/25/2022, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis which included Multiple Sclerosis (long lasting disease of the central nervous system), Anemia, Major Depressive Disorder ( affects how you feel, think and behave and can lead to a variety of emotional and physical problems), Muscle Weakness, Neuromuscular Dysfunction of Bladder, Urinary Tract Infection. During a review of Resident 26's MDS Section C dated 02/07/24, indicated the BIMS score was 9 which indicated Resident 26 was moderately cognitively impaired. During the initial tour of the facility on 03/25/24 at 9:56 a.m., in Resident 2's room, Resident 2's urinary catheter drainage bag was observed to be on the floor next to the left side of Resident 26's bed without a dignity bag (a bag the catheter drainage bag is placed into to shield the resident's urine from view). The catheter bag was visible from the hall outside of the room and in view of visitors, staff, and other residents. During the initial tour of the facility on 03/25/24 at 9:57 a.m., in Resident 26's room, Resident 26's urinary catheter drainage bag was observed attached to the left side of his wheelchair without a dignity bag. The catheter bag was visible from the hall outside of the resident's room and in view of visitors, staff, and other residents. During a concurrent interview and record review on 03/25/24 at 04:22 p.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 verified Resident 2 and 26's catheters were not in dignity bags. LVN 8 stated, it is the facility's policy that all catheter bags are to be placed in dignity bags. During a concurrent interview and record review on 03/27/24 at 11:12 a.m. with the Infection Preventionist (IP), IP Verified Resident 2 and 26's catheter was not in dignity bags. The IP stated, the urine catheter bags should always be in a dignity bag to protect the resident's dignity. IP stated, the facility's expectation of urinary catheter care is to follow the facility policy on urinary catheter care. During a concurrent interview and Record Review on 3/27/24 at 04:21 p.m. with the Director of Staff Development (DSD), the DSD verified Resident 2 and 26 catheters were not in dignity bags. The DSD stated the expectation of staff is to always place catheter bags into a dignity coverage bag to protect the dignity of the residents. During a concurrent interview and record review on 03/27/24 at 10:44 a.m. with the Director of Nursing (DON), the DON verified Resident 2 and 26's catheters were not in dignity bags. The DON stated, both catheter bags should have been placed in a dignity bag cover to respect the resident's dignity. During a review of the facility's Policy and Procedure (P&P), titled, Dignity dated 02/2021, the P&P indicated, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of wellbeing, at a level of satisfaction. With life, and feelings of self-worth and self-esteem .helping the resident to keep urinary catheter bags covered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 65) when Resident 65's functional limitation in range of motion was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 65's care needs not met. Findings: During a review of Resident 65's admission Record (document with resident demographic and medical diagnosis information), dated 3/28/24, indicated Resident 65 was admitted in the facility on 12/20/23, with diagnosis which included hemiplegia (severe or complete loss of strength and hemiparesis (mild loss of strength), muscle weakness and atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque [small, abnormal patch of tissue] in the inner lining of an artery). During a concurrent observation and interview on 3/25/24 at 10:53 a.m. with Resident 65 in room [ROOM NUMBER], Resident 65 was sitting in her wheelchair next to her bed. Resident 65 was observed with her left arm flexed and positioned on top of her lap. Resident 65 stated, . I had a stroke a few years ago and this is the result . Resident 65 stated she did not have the full mobility of her left arm like her right arm and needed help for everyday care. During an interview on 3/28/24, at 8:34 a.m. with Certified Nurse Assistant (CNA) 7, CNA 7 stated she was familiar with Resident 65's care. CNA 7 stated Resident 65 was weak on her left arm and needed assistance with her activities of daily living (ADL-skills required to care for self such as bathing, dressing, transfers, mobility and eating) care. During an interview on 3/28/24, at 8:47 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 65 has limited mobility on her left arm limiting her ability to be independent with her care. LVN 2 stated Resident 65 had always been weaker on one side since she was admitted to the facility. LVN 2 stated Resident 65 needed assistance with her ADL care. During a concurrent interview and record review on 3/28/24, at 11:43 a.m. with Minimum Data Set Registered Nurse (MDSRN), Resident 65's five (5) days assessment dated [DATE], section GG was reviewed. The MDSRN stated Resident 65 was coded as no impairment of upper extremity (shoulder, elbow, wrist, hand) on the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs). MDSRN stated she completed the assessment on Resident 65 and remembered Resident 65's left upper extremity did not have the same range of motion (ROM-extent or limit to which a body can be moved around a joint) as her right upper extremity. MDSRN stated on assessment Resident 65's right upper extremity helped raised her left upper extremity to reached/touched her head. MDSRN stated she made an error in her assessment of Resident 65. MDSRN stated Resident 65 should have been coded with impairment on one side of her upper extremity. MDSRN stated the facility did not have a policy on MDS, the facility follows the Long Term Care Facility Resident Assessment Instrument (RAI- core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) guideline. During an interview on 3/228/24, at 3:25 p.m. with the Director of Nursing (DON), the DON stated Resident 65 has limited mobility on her left upper extremity. The DON stated the MDSRN should have coded Resident 65 as having weakness on her upper extremity. The DON stated her expectation was to ensure staff are completing their assessments accurately. During a review of professional guideline titled, Long Term Care Facility Resident Assessment Instrument version 1.18.11 Manual (RAI- core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) dated 10/23, indicated, .With resident seated on a chair, instruct them to reach with both hands and touch palms to back of head . touch each shoulder with the opposite hand . Code 1, impairment on one side: if resident has an upper- and/or lower-extremity impairment on one side that interferes with daily functioning .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed for one of five sampled residents (Resident 27) when Resident 27 was diagnosed with major depressive disorder (persistent feeling of sadness and loss of interest), dementia (loss of of cognitive functioning-thinking, remembering and reasoning) and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and was started on psychotropic medications (medications used to treat mental health disorders) on 12/2/19. This failure had the potential for Resident 27 to not receive the necessary and appropriate psychiatric (relating to mental illness) level of treatment and evaluation in the facility. Findings: During a concurrent observation and interview on 3/25/24, at 9:50 a.m. during the initial tour of the facility in room [ROOM NUMBER], Resident 27 was lying in bed with eyes open. Resident 27 stated she had been in the facility for more than eight years. Resident 27 stated she did not have any concerns. During a review of Resident 27's admission Record (AR), dated 3/28/24, the AR indicated, Resident 27 was admitted to the facility on [DATE], with diagnoses which included depression (sadness), dementia (loss of of cognitive functioning-thinking, remembering and reasoning) and psychotic disorder. During a concurrent interview and record review on 3/28/24, at 10:28 a.m. with the admission coordinator (AC), the AC reviewed Resident 27's PASRR (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) assessment dated [DATE]. The AC stated she was aware Resident 27 has diagnosis of dementia and was currently on psychotropic medications but was not sure when medications were started. The AC stated she was not able to find a PASRR assessment completed after 11/8/19 to reflect Resident 27's diagnosis of dementia and use of psychotropic medications. The AC stated there should have been a PASRR assessment completed. The AC stated she was responsible in making sure PASRR assessment was completed for any significant changes in condition and hospitals are sending a copy of the completed assessments for new admission and re-admission. The AC stated the facility did not have a policy on PASRR and they follow current regulatory guidelines. During an interview on 3/28/24, at 3:10 p.m. with the Director of Nursing (DON), she stated, . I learned that when a resident was put on psychotropic medication, a new PASRR assessment should be completed to make sure resident who has mental condition be referred and received the proper treatment deserved The DON stated Resident 27 needed a new PASRR assessment when started on psychotropic medications.

Based on interview and record review, the facility failed to provide sufficient staff with the appropriate competencies and skill sets to provide nursing services to ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when one of four nursing staff (Infection Preventionist-IP) did not receive a competency skills check after being hired. This failure had the potential to place residents' at risk of being exposed to the spread of infections. Findings: During a concurrent interview and record review on 3/26/24, at 10:44 a.m., with the Director of Nursing (DON) and the Director of Staff Development (DSD), the facility document titled, Licensed Nurse Competency, undated was reviewed. The DON stated, the IP completed her employment application on 11/30/23 and was hired and started her orientation on 12/18/23. The DON stated, the IP was responsible for the facility's infection prevention and control program and reports to the DON. The DON stated, she does not recall initiating and validating the IP's nurse competency. The DSD stated, the DON was responsible in validating and completing the IP's nurse competency after being hired. The DON stated, without the nurse competency completed, the facility does not have a proof that the IP can provide appropriate nursing care to facility residents. During an interview on 3/26/23, at 12:30 p.m., with the IP, the IP stated, she submitted her employment application on 11/30/23 and was initially hired on 12/18/23. The IP stated, she spent the first day of orientation with the Human Resources staff and the DSD and went over the different areas of the new hire packet. The IP stated, I don't recall having my nurse competency checked by the DON or DSD. I don't remember signing a document related to nurse competency. During a review of the facility's policy and procedure (P&P) titled, Orientation Program for Newly Hired Employees, Transfers, Volunteers, dated 5/2019, the P&P indicated, . All newly hired personnel/volunteers/transfers must attend orientation within seven (7) days of hire . c. An introduction to resident care procedures, which includes, but is not limited to . (1) a review of the facility's most common Nursing Service Policies . (3) a review of the facility's infection control practices . Our orientation program is an in-depth review of our facility's [policy and procedures]. A checklist is used to record materials reviewed . During a review of the facility's document titled, Infection Preventionist Job Description, undated, the document indicated, . The Infection Preventionist is responsible for the facility's infection prevention and control program (IPCP), which is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Maintains current knowledge of federal, state, and local regulations . Performs any other duties as assigned by the supervisor .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs for one of seven sampled residents (Resident 25) when Resident 25's metoprolol (medication used to treat high blood pressure) was not available for administration for 1 day (3/27/24). This failure had the potential for Resident 25's blood pressure to be uncontrolled and lead to serious medical condition such as a stroke (a loss of blood flow to part of the brain, which damages brain tissue). Findings: During a concurrent medication pass observation and interview on 3/27/24 at 7:15 a.m., at Station 2, Registered Nurse (RN) 1 was preparing Resident 25's medications after checking blood pressure which was 150/85 (a normal blood pressure for adults is a systolic measurement of less than 120 milimeters of mercury (mmHg unit of measurement) and a diastolic reading under 80 mmHg) and pulse of 85. RN 1 did not administer Resident 25's metoprolol medication. RN 1 stated the medication was not available to give to Resident 25. RN 1 stated Resident 25's B/P was at 150/85 and could go higher and pulse rate was 85. RN 1 stated she would call the physician to notify them that Resident 25's metoprolol medication was not available to administer. During a review of Resident 25's admission Record [document with resident demographic and medical diagnosis information], dated 3/28/24, the admission record indicated, Resident 25 was admitted in the facility on 2/21/24, with diagnoses which included hypertension (pressure in the blood vessels are too high), heart failure (when the heart muscle can't pump enough blood to meet the body's needs) and muscle weakness. During a review of Resident 25's Progress Notes, dated 3/27/24, the Progress Notes indicated, . 03/27/2024 08:32 . [ metoprolol brand name] Tablet . Med not available. Called Medical Doctor (MD) . Call Pharmacy for medication . During an interview on 3/28/24, at 9:15 a.m. with Licensed Vocational Nurse (LVN) 2, she stated the facility practice when medication was not available was for administration to call the MD and follow up with the pharmacy. LVN 2 stated licensed nurses are responsible in making sure medications are available to administer to residents. LVN 2 stated, .We do not want our residents to miss their medication because we did not have it available . During an interview on 3/28/24, at 2:10 p.m. with RN 1, she stated she had not received report from the previous nurse regarding medication for Resident 25 not being available for administration and did know if it was followed up with pharmacy. RN 1 stated she was not sure if the medication was administered the previous days. RN 1 stated Resident 25 is taking the medication to regulate her pulse and if not administered Resident 25's pulse could even go higher which could lead to more serious medical condition. During an interview on 3/28/24, at 2:55 p.m. with the Director of Nursing (DON), she stated the licensed nurses are responsible in making sure they are ordering residents' medications from the pharmacy and available for administration. The DON stated the licensed nurse who administered the last dose should have followed up with the pharmacy, Resident 25's missed medication was for her high blood pressure and pulse if not given it could lead to more serious health conditions. During a review of facility's policy and procedure (P&P), titled, Medication Shortages, dated 2007, the P&P indicated, . The facility nurse must make every effort to ensure that a medication ordered for the resident is available to meet their needs . Nursing staff . Notify the attending physician of the situation . During a review of the facility's P&P, titled, Non Controlled Medication Orders, dated 2007, the P&P indicated, . 4. The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available .

Based on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, staff and the public when one of three medication rooms (Station 5) was observed with only one of four fluorescent lights was working. This failure had the potential for distribution of the wrong medications for residents and for staff to trip and fall. Findings: During a concurrent observation, interview and record review on 3/26/24, at 3:50 p.m. in Station 5 medication room with Licensed Vocational Nurse (LVN) 5, the medication room was observed to be dark when we entered the room, there were four fluorescent lights in the ceiling and only one of the four fluorescent lights was working. LVN 5 stated she did not usually worked in Station 5 and was not aware if the lights had already been reported to maintenance department. LVN 5 stated all four fluorescent lights should all be working to be better to see medication labels better. LVN 5 stated, . it could cause tripping and fall . During an interview on 3/26/24, at 5:02 p.m. with Registered Nurse (RN) 2, in Nursing Station 5, RN 2 stated she had only been working in the facility for two months. RN 2 stated, .It's been like that since I started working two months ago . RN 2 stated she had noticed the lights when she was training with another nurse and was told it was broken. RN 2 stated she did not remember putting in a request to get the lights fixed nor did she knew if the other nurse submitted a work order for the maintenance. RN 2 stated the medication room was dark and a a nurse can not really see or read medication labels, there is also possibility to cause a trip and fall. RN 2 stated it was not an ideal situation and the expectation was for the lights to be fully functional. During a concurrent observation and interview on 3/26/24, at 5:30 p.m. with the Maintenance Facility Director (MFD) in Station 5's medication room, MFD was observed looking up at the fluorescent lights and stated he was not aware of the issue with the lights prior today (3/26/24) at 5:20 p.m. The MFD stated the lights in the station 5's medication room was not acceptable, it was not a safe working environment. The MFD stated, . All the lights should have been working properly . The MFD stated it was safety issues which could lead to trip and fall and nurses may not be able to read the medication label properly which could lead to medication error. The MFD stated the nursing staff should have let maintenance know by putting the request in system named TELS (is a building management platform designed for Senior Living with integrated Asset Management, Life Safety, and Maintenance solutions). During an interview on 3/28/24, at 2:25 p.m. with the administrator (ADM), she stated the MFD took care of the lights on 3/26/24. The ADM stated she did not think the lack of enough light in the medication room would cause immediate health and safety hazard but just minor delay. The ADM stated the licensed nurses have an alternate means of lighting to appropriately to see the medication labels, the nurses could always use their cell phone lights and flash lights to read the medication labels or step outside into the nursing station where there was appropriate lights. The ADM stated, if the nurses had problems with the lights they should have put in work order in TELS report so maintenance can take care of it. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated, . The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike environment . includes . comfortable (minimum glare) yet adequate (suitable to the task) lighting . Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment . During a review of the facility's document, titled, Facility Assessment Tool, updated 10/24/23, the Facility Assessment Tool indicated, . Facility maintains routine service logs for most types of equipments and performs routine inspections . Facility Maintenance Lead ensures that all basic physical plant systems are maintained and operational at all times and works with professional contractors for repairs, upgrades as needed .

Based on observation, interview, and record review the facility failed to provide a comfortable homelike environment for three of 15 sampled residents (Residents 1, 29 and 81) when the air vents (an opening which allows air to pass out of or into a room) in Resident 1, 29, and 81's rooms were covered with black and brown stains and had dust in between the slits of the vent. This failure resulted in Residents 1, 29, and 81 not being provided a comfortable, homelike environment and had the potential to cause the residents to experience illness from breathing in dust from the air vents. Findings: During a concurrent observation and interview on 3/25/24 at 10:26 am with Resident 1 and 29 in their room, the air vent above their door was observed to have black and brown stain marks over the exterior. Resident 1 stated her air vent looked dirty to her and she could not recall when the air vent last looked clean. Resident 1 stated she would have never had the air vent in her own home in the same condition as the one in her current room. Resident 1 stated she would like to see the air vent cleaned. Resident 29 stated the air vent looked dirty and she would also like to see it improved. During a concurrent observation and interview on 3/25/24 at 10:27 a.m. with Certified Nursing Assistant (CNA) 10 in Resident 1 and 29's room, the air vent above the door looked to be stained with black and brown marks over the exterior. CNA 10 stated the air vent in Residents 1 and 29's room appeared dirty. CNA 10 stated the air vent did not appear homelike and she would not have them in the same condition in her house. CNA 10 stated the air vents should have been cleaned when the problem was noticed. During a concurrent observation and interview on 3/25/24 at 11:08 a.m. with Resident 81 in Resident 81's room, the air vent's exterior was covered in a layer of brown and gray dust and had a collection of dirt in between the spacing of the vent. Resident 81 stated it was not homelike and she would have preferred to have the vent in a clean condition. During a concurrent observation and interview on 3/25/24 at 11:09 a.m. with CNA 8 in Resident 81's room, the air vent's exterior was covered in a layer of brown and gray dust and had a collection of dirt in between the spacing of the vent. CNA 8 stated the air vent appeared dirty and she would not have it in the same condition in her home. CNA 8 stated the air vent may make Resident 81 feel uncomfortable to be in her room. During an interview on 3/27/24 at 10:17 a.m. with the Infection Preventionist (IP), the IP stated all air vents should be in a clean condition. The IP stated a dirty air vent may have caused the residents to breath in dirty air. The IP stated maintaining clean air vents would have been important for residents with respiratory issues like pneumonia (lung infection that can cause illness), chronic obstructive pulmonary disease (lung disease which makes breathing difficult), and asthma (lung condition which makes breathing difficult and causes wheezing and coughing) because these types of residents would be vulnerable to respiratory illnesses (diseases of the lungs). The IP stated if vents had too much dust build up it could have led to restricted air ventilation which could lead to increased respiratory distress (breathing difficulty) in vulnerable residents. During an interview on 3/27/24 at 11:59 a.m. with the Director of Hospitality (DOH), the DOH stated housekeeping staff were responsible for cleaning vents as part of their regular height dusting (cleaning of tall hard to reach areas). The DOH stated the air vents should have been cleaned as needed or requested in order to keep fresh air coming into resident's' rooms and so residents don't breathe in dust and debris. During a concurrent observation and interview on 3/27/24 at 2:18 p.m. with the DOH in Resident 1 and 29's room, the air vent above their door was observed to have black and brown stain marks over the exterior. The DOH stated the vent looked dirty and it could have been cleaned by housekeeping. The DOH stated if dust or dirt are present on the air vent, it does not provide a homelike experience. The DOH stated having dirty unappealing vents could have made residents uncomfortable where they lived. The DOH stated if vents were too stained to be cleaned, then maintenance should have replaced them. During an interview on 3/27/24 at 4:32 p.m. with the Maintenance Lead (ML), the ML stated air vents should have been replaced when the facility was redoing the air conditioning system. The ML stated air vents that were not able to be cleaned should be repainted or replaced. The ML stated not replacing or repainting the air vents did not promote a homelike environment for the residents. The ML stated it was important to clean, repaint or replace unappealing vents so residents feel comfortable in their rooms and so they don't breathe in dust or contaminants (things that can make a person sick). During an interview an interview on 3/28/24 at 11:22 am with the Assistant Director of Nursing (ADON), the ADON stated having clean air vents in residents' rooms was important because people may question the cleaning services of the rooms. The ADON stated if dust and dirt are found in the air vents, it could cause allergic reactions in residents. During an interview on 3/28/24 at 2:33 p.m. with the Director of Nursing (DON), the DON stated having dirty unappealing air vents did not promote a homelike environment. The DON stated the vents should be clean. During a review of the facility's document titled, Housekeeping Department description, undated, the form indicated, . A clean and sanitary environment is conducive (helpful) to the physical and mental well-being of residents and staff. Effective environmental sanitation is required to lessen the hazards of exposure to contaminated air, dust, furnishings (decorations such as curtains and rugs), equipment, and other fomites (objects or materials which are likely to carry infection). Frequent cleaning of the building's interior will aid on physically removing some of the microorganisms (bacteria that can cause infection) which might cause these hazards .the Houskeeping Department will contribute to the infection control am by providing a clean and sanitary building, and will comply with all local, state and federal laws, standards, regulations, and guidelines .Act jointly with the Infection Control Commitee in making periodic inspections of the facility to establish and maintain consistently high infection control standards . During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated February 2021, the P&P indicated, . Residents are provided with a safe, clean, comfortable, and homelike environment . 1. Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean sanitary and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 4's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/27/24, the AR indicated Resident 4 was admitted on [DATE] with diagnoses of obstructive and reflux uropathy (a condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys), retention of urine (a condition where the bladder does not empty completely or at all), type II diabetes mellitus (a disease that occurs when your blood sugar is too high) and congestive heart failure (a condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/6/24, the MDS section C indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 12 (a score of 0-7 indicated severe cognitive impairment, 8-12 indicated moderately impaired, 13-15 indicates cognitively intact), which indicated Resident 4 was moderately impaired. During a concurrent observation and interview on 3/25/24 at 11:17 a.m. with the Director of Nursing (DON) in Resident 4's room, Resident 4 was observed with her urinary catheter tubing touching the floor. The DON verifed the catheter tubing was on the floor. The DON stated the catheter tubing should not have been touching the floor. The DON stated the catheter tubing could have gotten dislodged. The DON stated if germs moved up the catheter, it could cause an infection in the resident. During an interview on 3/27/24 at 9:33 a.m. with CNA 8, CNA 8 stated Resident 4's urinary catheter tubing should not be on the floor. CNA 8 stated Resident 4's catheter tubing needed to be monitored. CNA 8 stated the tubing should be put in a bag without kinks and off the floor. CNA 8 stated the CNAs would put findings for resident monitoring in the resident's record in the computer, but mainly the findings were communicated with each other by talking to each other. During a concurrent interview and record review on 3/27/24 at 2:41 p.m. with the Assistant Director of Nursing (ADON), Resident 4's Care Plan (CP), dated (undated) was reviewed. The CP indicated, . check foley catheter bag for kinks every 2 hours each shift . The ADON stated all staff should have made sure Resident 4's indwelling catheter tubing was off the ground. The ADON stated the catheter tubing on the ground could cause an infection in Resident 4. During a concurrent interview and record review on 3/28/24 at 10:22 with the Director of Staff Development (DSD), Resident 4's chart was reviewed for documentation of urinary catheter monitoring. The DSD stated she did not see any charting for urinary catheter checks in Resident 4's chart. The DSD stated if the resident's tubing was on the ground, there could be cross-contamination and infection control issues. The DSD stated the charge nurses at each station would monitor staff by visually checking to see if resident monitoring was being done. During a concurrent interview and record review on 3/28/24 at 10:30 a.m. with LVN 2, Resident 4's CP, dated (undated) was reviewed. The CP indicated . check foley catheter bag for kinks every 2 hours each shift . LVN 2 stated she did not know there was a monitoring order for catheter checks. LVN 2 stated she did not see a physician (MD) order for every two-hour monitoring for Resident 4's catheter. LVN 2 stated there should have been a monitoring order put in. LVN 2 stated the order was what flagged the nurse to perform resident monitoring. LVN 2 stated an order would occur in the Treatment Administration Record (TAR) and the Medication Administration Record (MAR). LVN 2 stated charting for resident monitoring is in the MAR or TAR. Resident 4's TAR, dated 3/28/24 was reviewed. The TAR indicated no monitoring of Resident 4's urinary catheter was documented. LVN 2 stated if there was no order put in, monitoring would not be in the MAR or TAR. During a concurrent interview and record review on 3/28/24 at 11:11 a.m. with the ADON, Resident 4's CP, dated (undated) was reviewed. The CP indicated, . check foley catheter bag for kinks every 2 hours each shift . Resident 4's Order Summary Report, dated 3/27/24 was reviewed. The Order Summary Report indicated no catheter monitoring orders for Resident 4. Resident 4's TAR dated 3/28/24 was reviewed. The ADON stated no orders were documented for catheter checks on Resident 4's urinary catheter tubing. The ADON stated staff would need a resident monitoring order from the MD to put the order in the resident's CP. The ADON stated staff would not be monitoring the resident without an order. The ADON stated nurses would need a monitoring order to flag them to have this task performed, otherwise the nurses would not have anything to alert them to monitor the resident. The ADON stated her expectation was if staff saw a situation like this, they would notify the MD for an order for monitoring the resident. The ADON stated she would expect staff to make a progress note regarding why the order was put in the resident's CP. During a concurrent interview and record review on 3/28/24 at 2:33 p.m. with the Minimum Data Set Registered Nurse (MDSRN), Resident 4's CP, dated (undated) was reviewed. The CP indicated, . check foley catheter bag for kinks every 2 hours each shift . The MDS stated nurses and MDS would enter interventions in the resident's CP. The MDSRN stated there was no area to document urinary catheter monitoring. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, indicated, . the comprehensive, person-centered care plan will: . describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being . aid in preventing or reducing decline in the resident's functional status and/or functional levels . reflect currently recognized standards of practice for problem areas and conditions . no single discipline can manage an approach in isolation . the resident's physician (or primary healthcare provider) is integral to this process . the interdisciplinary team (IDT) must review and update the care plan: . at least quarterly, in conjunction with the required quarterly MDS assessment . Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 22 sampled residents (Residents 49, 80, 37 and 4) when: 1. Residents 49 and 80 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 49 and 80 to be injured while using the side rails. 2. Resident 37 had an order of ipratropium bromide (medication used for breathing) via hand-held nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled through a connected mouthpiece or facemask) once a day for respiratory illness. This failure placed Resident 37 at a potential risk for not being educated on how to use a hand-held nebulizer for prescribed treatments. 3. Resident 37 was using low air loss mattress to prevent skin breakdown (when skin is deprived of blood flow the skin can become damaged and begin to breakdown). This failure placed Resident 37 at risk for pressure ulcers (damage to the skin caused by constant pressure on the area for a long time). 4. Facility failed to implement a person-centered care plan to meet Resident 4's medical needs when staff did not implement urinary catheter monitoring for Resident 4's indwelling urinary catheter (an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag). This failure had the potential to put Resident 4 at an increased risk of developing a urinary tract infection (a condition in which bacteria invade and grow in the urinary tract [any part of the urinary system]). Findings: 1.During a review of Resident 49's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/27/24, the AR indicated, Resident 49 was admitted from a rehabilitation hospital on 2/19/24 to the facility, with diagnoses that included Fracture of Left Femur (thigh bone), Alzheimer's Disease (loss of memory and ability to carry simple tasks), Urinary Tract Infection (bladder infection), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Muscle Weakness, Constipation, and History of Falling. During an observation on 3/25/24, at 11:02 a.m., in Resident 49's room, Resident 49 was awake and laying in bed, on her back, with quarter-length side rails up on both sides of the bed. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 3/26/24, at 9:03 a.m., Resident 49's nursing Care Plan (CP) was reviewed. The ADON stated, Resident 49 had a risks and benefits form for side rail use and consent signed by family agreeing to the use of side rails on 2/19/24. The ADON reviewed Resident 49's care plans and stated, there was no care plan developed for the use of side rails. The ADON stated, the use of side rails should have been care planned to include interventions such as bed inspection, frequent visual checks and monitoring of side rails for continued use. The ADON stated, the care plan for side rails should have been developed when the consent was signed by Resident 49's responsible party (RP) and after obtaining a physician order (PO). During a review of Resident 80's AR, dated 3/28/24, the AR indicated, Resident 80 was admitted from an acute care hospital on 3/7/24 to the facility, with diagnoses which included Muscle Weakness, Unsteadiness on Feet, Lung Cancer, Protein Calorie Malnutrition (not consuming enough protein and calories), Bacteremia (presence of bacteria in the blood), and Methicillin-resistant Staphylococcus aureus (MRSA, a type of infection that is difficult to treat because of resistance to some antibiotics). During a concurrent observation and interview on 3/25/24, at 3:24 p.m., with Resident 80, in Resident 80's room, Resident 80 was sitting on the edge of her bed, with quarter-length side rails up on both sides of the bed. Resident 80 stated, I use the siderails to pull myself from lying to sitting position. I also use them to get up from my bed. During a concurrent interview and record review with the ADON, on 3/26/24, at 9:16 a.m., Resident 80's nursing CP was reviewed. The ADON stated, Resident 80 had a risks and benefits form for side rail use completed on 3/7/24 and the consent signed by the RP agreeing to the use of side rails on 3/7/24. The ADON reviewed Resident 80's care plans and stated, there was no care plan developed for the use of side rails. The ADON stated, the use of side rails should have been care planned to include interventions to prevent risks of entrapment, injury, and monitoring for continued use. The ADON stated, the care plan for side rails should have been developed when the consent was signed by Resident or RP and after obtaining a PO. During an interview with the Director of Nursing (DON), on 3/28/24, at 12:01 p.m., the DON stated, upon reviewing the risks and benefits form for side rail use and obtaining the consent from the RP, a physician order should be obtained from the Attending Physician and a care plan should be developed. The DON stated, the care plan drove resident care to ensure residents care was being met. The DON stated, the facility failed to follow the facility's P&P related to care planning process. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 2/2016, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is development and implemented for each resident . g. incorporated identified problem areas; h. Incorporate risk factors associated with identified problems . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Provides direct resident care in accordance with the Nurse Practice Act, applicable State and Federal regulations and facility policies and procedures . Performs assessment on all changes of condition and develops appropriate care plans . 2. During a concurrent observation and interview on 3/25/24, at 10:55 a.m. with Resident 37 in their room, Resident 37 was lying in bed awake and watching television. Resident was observed using oxygen via nasal cannula (device used to deliver supplemental oxygen). Observed at Resident 37's bedside table was a handheld nebulizer mouthpiece placed on top of the nebulizer machine (small machine that turns liquid medicine into a mist that can be easily inhaled through a connected mouthpiece or facemask). Resident 37 stated the nurse gives her medication using the mouthpiece for her breathing. During a review of Resident 37's admission Record (AR-a document with resident demographic and medical diagnosis information), dated 3/28/24, the AR indicated, Resident 37 was admitted on [DATE] with diagnoses which included chronic respiratory failure, asthma (airways in the lungs become narrowed and swollen, making it difficulty to breath), and shortness of breath. During a concurrent interview and record review on 3/28/24, at 8:54 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 37's physician orders was reviewed. LVN 2 stated Resident 37 had an order for ipratropium bromide inhalation solution (medication used for breathing) medication dated 3/15/24. LVN 2 stated she did not find a care plan for Resident 37's use of ipratropium bromide inhalation medication. LVN 2 stated there should have been a care plan developed as soon as the medication was ordered and it was the responsibility of the nurse who received the order to initiate a care plan in order to educate Resident 37 on it's use. During a concurrent interview and record review on 3/28/24, at 2:43 p.m., with the Director of Nursing (DON), the DON stated Resident 37 did not have a care plan for the use of ipratropium medication. The DON stated Licensed Nurses should have developed a care plan for Resident 37's use of ipratropium medication. The DON stated the nurse receiving the order was responsible in developing the care plan at the time the order was received. The DON stated care plan should be individualized because it provided a guide for the nursing staff on how to care for the resident. 3. During a concurrent observation and interview on 3/25/24, at 10:55 a.m. with Resident 37 in room [ROOM NUMBER], Resident 37 was lying in bed awake and watching television. Resident was observed using oxygen via nasal cannula. Resident 37 observed with a low air loss mattress in her bed and head of bed was elevated. Resident 37 stated she was using the special mattress to prevent her from developing bed sores (also know as pressure ulcers-injury to skin and underlying tissue resulting from prolonged pressure on the skin) During a review of Resident 37's admission Record (AR-a document with resident demographic and medical diagnosis information), dated 3/28/24, the AR indicated, Resident 37 was admitted on [DATE] with diagnoses which included muscle weakness and venous insufficiency (leg veins become damaged and struggle to send blood back to the heart). During a concurrent interview and record review on 3/28/24, at 8:56 a.m. with LVN 2, Resident 37's physician orders was reviewed. LVN 2 stated Resident 37's physician orders indicated low air loss mattress was ordered 7/13/23. LVN 2 stated she did not find a care plan for the use of low air loss mattress. LVN 2 stated there should have been a care plan developed for the use of low air loss mattress. LVN 2 stated care plan directs the plan of care of residents and licensed nurses are responsible in initiating a care plan when order was received. During an interview on 3/28/24, at 1:56 p.m., with Registered Nurse (RN) 1, RN 1 stated care plan is needed for all medication orders and treatments. RN 1 stated use of low air loss mattress should be care planned and the licensed nurse who received the order should have initiated the care plan. RN 1 stated care plan is important because it was a way to monitor if interventions are effective or if needed revision. During a concurrent interview and record review on 3/28/24, at 2:48 p.m. with the DON, the DON reviewed Resident 37's care plan was reviewed and stated she did not find a care plan for the use of low air loss mattress. The DON stated, . It was ordered, then she needs a care plan and there is not a care plan in [Resident 37's] record . During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan . Incorporate identified problem areas . risk factors associated with identified problems .Reflect treatments goals, timetables, and objectives in measurable outcomes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a concurrent observation and interview on 3/25/25 at 10:11 a.m. in Resident 52's room with Restorative Nursing Assistant (RNA) 1, Resident 52 was observed sleeping. Resident 52 was connected to an Oxygen Concentrator (a medical device used to deliver oxygen to those who require it). The Oxygen Concentrator had a setting set to deliver 3L (liters-a unit of measurement) of Oxygen to Resident 52. RNA 1 stated, Resident 52 was receiving 3L of oxygen as indicated by oxygen regulator settings. During a concurrent interview and record review on 3/25/25 at 10:20 a.m. with Registered Nurse (RN 3), Resident 52's Orders Summary (OS), dated, March 2024 was reviewed. The OS indicated, Oxygen at 4L/min [ L/min-liters per minute] via nasal canula every shift for Shortness of Breath. During a concurrent observation and interview on 3/25/25 at 10:25 a.m. with RN 3 in Resident 52's room, RN stated, the machine was set to deliver 3L of oxygen. RN stated, she needed to be on 4L. RN stated, 3L is not sufficient for the resident's oxygen needs. During a interview on 3/27/24 at 9:39 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, 3L is not sufficient for Resident 52 according to the Medical Doctor's (MD) orders. LVN 1 stated, by not having 4L being delivered to the resident, a drop in oxygen saturations could happen, and the resident's shortness of breath can worsen leading to respiratory distress (trouble breathing). During an interview on 3/28/24 at 8:55 a.m. with the Director of Nurses (DON), the DON stated, nurses should always observe the settings on the machines to make sure the doctor's orders are being followed. During an interview on 3/28/24 at 9:07 a.m. with the DON, the DON stated, there was potential for the resident not getting enough oxygen. The DON stated, not getting enough oxygen can cause respiratory distress. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated October 2010, the P&P indicated, Adjust oxygen delivery so .the proper flow of oxygen is being administered. During a review of the facility's P&P titled, Oxygen Administration, dated October 2010, the P&P indicated, after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: .the rate of oxygen flow . During a review of the facility's P&P titled, Medication and Treatment orders, dated July 2016, the P&P indicated, Orders for medications and treatments will be .safe and effective . During a review of Nursing 2024 The Peer-Reviewed Journal of Clinical Excellence (N2024), Who has the authority to give RNs an order?, dated 10/17/2018, the N2024 indicated, .you [nurses] have a legal duty to carry out a physician's .orders. 5. During a concurrent observation and interview on 3/25/25 at 10:25 a.m. with RN 3 in their room, RN 3 stated, the humidifier bottle was dated 3/19 and was the water inside was almost empty. The RN 3 stated, the bottle is due to be changed and should have been changed every three days. The RN 3 stated, it is important to have the humidifier bottle changed every three days to maintain efficacy of humidification of oxygen being delivered. The RN 3 states, if the bottle isn't changed, bacteria can grow inside the bottle. During a concurrent interview and record review on 3/27/24 at 9:30 a.m. with LVN 1 Resident 52's Order Summary (OS) dated March 2024 was reviewed. The OS indicated, Change Humidifier Bottle every night shift every 3 day(s). The LVN 1 stated, all licensed nurses are responsible for changing the bottle. The LVN 1 stated, if the liquid runs out .the oxygen may not be properly humidified, the patient may develop dry nose, and bacteria can grow with an expired bottle. During an interview on 3/28/24 at 8:51 a.m. with the DON, the DON stated, humidifier bottles should be changed every 3 days. The DON stated, if the bottle was dated 3/19, it should have been changed on 3/22/24. During a concurrent interview and record review on 3/28/24 at 8:55 a.m. with the DON, Resident 52's Medication Administration Record (MAR), dated March 2024 was reviewed. The DON stated, the MAR indicated, on 3/22 an LVN initialed to indicate the humidifier bottle was changed. The DON stated, it is not OK to sign that you did something that wasn't done. The DON stated, if the humidifier bottle hasn't been changed, the water could become stagnant and or run out. The DON stated, this can cause dry mucous membranes resulting in bleeding from the nose, discomfort, sores, and pain. During a review of the facility's P&P titled, Oxygen Administration, dated October 2010, the P&P indicated, Be sure there is water in the humidifying jar and the water level is high enough that the water bubbles as oxygen flows through .periodically re-check water level in humidifying jar. During a review of the facility's P&P titled, Medication and Treatment orders, dated July 2016, the P&P indicated, Orders for medications and treatments will be consistent with principles of safe and effective . During a review of Nursing 2024 The Peer-Reviewed Journal of Clinical Excellence (N2024), Who has the authority to give RNs an order?, dated 10/17/2018, the N2024 indicated, .you [nurses] have a legal duty to carry out a physician's .orders. During a record review of the Professional Standard (PS) titled, USAID-Reaching Impact, Saturation, and Epidemic Control (RISE) Standard Operating Procedure Operation and Maintenance of Oxygen Concentrator, https://media.path.org/documents/SOP_on_Oxygen_Concentrator_08032022-_USAID_RISE.pdf, undated, the PS indicated, The humidifer bottle is typically meant as a single use item .The water in the bottle must be changed regularly in order to prevent contamination. - 6. During a review of Resident 66's admission Record (AR) (document with resident demographic and medical diagnosis information), dated 3/27/24, the AR indicated Resident 66 had been admitted to the facility on [DATE]. Resident 66 had the diagnosis of Chronic obstructive pulmonary disease (disease which makes it hard to breath due to closing of the airways) upon admission. During a concurrent observation and interview on 3/25/24 at 10:13 a.m. with Licensed Vocational Nurse (LVN) 6 in Resident 66's room, Resident 66's nasal cannula (tube that delivers oxygen to the nose) tubing did not have a labeled with the nurse's initials or the date it was opened. LVN 6 stated the nasal cannula tubing should have been labeled with the date it was open and nurse initials. LVN 6 stated it was important to label tubing, so it gets changed out regularly. LVN 6 stated the tubing may have been contaminated if it was not changed. During a concurrent interview and record review on 3/26/24 at 4:46 p.m. with LVN 7, Resident 66's Order Summary, dated 3/25/24 was reviewed. The order summary indicated, . change oxygen tubing every night shift every [Sunday] (date and initial new tubing). LVN 7 stated the nasal cannula tubing should have been changed every Sunday and labeled with the date and nurses initials. LVN 7 stated it was important to label the tubing to prevent any contamination by throwing away expired tubing. LVN 7 stated if the tubing was not labeled it could have led to it being used past the ordered date which could have led to contamination of the tubing or an infection in the resident. During an interview on 3/27/24 at 11:39 a.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated oxygen tubing was supposed to be labeled with the date opened. CNA 9 stated if oxygen tubing was not labeled it may have been mixed up and used on a different resident. CNA 9 stated unlabeled tubing could have led to an infection if it was not replaced when it should have been. During an interview on 3/28/24 at 11:22 a.m. with the Assistant Director of Nursing (ADON), the ADON stated it was not the facilities standard to have the oxygen tubing without the date labeled. The ADON stated it was important to label the oxygen tubing, so staff members know when it was last replaced. The ADON stated the doctors order was not followed when the tubing was not labeled with the date. During an interview on 3/28/24 at 2:13 p.m. with the Infection Preventionist (IP), IP stated the oxygen tubing should have been labeled. The IP stated the unlabeled tubing could have led to an infection because the tubing could have been a portal of entry (Opening where the pathogen[bacteria that may cause diseases] may enter). The IP stated the doctor's order was not followed if the oxygen tubing was not labeled with the date. During an interview on 3/28/24 at 2:33 p.m. with the Director of Nursing (DON), the DON stated the oxygen tubing was supposed to be labeled with the date so it could have been replaced within seven days. The DON stated the staff should have labeled the tubing with the date first used. The DON stated labeling the tubing was important because tubing used beyond seven days could have led to bacterial growth within it. The DON stated the doctors order was not followed. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated October 2010, indicated, .Preparation 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the residents care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed . Based on observation, interview and record review, the facility failed to meet professional standards of practice for four of 12 sampled residents (Residents 25, 52, 55 and 66) when: 1. Registered Nurse (RN) 1 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 25's medications. This failure resulted in inaccurate charting and placed Resident 25 at a risk to not receive the medications ordered. 2. RN 1 did not follow the medication administration direction when she applied a lidocaine patch (medication patch applied on top of the skin for relief of pain) to Resident 25's left upper arm. This failure had the potential to put Resident 25 at risk for skin irritation. 3. LVN 4 did not follow medication administration direction when she administered Resident 55's medication without food. This failure had the potential to put Resident 55 at risk for stomach upset which could result in serious health condition. 4. Resident 52's oxygen flow rate was set to 3L (liters-a unit of measurement) instead of the ordered 4L. This failure resulted in Resident 52 not receiving the correct amount of oxygen as ordered which could have resulted in shortness of breath and respiratory distress (difficulty breathing). 5. Resident 52's humidifier (a device used to increase the mositure in level in the air with a room or enclosed space) bottle was not changed for six days. This failure had the potential to cause health risks from bacteria growing in the stagnant water (water that is left sitting for long periods of time) and inadequate humidification of the oxygen being delivered. 6. Resident 66's humidifier (a machine that makes the air in a place less dry) bottle was not being changed every three days. This had the potential for causing dry mucosal membranes (the moist, inner lining of some organs and body cavities) resulting in nosebleeds and/or pain. Findings: 1. During a concurrent observation, interview and record review on 3/27/24, at 7:40 a.m. in Station 2 hallway, RN 1 was observed preparing Resident 25's medications and clicked (checked as given) each medication in the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) as she popped each medications in a small medication cup and clicked saved after she popped all of Resident 25's medications. RN 1 administered the medications to Resident 25. RN 1 stated she had always clicked in the eMAR after she popped each medication from the bubble pack to make sure she has all the medications and clicked saved prior to administering the medications. RN 1 stated she was not sure why she documented the medication as administered prior to administering medications to Resident 25. RN 1 stated she should not have documented prior to administering medications to Resident 25 because it was not a good nursing practice. During a review of Resident 25's admission Record [document with resident demographic and medical disgnosis information], dated 3/27/24, the admission record indicated, Resident 25 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), muscle weakness and chronic pain. During an interview on 3/28/24, at 2:55 p.m. with the DON, she stated the practice had always been to administer medication to residents then document. The DON stated licensed nurses should never document medication was administered prior to administering the medication to a resident.The DON stated the licensed nurse should also make sure resident takes the medication then document the medicine as given. During a review of facility's poilicy and procedure (P&P) titled, Medication Administration General Guidelines, dated 05/16, the P&P indicated, . 20. The resident is always observed after administration to ensure that the dose was completely ingested . The individual who adinisters the medication dose, records the administration on the resident\s MAR immediately following the medication being given . During a review of the professional reference titled, Nursing 2022 Drug Handbook dated 2022, indicated, The eight 'rights' of medication administration .The right documentation: Completely and accurately document in the patient's medical record the drug administered; the monitoring of the patient, including the patient's response; and other nursing interventions . 2. During a concurrent observation, interview and record review on 3/27/24, at 7:40 a.m. in Station 2 hallway, RN 1 was observed preparing Resident 25's medications. RN 1 went inside Resident 25 with the lidocaine patch (medication patch applied on top of the skin for relief of pain). RN 1 was observed pulling up Resident 25's left sleeve and applied the lidocaine patch. RN 1, she stated she administered Resident 25's lidocaine patch without cleaning the site. RN 1 stated she read the lidocaine medication direction which indicated to clean the site and wait to dry then apply the patch. RN 1 stated she should have cleaned the site, waited for the skin to dry then applied the patch. RN 1 stated not cleaning the skin could affect the absorption of the medication. During a review of Resident 25's admission Record, dated 3/27/24, the admission record indicated, Resident 25 was admitted to the facility on [DATE], with diagnoses which included hypertension, muscle weakness and chronic pain. During a review of Resident 25's Medication Review Report, dated 3/27/24, the Medication Review Report, indicated, . Lidocaine External Patch 4 [four] % [percent] Apply to left upper arm . Order Date 2/22/24 . During an interview on 3/28/24, at 2:50 p.m. with the DON, she stated licensed nurse should follow the instruction/direction in the medication box. The DON stated the nurse should have cleaned the skin and waited for the skin to dry before she applied the patch. The DON stated, . Always follow the intsruction/direction. During a professional reference review retrieved from https://www.webmd.com/drugs/2/drug-1349-1252/lidocaine-hcl-topical/lidocaine-patch-topical/details If you are using the over-the-counter product to self-treat, read and follow all directions on the product package before using this medication. If you have any questions, consult your pharmacist. If your doctor has prescribed this medication, use it as directed. This product should only be applied to normal intact skin. Do not apply to skin that is broken or irritated. The dosage is based on your medical condition and response to treatment. Remove the protective liner and apply the patch to the skin area that is most painful. Apply the prescribed number of patches as directed by your doctor, usually once a day. Depending on your product, the patch may be left on the skin for up to 8 or 12 hours. Follow the instructions carefully . 3. During a concurrent observation and interview on 3/27/24, at 8:03 a.m. in Station 3 (three) hallway outside of Rom 307, LVN 4 prepared Resident 55's medications which included Potassium Chloride (used to treat low potassium level) oral tablet to be given with breakfast. LVN 4 administered medication to Resident 55 with water and not with breakfast as indicated in the medication direction. LVN 4 stated she should have made sure Resident 55 was eating her breakfast when she administered the medication. LVN 4 stated the medication could cause upset stomach causing discomfort and affects the absorption of the medication when the direction was not followed to give medication with breakfast. During a review of Resident 55s admission Record, dated 7/12/23, the admission record indicated, Resident 55 was admitted to the facility on [DATE], with diagnoses which included hypokalemia (low levels of potassium), hypertension (high blood pressure) and muscle weakness. During a review of Resident 55's Medication Review Report, dated 3/27/24, the Medication Review Report, indicated, . Potassium Chloride ER Oral tablet Extended Release 20 MEQ [milliequivalent-unit of measurement] . (Administer with Breakfast at 0700 with 4 [four] oz [ounces-unit of measurement] of water) . Order Date 6/26/23 . During a review of facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 05/16, the P&P indicated, . Medications are administered as prescribed in accordance with manufactures's specifications, good nursing principles and practices and only be person legally authorized to do so . 3. Medication administration timing parameters include the following: .Medications to be given with meals are to be scheduled for administration at the resident's meal time .

Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when: 1. Registered Nurse (RN) 1 did not administer metoprolol (medication used to treat high blood pressure and pulse). This failure resulted in Resident 25 not receiving her blood pressure medication as prescribed by the physician and had the potential for Resident 25 to have elevated or low blood pressure and pulse and serious medical condition. 2. Licensed Vocational Nurse (LVN) 4 did not follow direction on the medication label to administer with breakfast when she administered Resident 55's potassium chloride (medication used to treat hypokalemia [low potassium level]). This failure had the potential for Resident 55 to not receive the therapeutic effect of the medication which could lead to high or low potassium level and result in serious medical condition. These medication errors resulted in a calculated medication error of 7.69 percent. Findings: 1. During a concurrent medication pass observation and interview on 3/27/24, at 7:40 a.m. in Station 2, Registered Nurse (RN) 1 was passing medication. RN 1 stated she already checked Resident 25's blood pressure and pulse which were noted as blood pressure of 150/85 and pulse of 85. RN 1 prepared Resident 25's medications and administered nine of ten medications scheduled for Resident 25. RN 1 stated she did not administer metoprolol to Resident 25 because it was not available. RN 1 stated she should have given the medication to Resident 55 as ordered since Resident 25's blood pressure was elevated at 150/85 and pulse was 85. RN 1 stated Resident 25's blood pressure and pulse could go higher and cause more serious health condition since the medication was not administered. During a review of Resident 25's admission Record [document with resident demographic and medical diagnosis information], dated 3/27/24, the admission record indicated, Resident 25 was admitted in the facility on 2/21/24, with diagnoses which included hypertension (pressure in the blood vessels are too high) heart failure (condition in which the heart muscle can't pump enough blood to meet the dy's needs) and muscle weakness. During a review of Resident 25's Medication Review Report, dated, 3/27/24, the Medication Review Report, indicated, . [metoprolol] Oral Tablet Extended Release 24 hour 25 MG [milligram-unit of measurement] Give one [1] tablet by mouth one time a day related to ESSENTIAL . HYPERTENSION . Hold if systolic blood pressure [SBP-indicates how much pressure blood is exerting against the artery walls when the heart contracts] < (less) 100 or if heart rate [HR] <60 . Order Date: 2/23/24 . During an interview on 3/28/24, at 9:40 a.m. with Licensed Vocational Nurse (LVN) 2, she stated licensed nurses are responsible in making sure medications are available to administer to residents. LVN 2 stated she did not want residents to not have medications administered as ordered because the medication was not available. LVN 2 stated not administering medications as ordered could lead to more serious health issues. During an interview on 3/28/24, at 3:50 p.m. with the Director of Nursing (DON), she stated licensed nurses are responsible in making sure medications are available to administer to residents as ordered. The DON stated it was the licensed nurses responsibility to follow up with the physician for alternate medication and follow up with pharmacy for medication refills. The DON stated Resident 25's blood pressure and pulse could go higher and could lead to serious health condition because her medication was not available to be administered as ordered. During a review of the facility's policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, dated, 2/23, indicated, . A medication error is defined as the preparation or administering of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medication errors include: a. omission - a drug is ordered but not administered . Failure to follow manufacturer's instructions and/or accepted professional standards . 2. During a concurrent medication pass observation, interview and record on 3/27/24, at 8:03 a.m. at Station 3, with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared Resident 55's medications and administered four out of five scheduled medications for Resident 55. LVN 4 stated she administered potassium (brand name) to Resident 55 without breakfast. LVN 4 stated Resident 55's breakfast tray was on top of the bedside table and Resident 55 was lying in bed with eyes closed. LVN 4 stated she should have given Resident 55's medication with breakfast as ordered. LVN 4 stated Resident 55 may develop upset stomach and affect the effectiveness of the medication when given on empty stomach. During a concurrent observation and interview on 3/25/24, at 10:07 a.m., Resident 55 was lying in bed and appeared tearful. Resident 55 stated she had been in the facility for a long time and felt terrible but did not able to explain further. Observed breakfast tray at bedside covered and food was untouched. During a review of Resident 55's admission Record, dated 3/27/24, the admission record indicated, Resident 55 was admitted in the facility on 4/25/23, with diagnoses which included hypertensive heart disease with heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs), hypokalemia (low levels of potassium) and muscle weakness. During a review of Resident 55's Medication Review Report, dated, 3/27/24, the Medication Review Report, indicated, . [brand name] Oral Tablet Extended Release 20 MEQ [milliequivalent-unit of measurement] . Give one [1] tablet by mouth one time a day related to HYPOKALEMIA . (Administer with Breakfast at 0700 with four [4] oz [ounces] of water) . order date 06/26/2023 . During an interview on 3/28/24, at 2:05 p.m. with RN 1, she stated medications with direction to give with breakfast or food had to be followed. RN 1 stated Resident 55 should have been actively eating when medication was administered to prevent upset stomach like nausea, vomiting or diarrhea. RN 1 stated some medications are irritating to the stomach linings which could lead to more serious health conditions. During an interview on 3/28/24, at 2:15 p.m., with the DON, she stated medications should be given as directed. The DON stated when a medication direction is to give with breakfast, the resident should be actively eating when administering the medication in order for the resident to have some food in her stomach. The DON stated medications like potassium could make a resident nauseous and stomach discomfort which could cause a lot of harm. During a review of facility's policy and procedure (P&P) titled, Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated, 09/10, the P&P indicated, . 1. Medication error/variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm . Such events may be related to professional practice . procedures . including . administration . During a professional reference review retrieved from https://www.drugs.com/tips/potassium-chloride-patient-tips#:~:text=Take%20potassium%20chloride%20tablets%20with,are%20also%20high%20in%20potassium. Take potassium chloride tablets with food or just after a meal to reduce the risk of stomach irritation. Follow with a full glass of water. Some foods (such as squash, spinach, cabbage, lentils, kidney beans, orange juice, bananas, tomatoes, zucchini, or cucumber) are also high in potassium. Ask your doctor if there is a limit to how much of these foods you can eat. Some salt substitutes or low-salt dietary products also contain potassium - be careful how much of these you eat. Do not crush, break, chew, or suck extended-release potassium chloride tablets as doing this may cause too much potassium chloride to be released at once, irritating your throat and stomach. Tablets are designed to release potassium slowly over time. Sometimes you may notice the remnants of a potassium chloride tablet in your stool.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 3/27/24 at 10:10 am with LVN 1, in Station 2, inside cart 3, two boxes of omeprazole were in the third drawer of cart 3. The edge of the boxes with the expiration date had been removed. LVN 1 stated, she could not find an expiration date or a received date (a date when the medication had been opened) on either of the boxes. LVN 1 stated without an expiration date on the medication, Residents could potentially receive expired medication. LVN 1 stated expired medication could be less effective or have undesired side effects (unwanted, undesired effects). During a concurrent observation and interview on 3/27/24 at 10:30 a.m., in Medication room [ROOM NUMBER], with Director of Nurses, (DON), the DON confirmed the two boxes of omeprazole did not have received dates or expiration dates on them. The DON stated all medication in the medication carts are required to have expiration dates to prevent residents from receiving expired medications. During a review of the facility's policy and procedure titled, Medication Packaging dated 10/2007, indicated .a. All unit dose medications contain a lot number, expiration date, product name . Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles when two of two improper medication storage and labeling occured for: 1. Resident 5's hydromorphone (medication used to treat pain), hydrocodone-acetaminophen ( a narcotic medication used to treat pain) and lorazepam (medication used to treat anxiety) were found repacked in smaller plastic bags with no labels and placed back in the plastic medication container from the pharmacy. These failures had the potential for Resident 5 to not receive the right medication which could lead to more serious medical conditions and had the potential for drug diversion (abuse of prescription drugs or their use for purposes ot intended by the prescriber). 2. Medication cart three had two boxes of omeperazole (medication used to treat heartburn) without received dates (a date when the medication had been opened ) and did not have expiration dates on the boxes. This failure had the potential for residents to receive expired medications resulting in less efficacy. Findings: 1. During a concurrent observation and interview on 3/27/23, at 9:23 a.m. in Station 3, medication cart (cart 4). The medication cart contained a bottle of brand name of hydromorphone tablets were placed in three small plastic bags (used to crushed pills). The medication cart also contained a bottle of hydrocodone (a narcotic medication used to treat pain) tablets that were placed in three small plastic bags. Licensed Vocational Nurse (LVN) 4 stated Resident 5 was a hospice patient and hospice used a different pharmacy from the facility. LVN 4 stated since she started working in the facility, the loose narcotics had always been placed in smaller plastic bags for faster counting. LVN 4 stated she was not sure if the Director of Nursing (DON) or Assistant Director of Nursing (ADON) was aware of the practice of licensed nurses repacking narcotics in smaller plastic bags. During a review of Resident 5's clinical record titled, admission Record [AR-document containing resident ddemographic and medical diagnosis information], dated 3/28/24, the AR indicated, Resident 5 was admitted to the facility on [DATE] with diagnoses which included . heart failure [heart doesn't pump enough blood for the body's need], palliative care [care focused on providing pain relief and other serious illness] and chronic pain . During a review of Resident 5's Order Summary Report, dated 3/28/24, the Order Summary Report indicated, . [hydromorphone] Oral tablet two [2] MG [(Hydromorphone HCl) (hydrochloride] [milligram-unit of measurement] Give 0.5 tablet by mouth every four [4] hours as needed for pain 4-6 or dyspnea [difficulty breathing] . HYDROcodone-Acetaminophen Oral tablet 5-325 MG . Give one (1) tablet by mouth every six (6) hours related to OTHER CHRONIC PAIN . LORazepam Oral Tablet 0.5 MG (Lorazepam) . During an interview on 3/28/24, at 9:05 a.m., with LVN 2, she stated narcotics are labeled when delivered from pharmacy. LVN 2 stated, . It is a practice here to bag the narcotics in [set of 10 tablets] to make the counting process faster . LVN 2 stated she was not sure if it was a good practice placing the narcotics in smaller plastic bags then put back in the original container from the pharmacy because the plastic bags did not contain any labels. LVN 2 stated she was not sure if it was allowed to repack or transfer narcotics to smaller plastic bags because she was told by another nurse that they can to make counting of narcotics easy and faster. LVN 2 stated she now realized there was a higher chance of infection control and drug diversion (when medication is taken for use by someone other than whom it was prescribed). During an interview on 3/28/24, at 2:01p.m., with Registered Nurse (RN) 1, she stated, . Narcotics are never to be repacked, you have to leave the narcotics the way it was sent or delivered from the pharmacy . RN 1 stated narcotics can not be placed in small plastic bags for easy and faster counting. RN 1 stated licensed nurses can not repack and label narcotics, only pharmacist can. RN 1 stated she did not know why other nursing stations are repacking narcotics by transferring the tablets in smaller plastic bags. RN 1 stated it was not a good nursing practice. During an interview on 3/28/24, at 3:15 p.m., with the Director of Nursing (DON), she stated she was not aware the licensed nurses in other nursing stations were repackaging narcotics. The DON stated only the pharmacist has the right to repacked narcotics. The DON stated repacking narcotics is not approved practice, it could lead to a lot of other issues. During a review of facility's policy and procedure (P&P) titled, Medications and Medication Labels, dated 5/16, the P&P indicated, . 6. Medication labels are not altered . Contents are not transferred from one container to another . Only the pharmacy may place a label on the medication container .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide residents with a well-balanced diet to meet their nutritional needs for: 1.Three of five sampled residents (Resident 44, Resident 74 and Resident 83) when the Residents had a physician order for a supplement that was discontinued, and the Residents continued to receive the supplement. 2.Two of the five sampled residents (Resident 75 and Resident 30) when the Residents did not have a physician order for a chopped diet. This failure resulted in Resident 44, Resident 74 and Resident 83 receiving a discontinued supplement and had the potential to result in Resident 75's and Resident 30's nutritional needs not being met. Findings: 1. During a concurrent observation and interview on 3/25/24 at12:00 p.m., with [NAME] 3 and the Food Service Worker (FSW) 1, in the kitchen during the lunch meal service (a process when food is put into a tray) Resident 74 was missing a juice nutrition supplement (a nutritional supplement designed to support essential nutrients) eight ounces (oz). The surveyor asked FSW 1 if Resident 74 should have a juice nutrition supplement on her food tray. FSW 1 asked, What was a Breeze. [NAME] 3 indicated, there were no Breeze on the food tray for Resident 74. During a concurrent interview and record review on 3/26/24 at 4:42 p.m., with the Dietary Service Supervisor (DSS), Resident 74's Tray Ticket [a ticket which includes: name, room, diet, date, adaptive equipment, allergies, specific food and beverages items, likes and dislikes and notes] dated Tuesday March 26, 2024, was reviewed. The tray ticket indicated, on March 26, 2024, Resident 74 had supplements for Breeze 8 oz. The Surveyor and DSS reviewed the Ticket Tray for Resident 74. The DSS indicated, the Breeze was discontinued. The DSS stated, there were no communication slips (a paper form used to communicate to the kitchen of changes in diet) for Resident 74's. During a review of Resident 44's Tray ticket dated Wednesday March 27, 2024, the Tray ticket indicated, Resident 44's has supplement Honey Boost (a nutritional drink with protein and nutrients with honey consistency) 8 oz. During a review of Resident 44's .SNF-Progress Notes New (PNG) dated on 3/13/24 the PNG indicated the Registered Dietitian (RD) stated, Resident has boost nutritional supplement of equal or higher caloric value (8oz) TID with meals. Resident does not care for the nectar thickened fluids. Resident more receptive to drinking house shake. Rec house shake (4oz) TID with meals and d/c boost nutritional supplement of equal or higher caloric value (8oz) TID with meals--monitor on consumption of supplement. Will continue to monitor resident. During a record review of Resident 44's SNF-Order Audit Report (OAR) dated March 27, 2024, the OAR indicated, Order Summary .Boost/Nutritional Supplement of =/> caloric value with meals for Supplement (give 8 0z. (237 ml) by mouth was discontinued on 3/18/2024 at 3:49 p.m. During a review of Resident 83's Tray Ticket dated Wednesday March 27, 2024, the Ticket Tray indicated Resident 83 orders were for supplement Magic Cup ( a ice-cream like supplement with added calories and protein for Resident experiencing weight loss) 4 oz. During a review of Resident 83's SNF-Order Audit Report (OAR) dated [DATE], the OAR indicated, Order Summary: Magic cup two times a day for (give 4 oz (120 ml) with lunch and dinner at 1200 &1700 was discontinue 3/26/2024 @ 6:54 p.m. During an interview on 3/27/24 at 11:49 a.m. with the DSS, the DSS stated there was no diet communication slip to notify the kitchen of Resident 83's discontinues of the Magic cup. During an interview on 3/27/24 at 12:14 p.m., with the Director of Nursing (DON), the DON stated, the nurse should communicate the changes in diet order to the kitchen. The DON stated, the nurse could notify the kitchen of a discontinue or diet change to the kitchen by phone, in person or communication slip. During an interview on 3/27/24 at 12:37 with Resident 83, Resident 83 stated, I have asked them to stop giving magic cup a week ago. I put in the order for Sherbert cup yesterday. Resident 83 stated, I am not fond of it [magic cup] and they are good at letting me fix it [changing the supplement to something she likes]. During a concurrent interview and record review on 3/27/24 at 3:19 PM with the Assistant Director of Nursing (ADON), Resident 83's OAR dated [DATE], was reviewed. The OAR indicated Order Summary: Magic cup two times a day for (give 4 oz (120 ml) with lunch and dinner at 1200 &1700 was discontinued 3/26/2024 at 6:54 p.m. The DON indicated, the order was discontinued on 3/26/24. The ADON was asked the communication process between nurses and the kitchen staff. The ADON stated, I believe we have a communication log. The ADON indicated she was not sure and wanted to verify with the DON. The ADON went to the DON's office. The ADON confirmed with the DON and the ADON indicated, the nurses should communicate with the kitchen staff using the communication log. The ADON also indicated, the nurses can call or walk to the kitchen services to notify staff about the changes in the diet. The ADON indicated there was no communication slip sent to the kitchen about the discontinue Magic cup order for Resident 83. The ADON stated it was not acceptable to not communicate with the kitchen staff about changes in diet order for Resident 83. The ADON indicated lack of communication between the nurse and kitchen can lead to possible weight loss for Resident 83. During a review of the facility's (P&P) titled, Food and Service Policy & Procedures Manuel dated 2018, the P&P indicated, Nutrition Care .Diet orders for New Admission, diet changes, NPO, or hold meals .the facility will serve diets as ordered by the physician and in accordance with the approved diet manual .the nursing department is responsible for initiating the admission diet order . all diet orders and changes must be ordered on a Diet Communication Form (Page 93) and delivered to the Department of Food and Nutrition Services prior to the next meals . 2. During a record review of Resident 30's Tray Ticket dated Wednesday March 27, 2024, the Tray Ticket indicated, Resident 30's diet orders were for CCHO chopped meat, regular portion. During a record review of Resident 30's Order Details (OD) dated 2/19/2024, the OD indicated, Order Summary: CHHO diet, regular texture, regular (thin) consistency. No chopped meat was written in the OD. During a record review of Resident 75's Tray Ticket dated Wednesday March 27, 2024, the Tray Ticket indicated, Resident 75 diet orders were Regular chopped meat, regular portion. During a record review of Resident 75's Order Detailed (OD) dated 2/13/2024, the OD indicated, Order Summary: regular diet, regular texture, regular (thin) consistency. No chopped meat was written in the OD. During an interview on 3/27/24 at12:14 p.m., with the DON, the DON stated Resident 30 's diet order was CCHO regular texture and regular liquids. The DON stated, Resident 75's diet orders were regular diet and regular texture and thin consistency (regular thin fluids). During an interview on 3/27/24 starting at 2:24 p.m. with the RD and DSS, the RD stated diets or therapeutic diets should have a physician's order. During a record review of the facility's policy and procedure titled, Food Service Policy and Procedure (P&P) dated 2018, the P&P indicated, Menus .all menus will provide adequate nutrients to meet the special needs of the residents/patients, including special dietary modifications .Menus are planned to meet the nutritional needs of the residents/patients in accordance with the physician's diet order, the approved diet manual, federal/state regulations and in accordance with the most current edition of Dietary Reference intakes (DRI) from the Food and Nutrition Board of Institute of Medicine

Based on observations interviews and record review, the facility failed to ensure two of the seven sample residents (Resident 13 and Resident 21) small portion diet were not followed according to their alternate menu for lunch on March 25, 2024. The failure had the potential result to not meet the resident's caloric intake and contribute to weight loss, further compromising the medical status. Finding: During an observation on 3/25/24 at 12:00 p.m., in the kitchen during the lunch meal service, [NAME] 1 was observed using a #16 scoop (1/4 cup) of Spanish rice on Resident 13's and Resident 21's lunch tray. Review of the lunch tray ticket for Resident 13 and Resident 21 showed, they were on a small portion diet. During a concurrent interview and record review of the lunch menu on 3/25/24 at 12:33 p.m. after the lunch meal service was completed, with [NAME] 1 and Dietary Service Supervisor (DSS), the Daily Spreadsheet dated March 25, 2024, was reviewed. The Daily Spread sheet indicated Spanish rice small portion scoop size was #12 scoop (1/3 cup). [NAME] 1 stated scoop size #16 was used to serve Spanish rice for small portion. [NAME] 1 stated scoop size #16 was for the small portions diet. [NAME] 1 was asked by the surveyor to look at the lunch Daily Spreadsheet (menu) and identify the scoop size on the menu. [NAME] 1 did not respond. The DSS asked the surveyor team to clarify the question. The DSS confirmed the Spanish rice was supposed to be scoop sized #12 and not scoop size #16. During a record review of Resident 21 California Armenian Home-SNF Order Audit Report (OAR) dated 4/20/23 at 5:41 p.m. the OAR indicated, Resident 21 Order Summary for regular diet, regular texture, regular thin consistency and small portions. During a record review of Resident 13 California Armenian Home-SNF Order Audit Report dated 12/4/20 at 4:19 p.m. the OAR indicated, Resident 13 Order Summary for regular diet, regular texture, regular thin consistency and small portions. During an interview on 3/27/24 at 2:45 p.m. with the Registered Dietitian (RD), the RD was asked about her expectation for the kitchen staff for scoop sized. The RD stated the expectation is the correct scoop size should be followed for each resident based on the Daily Spreadsheet (menu). The RD she was notified of the resident getting scoop size #16 instead of scoop size #12. The RD stated the Daily Spreadsheet was not followed. The RD stated the portion size can potentially cause further weight loss for residents if not given the correct amount. During a review of the facility's Policy and Procedure (P&P) titled, Food Service Policy &Procedures Manuel dated 2018 the P&P indicated, Food preparation .portion control assures correct quantities are served to resident/patients to meet the nutritional specification as determined by the menu .resident/patient satisfaction is highest when expectation about amount of food received . The procedure stated scoops are sized according to the number of scoops need to equal one quart. The smaller the number, the larger the size.

Based on observation, interview and record review, the facility failed to ensure the food was prepared in accordance with professional standard for food service safety when one of two sampled kitchen staff (Cook 2) did not have a beard restraint while preparing food. This failure had the potential for [NAME] 2's hair to fall into the food and caused contamination. Findings: During a concurrent observation on 3/26/24 at 9:10 a.m. with the Dietary Service Supervisor (DSS), in the kitchen during food preparation, [NAME] 2 was observed slicing and measuring roast beef. [NAME] 2 was observed with a surgical mask that covered his mouth and nose only. It was observed that he had facial hair on the sides of his face that was without a beard restraint to cover his facial hair and beard. During an observation on 3/26/24 at 9:36 a.m. in the kitchen during food preparation, [NAME] 2 was observed putting roast beef into a food processor and chopped it. [NAME] 2 was observed putting roast beef with the juice from the roast beef into the food processor and blending it. [NAME] 2 was observed without no beard restraint to cover his facial hair and beard. During an interview on 3/27/24 at 2:25 p.m. with the Registered Dietitian (RD), the RD stated kitchen staffs were expected to wear a snood (a hairnet or fabric bag worn over the hair at the back). The RD stated beard restraint should be used in the kitchen. During an interview on 3/27/24 at 2:35 p.m. with the DSS, the DSS stated [NAME] 2 was not wearing his snood during food preparation. During a review of the facility's policy and procedure (P&P) titled, Food Service Policy and Procedures Manuel dated 2018, the P&P indicated, Sanitation and Infection Control .a hair net and/or head covering which, completely cover all hair, should be worn during meal preparation and service . Beards and/or mustaches should be covered during meal preparation and service .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 29's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 29 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), atherosclerotic heart disease (when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff), chronic systolic heart failure (when the heart is weak, and the left side can't contract [squeeze] normally when the heart beats), cardiomegaly (enlargement of the heart), anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), muscle weakness and shortness of breath. During a review of Resident 29's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS Section C indicated Resident 29 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 indicates severe cognitive impairment, 8-12 indicates moderately impaired, 13-15 indicates cognitively intact). Resident 29's BIMS score of 15 indicated Resident 29 was cognitively intact. During an interview on [DATE] at 11:04 a.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated a residents POLST should be filled out with the doctor's name and contact information. CNA 9 stated if the phone number was not written on the POLST, someone reading the POLST may not be able to get in contact with the doctor in case of an emergency. CNA 9 stated everything on the POLST should be filled out since it was a doctor's order. During a concurrent interview and record review on [DATE] at 9:21 a.m. with Registered Nurse (RN) 3, Residents 29's POLST, dated [DATE] was reviewed. The POLST indicated no physician phone number was present on Resident 29's POLST order. RN 3 stated the POLST was not fully completed. RN 3 stated the phone number should have been filled out by the physician. RN 3 stated a POLST was sent with residents whenever they were transferred out of the facility. RN 3 stated having the phone number was important to have in order to call the doctor in case of an emergency. During a concurrent interview and record review on [DATE] at 11:22 a.m. with the Assistant Director of Nursing (ADON), Residents 29's POLST, dated [DATE] was reviewed. The POLST indicated no physician phone number was present on Resident 29's POLST order. The ADON stated the POLST let people know if someone should receive cardiopulmonary resuscitation (CPR-lifesaving procedure done when someone's heart stops beating). The ADON stated the POLST was sent out with the resident if they were going to the hospital or when being discharged . The ADON stated she would have questioned the validity of a POLST if she saw the signature was missing. During a review of Resident 77's AR, dated [DATE], the AR indicated Resident 77 was admitted on [DATE] with diagnoses of heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), end stage renal disease (a condition where the kidneys can no longer function on their own and dialysis [a process of removing excess water, and waste products from the blood] or kidney transplant is required to survive), and chronic atrial fibrillation (an irregular and often very rapid heart rhythm lasting more than a week). During a review of Resident 77's MDS, dated [DATE], the MDS section C indicated Resident 77 had a BIMS score of 15, which indicated Resident 77 was cognitively intact. During a concurrent interview and record review on [DATE] at 9:51 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 77's POLST, dated [DATE] was reviewed. The POLST indicated, the Physician/Nurse Practitioner (NP)/Physician's Assistant (PA) Phone number fields were not completed and the Physician/PA License number, NP Certification number were not completed. LVN 6 stated Resident 77's POLST was incomplete. LVN 6 stated the physician phone number and physician license number were missing. LVN 6 stated the physician phone number and license number should be completed. LVN 6 stated Resident 77's POLST was null and void. LVN 6 stated staff would not get in touch with the physician right away and that could delay treatment. During a concurrent interview and record review on [DATE] at 11:23 a.m. with the Director of Nursing (DON), Resident 77's POLST, dated [DATE] was reviewed. The POLST indicated, the Physician/Nurse Practitioner (NP)/Physician's Assistant (PA) Phone number fields were not completed and the Physician/PA License number, NP Certification number were not completed. The DON stated the POLST told the nurse and staff members what the wishes were of the resident or responsible party (RP). The DON stated the POLST indicated if Cardiopulmonary Resuscitation (CPR - an emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped. CPR combines rescue breathing and chest compressions), nutrition or certain measures were in place, such as comfort measures. The DON stated the POLST was sent with the resident if they were transported out of the facility. The DON stated without the physician phone number and license number, the POLST was not completed. The DON stated if the POLST was not completed staff would have to do CPR on the resident, which could violate the wishes of the resident or family member if that is not what they wanted. The DON stated her expectation was for the POLST to be completed. During an interview on [DATE] at 11:45 a.m. with the admission Coordinator (AC), the AC stated the POLST let us know what the wishes were for the resident in the event of an acute emergency. The AC stated the POLST would go with the resident if they were transported out of the facility. The AC stated if the POLST did not have the physician phone number or license number, staff could still use it. The AC stated she did not believe the physician's phone number and license number were required for the POLST to be a valid document. The AC refused to validate if the POLST was incomplete without the Physician/NP/PA phone number, Physician/PA License number, NP Certification number, or additional contact fields completed. During a review of Resident 81's AR, dated [DATE] , the AR indicated Resident 81 was admitted on [DATE] with diagnoses of diffuse large B-cell lymphoma (blood cancer that affects the white blood cells), Major depressive disorder (disease that causes sadness), anemia (disease that occurs when the body doesn't have enough red blood cells to carry oxygen) and tumor lysis syndrome (condition In which cancer cells go into the bloodstream). During a review of Resident 81's MDS, dated [DATE], the MDS section C indicated Resident 81 had a BIMS score of 15, which indicated Resident 81 was cognitively intact. During a concurrent interview and record review on [DATE] at 9:21 a.m. with RN 3, Residents 81's POLST, dated [DATE] was reviewed. The POLST indicated no physician phone number was present on Resident 81's POLST order. RN 3 stated Resident 81's POLST was not fully completed. RN 3 stated the phone number should have been filled out by the physician to have a complete form. RN 3 stated having the phone number was important in order to call the doctor in case of an emergency. During a concurrent interview and record review on [DATE] at 11:22 a.m. with the assistant director of nursing (ADON), Residents 81's POLST, dated [DATE] was reviewed. The POLST indicated, no physician phone number was present on Resident 81's POLST order. The ADON stated a POLST lets people know if someone should receive CPR or not. The ADON stated she would have questioned the validity of a POLST if she saw the signature missing. The ADON refused to validate if Resident 81's POLST was incomplete. During a review of Resident 83's AR, dated [DATE], the AR indicated Resident 83 was admitted on [DATE] with diagnoses of multiple fractures of pelvis (a break of the ring of bones that connect your spine to the hips), fracture of sacrum (a break of the large triangular bone at the bottom of the spine), and multiple fractures of ribs (several breaks in the rib bones). During a review of Resident 83's MDS, dated [DATE], the MDS section C indicated Resident 83 had a BIMS score of 15, which indicated Resident 83 was cognitively intact. During an interview on [DATE] at 11:02 a.m. with Resident 83, Resident 83 stated she would want her significant other and daughter-in-law notified if she were sent out to another facility. During a concurrent interview and record review on [DATE] at 9:51 with LVN 6, Resident 83's POLST was reviewed. LVN 6 stated the Additional Contact field was not completed. LVN 6 stated no additional contact information was entered. LVN 6 stated the information should be entered. LVN 6 stated having additional contact information would be helpful to notify the person listed as an additional contact if the resident was sent out of the facility. LVN 6 stated Resident 83's family would want to be notified. During an interview on [DATE] at 11:45 a.m. with the AC, the AC stated the POLST let us know what the wishes were for the resident in the event of an acute emergency. The AC stated the POLST would go with the resident if they were sent out of the facility. The AC stated the family information is on the admit sheet. The AC stated the facility would communicate with the family who was next in line if the resident was sent out of the facility. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, indicated, . documentation in the medical record will be objective (not opinionated or speculative), complete and accurate . Based on interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards when: 1. One of four residents (Resident 52) medical record did not reflect when change of the humidifier bottle (medical devices filled with water that increase the humidity in the oxygen being delivered) and amount of oxygen administered was not accurately documented. This failure placed Resident 52 at risk of the humidifier bottle not being changed timely, the water becoming stagnant (stale or foul), oxygen would not be humidified leading to dry, cracked and bleeding mucosal membranes (the moist outer layer that lines various cavities in the body) and receiving the incorrect amount of oxygen. 2. Four of eight sampled residents (Residents 29, 77, 81and 83) Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. This failure had the potential for Resident 29, 77, 81 and 83's decisions regarding treatment options and end of life wishes to not be honored. Findings: 1. During a concurrent observation and interview on [DATE] at 10:25 a.m. with Registered Nurse (RN) 3 in Resident 52's room, the humidifier bottle was observed to have a date label of 3/19. The RN 3 stated, it was last changed at that date and needed to be changed every 3 days. The RN stated, it should have been changed on 3/22. During a concurrent interview and record review on [DATE] at 9:30 a.m. with Licensed Vocational Nurse (LVN) 1 Resident 52's Order Summary (OS) dated [DATE] was reviewed. The OS indicated, Change Humidifier Bottle every night shift every 3 day(s). The LVN 1 stated, all licensed nurses are responsible for changing the bottle. The LVN 1 stated, if the liquid runs out .the oxygen may not be properly humidified, the patient may develop dry nose, and bacteria can grow with an expired bottle. During a concurrent interview and record review on [DATE] at 9:57 a.m. with LVN 1 Resident 52's Medical Administration Record (MAR), dated [DATE] was reviewed. The MAR indicated, the humidifier bottle was changed on Fri 22 signed by SJL. The LVN 1 stated, because the bottle was still dated 3/19, it did not reflect the MAR documentation that it was changed on 3/22. The LVN 1 stated, the bottle was not changed on 3/22. During an interview on [DATE] at 8:51 a.m. with the Director of Nurses (DON), the DON stated, humidifier bottles should be changed every 3 days. The DON stated, if the bottle was dated 3/19, it should have been changed on 3/22. During a concurrent interview and record review on [DATE] at 8:55 a.m. with the DON, Resident 52's MAR, dated [DATE] was reviewed. The DON stated, the MAR indicated, on 3/22 an LVN initialed to indicate the humidifier bottle was changed. The DON stated, it is not OK to sign that you did something that wasn't done. The DON stated, if the humidifier bottle hasn't been changed, the water could become stagnant and or run out. The DON stated, this can cause dry mucous membranes resulting in bleeding from the nose, discomfort, sores, and pain. During a concurrent interview and record review on [DATE] at 9:15 a.m. with the DON, Resident 52's MAR, dated [DATE] was reviewed. The DON stated, no they [MAR documentation of change of the humidifier bottle signed 3/22] are not accurate, it does not appear to be accurate. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated [DATE], the P&P indicated, Documentation in the medical record will be .accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement safe infection control measures for two of three sampled residents (Resident 2 and Resident 4) when: Resident 2's urinary catheter bag (a tube that is inserted into the bladder, allowing the urine to drain freely into an attached bag), and Resident 4's urinary tubing was observed lying on the floor. This failure had the potential to spread harmful bacteria (microorganisms that can be found on surfaces and in the body), infections to both Resident 2 and Resident 4. Findings: During a review of Resident 4's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/27/24, the AR indicated Resident 4 was admitted on [DATE] with diagnoses of obstructive and reflux uropathy (a condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys), retention of urine (a condition where the bladder does not empty completely or at all), type II diabetes mellitus (a disease that occurs when your blood sugar is too high) and congestive heart failure (a condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/6/24, the MDS section C indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 12 (a score of 0-7 indicates severe cognitive impairment, 8-12 indicates moderately impaired, 13-15 indicates cognitively intact), which indicated Resident 4 was moderately impaired. During a concurrent observation and interview on 3/25/24 at 11:17 a.m. with the Director of Nursing (DON) in Resident 4's room, Resident 4 was observed with her urinary catheter tubing touching the floor. The DON verified the catheter tubing was on the floor. The DON stated the catheter tubing should not be touching the floor. The DON stated the catheter tubing could get dislodged. The DON stated if germs move up the catheter, it could cause infection in the resident. During an interview on 3/27/24 at 9:33 a.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated the catheter tubing should not be on the floor. CNA 8 stated if the catheter was on the floor it was contaminated. CNA 8 stated the resident could catch an infection. CNA 8 stated the tubing should be stored in a privacy bag for cover and so it would not be on the floor. During an interview on 3/27/24 at 9:51 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated the catheter tubing should not be dragging on the floor. LVN 6 stated the catheter should be covered with a protected cover. LVN 6 stated if the resident is in a wheelchair, the catheter should be on the side of the wheelchair, the catheter tubing should not drag on the ground. LVN 6 stated it is an infection control issue for the resident and everyone else. LVN 6 stated if the catheter wasn't cleaned properly, it could get urine on ground. LVN 6 stated if there were germs on the ground, they could travel back up to the resident through the catheter tubing and the resident could get an infection. During a review of Resident 2's admission Record (AR), dated 03/27/24, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis which included Dementia (impaired thinking, remembering or reasoning), Type 2 Diabetes Mellitus (high levels of sugar in the blood), Anemia (lower than normal red blood cells), Neuromuscular Dysfunction (nerve and muscle weakness and pain), Hypertensive Heart Disease with Heart Failure (higher than normal blood pressure causing the heart not to function correctly), Dysphagia (swallowing difficulties), Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms (a buildup of prostatic tissue against the urethra making it difficult to urinate). During a review of Resident 2's MDS Section C dated 06/22/24, Resident 2's BIMS score was 4 which indicated severe cognitive impairment. During the initial tour of the facility on 03/25/24 at 9:57 a.m., in Resident 2's room, Resident 2's urinary catheter drainage bag was observed lying on the floor next to the left side of Resident 2's. During a concurrent interview and record review on 03/25/24 at 04:22 p.m., with LVN 8, LVN 8 verified the catheter bag was on the floor. LVN 8 stated the Catheter bag should not be on the floor. LVN 8 stated the bacteria from the floor could have gone up the catheter tubing into the resident. During a concurrent interview and record review on 03/27/24 at 11:12 a.m. with the Infection Preventionist (IP), IP verified that the catheter bag was on the floor. IP stated, urine catheter bags should never be on the floor, it put the resident at risk for infection. The IP stated the facility's policy on urinary catheter care was not followed. During a concurrent interview and record review on 03/27/24 at 4:21p.m. with the Director of Staff Services (DSD), DSD verified the catheter bag was on the floor. The DSD stated, Resident 2's catheter bag should never have touched the floor. DSD stated the urinary catheter bag should not have contact with the floor it could have spread infection from the floor up the catheter tubing and into the resident. The DSD stated the catheter on the floor is not the expected practice for catheter care. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 8/2022, indicated, . the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . be sure the catheter tubing and drainage bag are kept off the floor . During a review of the facility's P&P titled, Policies and Practices - Infection Control, dated 10/2018, indicated, . the objectives of our infection control policies and practices are to: prevent, detect, investigate, and control infections in the facility .

Based on interview and record review, the facility failed to follow the policy and procedure titled In-service Training to ensure Licensed Nurses (LNs), Certified Nursing Assistants (CNAs) and ancillary (additional) support staff received and demonstrated competency to prevent and recognize resident abuse and the necessary skills and techniques necessary to care for residents with Dementia [a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning] when: 1. 36 of 67 CNAs had not attended and completed the 2023 annual mandatory in-service training for Dementia Module 1 titled Caring for Persons with Dementia. 2. 47 of 67 CNAs had not attended and completed the 2023 annual mandatory in-service training for Dementia Module 4 titled More than Words. 3. 22 of 120 facility staff had not attended and completed the 2023 annual mandatory in-service training for Fall Prevention. 4. 50 of 120 facility staff had not attended and completed the 2023 annual mandatory in-service training for Abuse Prevention. These failures had the potential to place residents at risk for care not provided in a safe and competent manner. Findings: During a concurrent interview and record review on 3/26/24, at 4:14 p.m., with the Director of Staff Development (DSD), the in-service training for Dementia Module 1, titled Caring for Persons with Dementia, dated 1/11/23 and 1/23/23 was reviewed. The DSD stated, they have 67 CNAs providing direct care to facility residents. The document indicated 36 of 67 CNAs had not attended the mandatory training. The DSD stated, Dementia modules, including Module 1, were mandatory trainings for CNAs and should be completed annually. During a concurrent interview and record review on 3/26/24, at 4:19 p.m., with the DSD, the in-service training for Dementia Module 4, titled More Than Words, dated 9/26/23 and 9/28/23 was reviewed. The document indicated 47 of 67 CNAs had not attended the mandatory training. The DSD stated, Dementia modules, including Module 4, were mandatory trainings for CNAs and should be completed annually. During a concurrent interview and record review on 3/26/24 at 4:27 p.m. with the DSD, the in-service training for Fall Prevention dated 9/28/23 and 9/29/23 was reviewed. The DSD stated, they have 120 employees providing direct and indirect care to facility residents. The document indicated 22 of 120 facility staff had not attended the mandatory training. The DSD stated, the in-service training for Fall Prevention was mandatory training for all staff. The DSD stated, without the training, staff would not have the proper knowledge on preventing residents from falling. During a concurrent interview and record review on 3/26/24 at 4:35 p.m. with the DSD, the in-service training for Abuse Prevention dated 5/5/23, 5/25/23 and 5/31/23 was reviewed. The document indicated 50 of 120 facility staff had not attended the mandatory training. The DSD stated, the in-service training for Abuse Prevention was mandatory training for all staff. The DSD stated, without the training, staff would not have the proper knowledge on preventing resident abuse. During a concurrent interview and record review on 3/28/24 at 11:47 a.m. with the Director of Nursing (DON), the 2023 In-service Training Calendar was reviewed. The DON stated, the trainings for Abuse Prevention, Fall Prevention, and Dementia Module 1 and Module 4 were mandatory trainings and should be completed annually. The DON stated, in-service training should be attended by LNs, CNAs, and support staff to provide proper care to facility residents. During a review of the facility's Resident matrix [listing of residents by medical conditions] dated 3/25/24, indicated there were 27 of 87 residents diagnosed with Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) or Dementia. During a review of the facility's policy and procedure (P&P) titled, Staff Development Program, undated, the P&P indicated, . All employees receive, at time of hire and periodically thereafter, in-service training relative to resident rights and our facility's abuse prevention program policies and procedures . Annual in-service training programs include educational sessions on such topics as: a. Understanding the resident's abusive actions . d. Recognizing signs and symptoms of abuse . f. dealing with aggressive or catastrophic resident behavior/reactions . During a review of the facility's P&P titled, Preventing Resident Abuse, undated, the P&P indicated, . Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training program, systems . 2. Our abuse prevention/intervention program includes . c. In-service training programs designed to teach staff how to better understand the resident's abusive actions . The professional reference document titled Center for Clinical Standards and Quality/Survey & Certification Group, dated 9/14/12, indicated The Affordable Care Act: Section 6121 requires the Centers for Medicare & Medicaid Services (CMS) to ensure that nurse aides receive regular training on caring for residents with dementia and on preventing abuse. CMS created this training program to address the requirement for annual nurse aides training on these important topics. During a review of the facility's document titled, Certified Nurse Aide Job Description, undated, the document indicated, . Provides for resident's personal hygiene, give bedpans, urinals, baths, backrubs . Provides comfort needs of residents . Follows all policies, procedures and regulations governing the facility . Attend all required In-service Training sessions . During a review of the facility's document titled, Director of Staff Development Job Description, undated, the document indicated, . Functions as an education instructor in the development and implementation of policies and procedures. Provides on-going In-service Education as required by regulation and facility needs . Develops In-service education calendar for all mandatory in-service meetings per regulations . During a professional reference review retrieved from https://www.nursinghomeabuse.org/articles/nursing-home-abuse-training/ titled, Abuse and Neglect Training in Nursing Homes, dated 3/31/21, the professional reference indicated, .Nursing home abuse and neglect is unfortunately still a problem in nursing homes across the country. Nursing homes can significantly reduce the incidence of abuse and neglect in their facilities by investing in training and prevention. Nursing home facilities that do offer training have shown to have fewer cases of abuse and neglect .

Based on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed of properly when two of two trash dumpsters were not closed after disposing of garbage bags. This failure had the potential to attract pests to the dumpsters that could lead to pests in the facility kitchen and compromise the food served to residents. Findings: During a concurrent observation and interview on 3/1/23, at 11:58 a.m., with the Dietary Manager (DM), outside the kitchen near the outside dumpsters, there were two trash dumpsters filled with white trash bags, with both lids opened and exposed to the outside. The DM stated the trash dumpster lids should have been closed. The DM stated facility staff should have closed the dumpster lids after placing trash bags in dumpsters. The DM stated it was important to have the dumpster lids close to prevent any pests such as insects and rodents from feeding on trash. The DM stated pests could begin to congregate near the trash and possibly lead into the kitchen and compromise the sanitation of the kitchen. During an interview on 3/2/23, at 11:30 a.m., with the Director of Nursing (DON) and Director of Staff Development (DSD), the DON stated trash dumpsters lids should have been closed to prevent any pests from tracking into the facility's kitchen. The DON stated it was important to keep any pests out of the facility to ensure proper sanitation of the facility. During a review of the facility's policy and procedure titled, Waste Control and Disposal, dated 2018, indicated, . 9. Keep lids of outside trash dumpsters closed. 10. Outside trash compactors require a protective cover to prevent pests, animals, or debris from falling in .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adhere to proper infection control practices to prevent the transmission of Norovirus (contagious [spreads from one person to another] virus spreads through contaminated food, water or surfaces and causes vomiting and diarrhea) when: 1. One of two Certified Nursing Assistant (CNA 1) did not don (put on) a gown when entering five residents' rooms (Resident 1, 2, 3, 4, and 5) who were under contact (physical touching) isolation precaution (steps that healthcare facility visitors and staff need to follow before going into a patient's room; help stop germs from spreading so other people don't get sick; precautions used for patients who have germs that can spread by touching the patient or surfaces in their room) for Norovirus. 2. Two of two CNAs (CNA 1 and 2) did not properly perform hand hygiene for five residents (Resident 1, 2, 3, 4, 5) when exiting residents' rooms who were under contact isolation for Norovirus. These failures had the potential to result in spread of the Norovirus infection to other residents or staff which could result in stomach complications (severe dehydration, nausea, vomiting, diarrhea) leading to death. Findings: 1. During an interview on 3/1/23, at 10 a.m., with the Director of Nursing (DON), the DON stated the facility had an outbreak of Norovirus which started on 2/20/23. The DON stated a resident was sent to the hospital on 2/20/23 and tested positive for Norovirus. The DON stated the facility had set up Nurses Station 3 to isolate residents who had symptoms related to Norovirus such as nausea, vomiting and diarrhea. The DON stated there were five residents on isolation precautions on Nurses Station 3. During a review of Resident 1's admission Record, (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/2/23, the AR indicated, . admission Date 8/10/21 . During a review of Resident 1's Order Summary Report (OS), dated 3/1/23, the OS indicated, . Resident is placed on contact precaution isolation for five days . During a review of Resident 2's AR, dated 3/2/23, the AR indicated, . admission Date 9/23/19 . During a review of Resident 2's OS, dated 3/1/23, the OS indicated, . Resident is placed on contact precaution isolation for five days . During a review of Resident 3's AR, dated 3/2/23, the AR indicated, . admission Date 2/3/23 . During a review of Resident 3's OS, dated 3/1/23, the OS indicated, . Resident is placed on contact precaution isolation for five days . During a review of Resident 4's AR, dated 3/2/23, the AR indicated, . admission Date 12/4/20 . During a review of Resident 4's OS, dated 3/1/23, the OS indicated, . Resident is placed on contact precaution isolation for five days . During a review of Resident 5's AR, dated 3/2/23, the AR indicated, . admission Date 12/11/20 . During a review of Resident 5's OS, dated 3/1/23, the OS indicated, . Resident is placed on contact precaution isolation for five days . During an observation on 3/1/23, at 12:22 p.m., at the Nurses Station 3, near Resident 1's room (room [ROOM NUMBER]), there was a sign on the wall. The sign indicated . Warning Contact Precautions All persons entering the room must wear gloves, gown . CNA 1 walked into Resident 1's room with a meal tray with no gown. CNA 1 walked into Residents 2, 3, 4, and 5's rooms without wearing a gown while passing meal trays. During an interview on 3/1/23, at 1 p.m. with CNA 1, CNA 1 stated Nurses Station 3 was set up to be an isolation unit for any resident experiencing symptoms of Norovirus such as nausea, vomiting and diarrhea. CNA 1 stated staff needed to wear gloves and gown when coming in contact with residents, especially when performing ADL (activities of daily living-dressing, toileting, feeding) care. CNA 1 stated she did not need to wear a gown while passing meal tray to residents, as she was not touching any surfaces in the room. During an interview on 3/1/23, at 1:08 p.m., with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated any staff walking into contact isolation rooms needed to wear gown and gloves. LVN 1 stated all CNAs passing trays should have been wearing gowns because they could touch surfaces accidentally and could pass the Norovirus to other areas or residents. LVN 1 stated it was important to wear all personal protective equipment (PPE- gown and gloves for all interactions that involved contact with the patient and the patient environment). LVN 1 stated PPE should be donned prior to room entry and doffed at the point of exit. LVN 1 stated prevention of spread of the Norovirus was important to ensure no residents or staff would get infected and become sick. LVN 1 stated CNA 1 should have worn a gown while passing meal trays to residents. During an interview on 3/2/23, at 11;30 a.m., with the DON and the Director of Staff Development (DSD), the DSD stated staff were provided in-services on proper PPE use for residents experiencing gastrointestinal (pertaining to the stomach and intestines) symptoms associated with the Norovirus. The DSD stated all staff working in the contact isolation unit should have been wearing gowns and gloves anytime when entering residents' rooms. The DON stated CNA 1 should have been wearing a gown while passing trays to residents in contact isolation to prevent the potential spread of the virus to other areas and/or residents. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment, dated October 2018, indicated, . 1. Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate protective equipment (PPE) . 3. The type of PPE required for the task is based on: a. the type of transmission-based precautions . 5. Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals . During a review of the facility's P&P titled, Personal Protective Equipment-Gowns, Aprons, Lab Coats, dated July 2009, indicated, . 1. Personnel must wear a gown, apron, or lab coat when performing a task that will likely soil the employee's clothing with blood, body fluids, secretions, or excretions . 9. Employees must receive training relative to the use of gowns, aprons, and lab coats and other protective equipment prior to being assigned tasks that involve potential exposure to blood or body fluids and when new or modified protective equipment or procedures have been introduced into the workplace . 2. During an observation on 3/1/23, at 12:22 p.m., at the Nurses Station 3, near Resident 1's room, there was a sign on the wall. The sign indicated, Warning Contact Precautions All persons exiting this room must wash hands with soap and water . CNA 1 exited Resident 1's room and used the alcohol based hand rub (ABHR-hand sanitizer used when your hands are not visibly soiled to reduce the number of most transient microorganisms on your hands) to clean her hands. During an observation on 3/1/23, at 3:35 p.m., at the Nurses Station 3, near Resident 1's room, CNA 2 walked out of the room and used hand sanitizer. CNA 2 walked into Resident 4 and 5's rooms, exited the room and used hand sanitizer to clean hands after exiting. During an interview on 3/1/23, at 4:05 p.m., with CNA 2, CNA 2 stated she should have used the hand sanitizer when entering and exiting residents' rooms. CNA 2 stated it was important to perform proper hand hygiene after caring for residents with suspected Norovirus to prevent the spread to other residents in the facility. During an interview on 3/2/23, at 11:30 a.m., with the DON and DSD, the DSD stated staff needed to be in-serviced on proper hand hygiene when caring for residents with Norovirus symptoms. The DSD stated all staff entering into contact isolation rooms with residents suspected of Norovirus should have been washing hands with soap and water in between resident care and when exiting residents' rooms. The DSD stated staff should have been washing hands with soap and water inside the residents' restroom before exiting the rooms. The DON stated it was important to perform proper hand hygiene for residents suspected of Norovirus to prevent the spread any further infection to other resident and/or staff. During a review of the facility's P&P titled, Norovirus Prevention and Control, dated October 2011, indicated, . This facility will implement strict infection control measures to prevent the transmission of norovirus infection . 7. During outbreaks, use soap and water for hand hygiene after providing care or having contact with residents suspected or confirmed with norovirus gastroenteritis (a very common condition that causes diarrhea and vomiting. It's usually caused by a bacterial or viral stomach bug) . During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated August 2019, indicated, . 3. Hand hygiene products and supplies (sinks, soap, towels .) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . 6. Wash hands with soap and water for the following situations . b. After contact with a resident with infectious diarrhea including, but no limited to infections caused by norovirus .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a baseline care plan for one of three sampled residents (Resident 73), when Resident 73 was admitted with hearing aids and the facility did not establish a care plan with interventions to address Resident 73's hearing needs. This failure had the potential to result in Resident 73 not having her hearing needs met. Findings: During a concurrent observation and interview on 4/18/22, at 3:19 p.m., with Resident 73, in Resident 73's room, Resident 73 was awake in her bed. Resident 73 had a hearing aid to her left ear and without a hearing aid to the right ear. Resident 73 stated her right hearing aid was missing. Resident 73 stated she kept her hearing aids in a pink box in her room. During a review of Resident 73's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 4/6/22, the MDS assessment indicated, Resident 73 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation, and memory recall) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 73 had no cognitive impairment. During a concurrent interview and record review, on 4/19/22, at 9:19 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 73's .Resident's Personal Items dated 3/30/22 was reviewed. The Personal Items indicated, . 3/30/22 . hearings aids [with] bag . LVN 2 stated Resident 73 wore hearings aids. During an interview on 4/20/22, at 9:41 a.m., with Certified Nursing Assistant (CNA) 9, CNA 9 stated 4/20/22 was the first time she cared for Resident 73. CNA 9 stated she was not aware Resident 73 wore hearing aids. During an interview on 4/20/22, at 3:15 p.m , with LVN 1, LVN 1 stated she was aware Resident 73 wore hearing aids. LVN 1 stated when a resident was admitted with hearing aids, a care plan should be developed for the hearing aids. LVN 1 stated a care plan for Resident 73's hearing aids was developed on 4/20/22. LVN 1 stated Resident 73's care plan for hearing aids should have been developed upon admission on [DATE]. LVN 1 stated it was important to have a care plan in place in case the hearing aids went missing. LVN 1 stated the care plan needed to indicate the reasons why Resident 73 wore hearing aids. During a review of Resident 73's .Resident's Personal Items, dated 3/30/22, the Resident's Personal Items indicated, Resident 73 was admitted with black Hearing Aids [with] bag. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated, .8. The Comprehensive, person-centered care plan will . Incorporate identified problem areas .; Incorporate risk factors associated with identified problems . Aid in preventing or reducing decline in the resident's functional status and or functional levels . The comprehensive, person-centered care plan is developed within (7) days of the completion of the required comprehensive assessment (MDS) .

Based on interview and record review, the facility failed to develop a comprehensive care plan with measurable objectives and timeframes for one of 19 sampled residents (Resident 52), when Resident 52 required oxygen at night and a care plan was not developed to address Resident 52's respiratory needs. This failure had the potential for Resident 52's respiratory needs to be not met, which could lead to respiratory issues and/or death. Findings: During a review of Resident 52's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 7/2/21 .Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) . During a review of Resident 52's Order Summary Report (OS), dated 7/9/21, the OS indicated, .Oxygen at 2L/min (liters per minute- unit of measurement) via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person) at bedtime for shortness of breath (SOB) . During a concurrent interview and record review on 4/20/22, at 2:19 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 52's Care Plan was reviewed. LVN 1 stated Resident 52 used oxygen at night for SOB. LVN 1 stated there was no care plan indicating interventions for oxygen use. LVN 1 stated there needed to be a care plan for oxygen use to identify goals and interventions Resident 52 may need to maintain normal oxygen levels. During an interview on 4/20/22, at 2:48 p.m., with the Director of Nursing (DON), the DON stated care plans for oxygen dictate what problems nurses could anticipate with oxygen and how to resolve those issues. The DON stated an oxygen care plan could assist nurses, and therapists in determining the oxygen levels Resident 52 could tolerate. The DON stated there should have been an oxygen care plan in place for Resident 52 to identify goals for respiratory status. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plans, dated December 2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 55 and Resident 44) with an indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder) received appropriate care when: 1. Resident 55's indwelling urinary catheter had sediment (substances present in urine) trapped in the tubing and the physician was not notified; and 2. Resident 44's indwelling urinary catheter bag was partially folded and placed sideways in the catheter bag (bag used to cover the urinary catheter bag for privacy), preventing the free flow of urine. These failures placed Residents 55 and 44 at risk for urinary tract infections (infection in any part of the urinary system, the kidneys, bladder, or urethra). Findings: 1. During a review of Resident 55's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 3/15/22 .Diagnosis Information . Other Pulmonary Embolism (blood clot in the lungs) .Neuromuscular Dysfunction of Bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) . Urinary Tract Infection . Encounter for fitting and Adjustment of Urinary Device (drain urine via tubing attached to a bag ) . During a review of Resident 55's Order Summary Report (OS), dated 4/20/22, the OS indicated, .Change Foley Catheter . draining to gravity as needed for infection, obstruction or closed system is compromised related to NEUROMUSCULAR DYSFUNCTION OF BLADDER . During a concurrent observation and interview on 4/18/22, at 2:11 p.m., with Certified Nursing Assistant (CNA) 1, Resident 55's indwelling urinary catheter hung in a bag on the bedrail and had a large amount of sediment in the tubing. CNA 1 stated Resident 55 did not drink water often and the sediment was normal for her. During a concurrent observation and interview on 4/19/22, at 2:56 p.m., with Licensed Vocational Nurse (LVN) 4, Resident 55's indwelling urinary catheter tubing had a large amount of sediment. LVN 4 stated the buildup of white sediment in the tubing was not normal. During a concurrent interview and record review on 4/19/22, at 3:03 p.m., with LVN 4, Resident 55's physician orders and progress notes were reviewed. LVN 4 stated she was unable to locate documentation Resident 55's physician had been notified about the sediment in her urine. LVN 4 stated urine should be clear and Resident 55's urine should be checked for an infection. During a concurrent observation, interview, and record review on 4/21/22, at 8:47 a.m., with LVN 3, Resident 55's indwelling urinary catheter was observed. LVN 3 stated the night nurse changed the indwelling urinary catheter bag once a week and would date the bag when it was changed. LVN 3 donned (put on) gloves and picked up Resident 55's indwelling catheter bag. LVN 3 stated she was unable to locate a date on the bag. LVN 3 stated Resident 55's urine had an abnormal appearance and the sediment in the tubing could cause the urine to flow back into the bladder. LVN 3 reviewed Resident 55's electronic medical record and stated Resident 55 had a urinalysis (test of urine used to detect a wide range of disorders, such as urinary tract infections, kidney disease and diabetes) on 2/27/22 and it indicated she had a urinary tract infection. During an interview on 4/21/22, at 12:08 p.m., with the Director of Nursing (DON), the DON stated when an indwelling urinary catheter had a large amount of sediment, the bag should be changed and reported to the physician. The DON stated the bag should be dated when it was changed. The DON reviewed the photo of Resident 55's indwelling urinary catheter tubing and stated the physician should have been notified for further follow up. The DON stated the risk of sediment buildup in the urinary catheter tubing would be that the resident could become septic (life-threatening condition in which the body is fighting a severe infection that has spread via the bloodstream). During a record review Resident 55's care plan, untitled and undated, the care plan indicated, .Problem . Foley Catheter . draining to gravity r/t (related to) Neurogenic bladder . Goal . The resident will show no s/sx (signs and symptoms) of Urinary infection . Monitor/record/report to MD for s/sx UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness . foul smelling urine . During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated September 2014, the P&P indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections . Complications . 1. Observe the resident for complications associated with urinary catheters . b. Check the urine for unusual appearance (i.e., color, blood, etc.) . e. Observe for other signs and symptoms of urinary tract infection or . Report findings to the physician or supervisors immediately . Documentation . The following information should be recorded in the resident's medical record: .4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor . 2. During a review of Resident 44's AR, dated 4/20/22, the AR indicated, admission Date 3/3/22 .Diagnosis Information . Pneumonia (lung inflammation caused by bacterial or viral infection) . Neuromuscular Dysfunction of Bladder . Urinary Tract Infection . Encounter for fitting and Adjustment of Urinary Device . During a review of Resident 44's OS, dated 4/20/22, the OS indicated, .Change Foley Catheter .draining to gravity as needed for infection, obstruction or closed system is compromised related to NEUROMUSCULAR DYSFUNCTION OF BLADDER . During an observation on 4/19/22, at 2:38 p.m., at Resident 44's bedside, Resident 44's indwelling urinary catheter bag was folded over on itself and placed in the bag sideways. During a concurrent observation and interview on 4/19/22, at 2:42 p.m., with CNA 1, Resident 44's catheter bag was observed halfway in the dignity bag. CNA 1 stated Resident 44's indwelling urinary catheter bag was crunched and put in the bag. CNA 1 stated the catheter bag should be hung on the bedframe hanging down so the urine could flow freely through the tubing. CNA 1 took Resident 44's indwelling urinary catheter bag out of the bag. CNA 1 stated the position the indwelling urinary catheter bag was in, would have prevented it from draining correctly. During an interview on 4/19/22, at 3:09 p.m., with LVN 4, LVN 4 viewed a photo of Resident 44's catheter bag and stated, the catheter bag should not be put in the bag sideways. LVN 4 stated the bag was folded over and the tube would not flow straight into the bag. LVN 4 stated the bag should have hung freely so it could drain correctly. LVN 4 stated if the urine were to back up into the bladder, it could cause an infection or kidney failure (condition in which the kidneys lose the ability to remove waste). During an interview on 4/21/22, at 12:08 p.m., with the DON, the DON viewed the photo of Resident 44's catheter bag in the bag and stated, the catheter bag was scrunched up in the picture and the urine would not flow out properly. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated September 2014, the P&P indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections . Maintaining Unobstructed Urine Flow . 1. Check the resident frequently to be sure he or she is not lying on the catheter and keep the catheter and tubing free of kink . 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent that urine in the tubing and drainage bag from flowing back into the urinary bladder .

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 25), that received dialysis (treatment that uses the blood stream to filter out wastes in the body for people whose kidneys are failing) treatments, received ongoing assessments, when the facility did not perform post (after) dialysis assessments (includes vital signs [clinical measurements including heart rate, temperature, respiration rate and blood pressure that indicate the state of a resident's essential body functions], access site [used for connecting to a machine that filters blood during treatment] assessment, and condition of resident) three out of five days (4/8/22, 4/11/22, 4/13/22). This failure resulted in incomplete assessments for Resident 25 and had the potential for the facility to not recognize dialysis related complications (low blood pressure, fluid overload, blood clots, muscle cramps, access site infection, and itchy skin) for Resident 25, that could lead to harm or death. Findings: During a review of Resident 25's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 12/19/20 .Diagnosis Information .End Stage Renal Disease (ESRD-medical condition in which a person's kidneys stop functioning on a permanent basis and needing long-term dialysis) . During a review of Resident 25's Order Summary Report (OS), dated 12/19/20, the OS indicated, Dialysis at [name of dialysis clinic] one time every Mon, Wed, Fri . During a review of Resident 25's SNF (Skilled Nursing Facility)/Dialysis Communication Form, dated 4/8/22, the form indicated, . Dialysis Assessment After Return to [name of facility] .General Comments on Resident Overall Condition [all entries blank] .Vascular Access Site (site on body where a device is used to remove the resident's blood so that it could be filtered during dialysis treatment) [all entries blank] . During a review of Resident 25's SNF/Dialysis Communication Form, dated 4/11/22, the form indicated, . Dialysis Assessment After Return to [name of facility] .[vital signs] .[all entries blank] General Comments on Resident Overall Condition [all entries blank] .Vascular Access Site [all entries blank] . During a review of Resident 25's SNF (Skilled Nursing Facility)/Dialysis Communication Form, dated 4/13/22, the form indicated, . Dialysis Assessment After Return to [name of facility] .General Comments on Resident Overall Condition [all entries blank] .Vascular Access Site [all entries blank] . During an interview on 4/19/22, at 2:38 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 25's vital signs and condition needed to be assessed by a nurse before every dialysis appointment and after returning to the facility from dialysis. LVN 1 stated all findings should have been documented in the SNF/Dialysis Communication Form. LVN 1 stated there was missing documentation on the dialysis communication forms for the dates of 4/8/22, 4/11/22, and 4/13/22. LVN 1 stated all forms should have been completed to ensure Resident 25 was stable and to monitor any abnormalities such as a low blood pressure and follow up with the physician if any findings could cause Resident 25 harm. During an interview on 4/20/22, at 12 p.m., with the Director of Nursing (DON), the DON stated nurses should have assessed Resident 25 before and after dialysis appointments and completed the SNF/Dialysis Communication Forms to ensure Resident 25's safety. During a review of the facility policy and procedure (P&P) titled, Care of a Resident with End-Stage Renal Disease (ESRD), dated September 2010, the P&P indicated, .2. Education and training of staff includes .b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis . During a review of the facility P&P titled, Charting and Documentation, dated July 2017, the P&P indicated, .2. The following information is to be documented in the resident medical record a. Objective observations .d. Changes in the resident's condition .7. Documentation of procedures and treatments will include care-specific details, including .c. The assessment data and/or any unusual findings obtained during the procedure/treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an annual gradual dose reduction (GDR-tapering of a medication dosage to determine if symptoms, conditions, or risks can be managed by a lower dose or it can be discontinued) of antipsychotic medication (medication for the treatment of psychosis [involves a loss of contact with reality and can feature hallucinations and delusions]) in accordance with the facility policy and procedure titled Medication Monitoring Medication Management, dated 2007, for one of five sampled residents (Resident 70) when Resident 70 was prescribed and administered an antipsychotic medication and the previous effort to conduct a GDR was 2/20/21. There were no documented clinical contraindications (specific situation in which a drug, procedure, or surgery should not be used because it may be harmful to the person) related to the antipsychotic to not conduct the GDR. This failure had the potential to result in Resident 70 receiving unnecessary antipsychotic medications. Findings: During a review of Resident 70's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 1/12/20 .Diagnosis Information . Type 2 Diabetes Mellitus (impairment in the way the body regulates and uses sugar as fuel) . Alzheimer's Disease (brain disorder that slowly destroys memory and thinking) . Unspecified Psychosis . Major Depressive Disorder (persistently depressed mood) . During a review of Resident 70's Order Summary Report (OS), dated 4/21/22, the OS indicated, .Monitor behavior for episodes of striking out during essential care every shift related to UNSPECIFIED PSYCHOSIS . [brand name of antipsychotic] 100 mg (milligrams- unit of measurement) (quetiapine fumarate) Give tablet by mouth every 12 hours related to Unspecified Psychosis . During a concurrent interview and record review on 4/20/22, at 3:29 p.m., with Licensed Vocational Nurse (LVN) 6, Resident 70's behaviors documented on the Medication Administration Record (MAR- legal record of the drugs administered to a patient at a facility by a health care professional) was reviewed. LVN 6 stated Resident 70 had a history of behaviors such as striking out and attempting to go outside. LVN 6 reviewed Resident 70's behaviors documented on the MAR and stated Resident 70 had 20 behaviors in April 2022. LVN 6 stated the specific behaviors should be addressed in Resident 5's progress notes, but was unable to locate progress notes which addressed the behaviors. During an interview on 4/21/22, at 11:10 a.m., with Social Service Supervisor (SSS), the SSS stated the interdisciplinary committee met for each resident monthly and would review the residents on psychotropic medications annually to consider a GDR. The SSS stated the committee would complete a Psychotrophic [sic] Drug Regimen Review note and send recommendations to the resident's physician for follow up. During a concurrent interview and record review on 4/21/22, at 11:23 a.m., with the SSS, Resident 70's note titled Psychotrophic Drug Regimen Review, dated 2/10/21, was reviewed. The note indicated .Pharmacy review .GDR of [brand name of previous antipsychotic] 5mg 1 tab (tablet) PO (by mouth) QD (every day) for psychosis m/b (manifested by) agitation and striking out . is contraindicated at this time due to risk of potential emotional distress & harm to self or others . signed by the IDT members. The note indicated, . Other Drugs attempted in the past with poor response . yes, I agree (see new order) [left blank] . yes, but I wish to modify (see new order [left blank] . No, I disagree (List Risk vs. [versus] benefits) [left blank] . signed by Resident 70's physician. The SSS stated the IDT determined a GDR was not appropriate for Resident 70 because of his behavior history. The SSS stated he was unable to locate a more current Psychotrophic Drug Regimen Review note. During an interview on 4/21/22, at 11:37 a.m., with the Pharmacist (PHM), the PHM stated for Resident 70, the facility attempted a GDR approximately a year ago. The PHM stated she did not have Resident 70's information with her, so she was unsure of the dates and what Resident 70's behaviors were. The PHM stated after the GDR, Resident 70 fell more frequently and the physician ordered to increase the [antipsychotic] medication to the previous dosage. During an interview on 4/21/22, at 12:44 p.m., with the Director of Nursing (DON), the DON stated the IDT met monthly and would review the residents on psychotropic medications for GDR annually. During an interview on 4/21/22, at 2:34 p.m., with the SSS, the SSS stated GDRs were important because antipsychotic medication should be used at the lowest dose to prevent side effects and any risks to the resident. During a concurrent interview and record review on 4/21/22, at 3 p.m., with the SSS, Resident 70's electronic medical record was reviewed. The SSS looked through Residents 70's notes and stated Resident 70's last GDR was on 12/6/19. During a review of a professional reference found at https://www.umassmed.edu/globalassets/[NAME]-primary-care-institute/iadapt_toolkit_printingfull_final_10.04.12.pdf, titled, Caring for Residents with Dementia: A Guide for Behavior Management and Evidence-Based Medication Use, dated July 2012, pages 40-43, the reference indicated, . Atypical antipsychotic medications are not FDA-approved for behavior management in elderly people with dementia . Atypical antipsychotics have serious side effects . Appropriate indications include . Aggressive behavior (resident is a danger to self and/or others) . Hallucinations or delusions (if these behaviors cause impairment in functional capacity) . For all persons receiving an antipsychotic (regardless of indication) . Reassess the need for therapy . Attempt taper to minimal effective dose . Include resident centered behavioral management . Inappropriate Use of Antipsychotics . Verbally Aggressive/Threatening . Combative . Substantial Difficulty Receiving care . Hallucinations Not Impairing Functional Capacity . Delusions Not Impairing Functional Capacity . Hitting/Striking out . The patient has one of the following diagnosis . Atypical Psychosis . Delusional Disorder . Acute Psychotic episodes . Specific behaviors which cause the resident to present a danger to themselves or others . Continuous crying out, screaming, yelling, or pacing if these specific behaviors cause an impairment in functional capacity . Psychotic symptoms (hallucinations, paranoia, delusions) . During a review of the facility's policy and procedure titled, Medication Monitoring Medication Management, dated 2007, the P&P indicated, . In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences . 1. Antipsychotics . d. Inadequate Indications . In many situations, antipsychotic medications are not indicated . f. Dosage . Doses for acute indications . may differ from those used for long-term treatment, but should be the lowest possible to achieve the desired therapeutic effects . Tapering of a medication dose/gradual dose reduction (GDR) . after the first year, a GDR must be attempted annually .

Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate did not exceed five percent, when two of 25 medication administration opportunities observed were not administered in accordance with facility policy and procedure (P&P) and standards of practice. This failure resulted in a medication error rate of 8% (percent- unit of measurement) and placed Resident 63 at risk for drug interaction and clumping of medications, which could result in plugging of the gastrostomy tube (G-tube- a tube surgically inserted through the abdominal wall that brings nutrition directly to the stomach) and prevent Resident 63 from getting the full therapeutic effect of all administered medications and nutrition. Findings: During a review of Resident 63's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/21/22, the AR indicated, admission Date 7/18/18 .Diagnosis Information . Pneumonia (lung inflammation caused by bacterial or viral infection) . Dysphagia (difficulty swallowing) . Unspecified Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) . Neuroleptic Induced Parkinsonism (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) . During a review of Resident 63's Order Summary Report (OS), dated 4/21/22, the OS indicated, .May crush or pull apart medications unless contraindicated . Carbidopa-Levodopa (medication used to treat Parkinson's Disease) Tablet 25-100 mg (milligrams- units of measurement) give 1 tablet via (by) G-tube every 6 hours for Dx (diagnosis): Parkinson Disease . Hydrocodone-Acetaminophen (medication used to treat moderate to severe pain) Tablet 10-325 mg Give 1 tablet via G-tube every 6 hours related to OTHER CHRONIC PAIN . During an observation on 4/20/22, at 12:54 p.m., Registered Nurse (RN) 1 in orientation with Licensed Vocational Nurse (LVN) 5, prepared Resident 63's medication and enteral (tube feeding) feeding. RN 1 crushed Resident 63's hydrocodone-acetaminophen tablet and poured the crushed pill into a medication cup. RN 1 crushed Resident 63's carbidopa-levodopa tablet and poured it into the same cup with the hydrocodone-acetaminophen. RN 1 poured water into the medication cup and mixed it. RN 1 opened the end of Resident 63's G-tube and inserted the tip of the syringe without the stopper. RN 1 poured the water mixed with two medications into the syringe and allowed the medications to drain into the G-tube tube by gravity. LVN 5 stated there were two medications mixed in the medication cup and administered at the same time. LVN 5 stated medications should always be administered separately in G-tubes because if there were problems with a medication you would not know which medication caused it. LVN 5 stated there was a risk of clogging the G-tube from too much of the crushed medication at the same time. During an interview on 4/21/22, at 12:29 p.m., with the Director of Nursing (DON), the DON stated when G-tubes were clogged, it was usually from ineffective administration of medication. During a review of the facility's policy and procedure (P&P) titled Medication Administration Enteral Tubes, dated 2007, the P&P indicated, .Policy . The nursing care center assures the safe and effective administration of enteral formulas and medications . 10. Crushed medications are not mixed together. The powder from each medication is mixed with water before administration. The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose . 12. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid physical interactions . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19052281/, titled Medication administration through enteral feeding tubes, undated, the professional reference indicated, .Purpose: An overview of enteral feeding tubes, drug administration techniques . Summary: Enteral nutrition through a feeding tube is the preferred method of nutrition support in patients who have a functioning gastrointestinal tract but who are unable to be fed orally. This method of delivering nutrition is also commonly used for administering medications when patients cannot swallow safely. However, several issues must be considered with concurrent administration of oral medications and enteral formulas. Incorrect administration methods may result in clogged feeding tubes, decreased drug efficacy, increased adverse effects, or drug-formula incompatibilities . Liquid medications, particularly elixirs and suspensions, are preferred for enteral administration . Before solid dosage forms are administered through the feeding tube, it should be determined if the medications are suitable for manipulation, such as crushing a tablet or opening a capsule .

Based on observation, interview, and record review, the facility failed to follow one of five sampled residents' (Resident 16) food preferences and dislikes, when Resident 16 received canned fruit instead of the preference for fresh fruit on her meal tray for lunch on 4/18/22. This failure had the potential to result in decreased food consumption for Resident 16. Findings: During a concurrent observation and interview on 4/18/22, at 11:36 a.m., with Resident 16, in Resident 16's room, Resident 16 stated she received canned fruit and not fresh fruit. Resident 16's lunch tray was observed to have a container of canned chopped peaches. Residents 16's meal tray had a tray ticket that did not indicate likes or dislikes for fruit. During an interview on 4/19/22, at 9:29 a.m., with Resident 16, Resident 16 stated she received canned fruit on her meal tray. Resident 16 stated the canned fruit was not appealing. During a concurrent observation and interview on 4/20/22, at 12:27 p.m., with Resident 16, in Resident 16's room, Resident 16 stated most of her meals came with fruit, but it was canned fruit. Resident 16 stated she told someone (Registered Dietician [RD]) in the food services department her food likes and dislikes. Resident 16 stated she was visited by the food services department once a month. Resident 16 stated when she received canned fruit, she would notify the staff she did not like the canned fruit. Residents 16's meal tray had a tray ticket that did not indicate likes or dislikes for fruit. During a review of Resident 16's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 4/13/22, the MDS assessment indicated Resident 16 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 4/21/22, at 10:24 a.m., with the RD, the RD stated she or the Dietary Supervisor talked to the residents about their food preferences as often as needed. The RD stated she was familiar with Resident 16. The RD stated she would make the Certified Dietary Manager (CDM) aware of resident preferences. The RD stated the CDM had access to update preferences on resident tray tickets. During a concurrent interview and record review, on 4/21/22, at 2:12 p.m., with the RD, Resident 16's Nutrition/Dietary Department Note (NDDN), dated 1/7/22, 2/12/22, and 2/22/22 were reviewed. The NDDN, dated 1/7/22 indicated, .RD visited resident .has food preference of fruits, will communicate with kitchen . The NDDN dated 2/13/22, indicated, .Resident states likes to snack in the day and would like it scheduled in the day-prefers fresh fruit . The NDDN dated 2/22/22, indicated .Resident preferences updated-fresh fruit only . The RD stated she informed the CDM of Resident 16's preferences. The RD stated it was important to honor Resident 16's preferences to maintain a homelike environment and uphold Resident 16's resident rights. During a concurrent interview and record review on 4/21/22, at 2:24 p.m., with the CDM, the CDM stated she was notified by the RD that Resident 16 wanted fresh fruit. The CDM validated that on 4/18/22, Resident 16 received canned fruit for lunch. The CDM reviewed Resident 16's tray card dated 4/20/22 and verified Resident 16's preferences were not listed on the tray card. The CDM stated she would be honoring Resident 16's preference by indicating the preference on the tray card and ensuring that fresh fruit was on Resident 16's tray. During a review of the facility's policy and procedure (P&P) titled, Nutrition Care, dated 2018, the P&P indicated, .Resident/Patient Food Preferences .1. The resident/patient food preferences should be updated and placed on the profile card/tray card as needed .

Based on interviews and record review, the facility failed to ensure each resident was offered the influenza (viral infection that attacks the respiratory system - your nose, throat and lungs) vaccine annually, when one of five sampled residents (Resident 64), was last offered the influenza vaccine in 2013, and no further education, offering, or declination (refusal) was obtained. This failure resulted in Resident 64 and/or their responsible parties (a person other than the resident, designated to make health care decisions on behalf of the resident), who had previously refused the vaccine, to not receive education and be offered the vaccine annually. Findings: During an interview on 4/19/22, at 9:03 a.m., with the Infection Preventionist (IP), the IP stated, he had worked at facility since 2017 as a nurse and had been the facility's IP since February 2020. During a review of Resident 64's Influenza Immunization Informed Consent, dated 10/21/13, the Influenza Immunization Informed Consent indicated Resident 64 had not been offered nor declined the influenza vaccination since 2013. Resident 64's electronic medical record (EMR) indicated, no record of vaccination history for COVID-19 (communicable, respiratory disease that can cause severe illness in some people), influenza or pneumococcal (infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus), vaccinations or refusals of the offered vaccines. During a concurrent interview and record review, on 4/20/22, at 9:52 a.m., with the IP, Resident 64's Influenza Immunization Informed Consents were reviewed. The IP stated, if a resident had a declination of the immunization on file, the declination was valid for the entire time of the resident's stay. The IP stated if a resident's mental status changed and the resident required a responsible party to make decisions, the RP would be offered the education and decide if the resident should receive the vaccine and the consent would be updated. The IP stated Resident 64 was not her own responsible party. The IP searched Resident 64's charts and stated there was no additional information documented for Resident 64's influenza refusal since 2013. During a review of the facility's policy and procedure titled, Influenza Vaccine, dated October 2019, the policy and procedure indicated, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza .6. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record .

5. During an interview on 4/18/22, at 11:48 a.m. with Family Member (FM), FM stated Resident 45 had been at the facility since November 2020. FM stated Resident 45 had a g-tube. FM stated when Resident 45 consumed less than 50% of the meal by mouth, Resident 45 was given the tube feeding formula. During a review of Resident 45's Order Summary Report (OS), dated 2/16/22, the OS indicated, [brand name (tube feeding formula)] three times a day for Supplement (Administer 8 [ounces- units of measurement] [237 milliliters- units of measurement] via [gastrointestinal tube] if resident eats [less than] 50% (Administer at [8 a.m., 1 p.m. and 6 p.m.]-Start date-2/16/2022. During a concurrent interview and record review on 4/21/22, at 9:25 a.m., with the Registered Dietician (RD), Resident 45's Medication Administration Record (MAR), dated April 2022 was reviewed. The MAR indicated: On 4/1/22, at 8 a.m., Licensed Nurse (LN) documented Resident 45 was not administered tube feeding formula when she ate 0% of her meal. On 4/4/22, at 1 p.m. and 6 p.m., LN documented Resident 45 was not administered tube feeding formula when she ate 25% of her meal. On 4/16/22, at 1 p.m., LN documented Resident 45 was not administered tube feeding formula when she ate 25% of her meal. The RD validated on Resident 45's MAR there were four instances in the month of April where Resident 45 ate less than 50% of her meals and was not administered the tube feeding formula. The RD validated the dates were 4/1/22, twice on 4/4/22 and 4/16/22. The RD stated Resident 45 should have been given the tube feeding formula. The RD stated she did not know why the physician's order was not followed. The RD stated the licensed nurses should know why the tube feeding formula was not administered. During a concurrent interview and record review on 4/21/22, at 12:23 p.m., with LVN 5, Resident 45's MAR, dated April 2022 was reviewed. The MAR indicated, Resident 45 did not receive the tube feeding formula on 4/1/22, twice on 4/4/22 or 4/16/22, after eating less than 50% of her meal. LVN 3 validated on 4/1/22, twice on 4/4/22, and 4/16/22 Resident 45 was not given tube feeding formula when she should have received it for eating less than 50% of her meal. LVN 3 stated Resident 45 had the potential to lose weight and needed the tube feeding formula for nutrition. During a concurrent interview and record review, on 4/21/22, at 3:02 p.m., with the DON, Resident 45's MAR, dated April 2022 was reviewed. The MAR indicated, Resident 45 did not receive the tube feeding formula on 4/1/22, twice on 4/4/22 and 4/16/22 after eating less than 50% of her meal. The DON stated the physician's order was to administer the tube feeding formula when Resident 45 ate less than 50% of meals. The DON stated the physician's order was not followed on 4/1/22, twice on 4/4/22 and 4/16/22. The DON stated the licensed nurses should have documented in the progress notes the reason why the tube feeding formula was not administered. The DON stated the licensed nurses should have notified the physician and Resident 45's family. The DON stated there was no documentation from the licensed nurses as to why the physician's order for the tube feeding formula was not given to Resident 45 on 4/1/22, twice on 4/4/22 and 4/16/22. The DON stated the tube feeding formula was ordered to maintain her weight and nutrition due to her weight loss. The DON stated Resident 45 had the potential for further weight loss if the tube feeding formula not administered. During a review of Resident 45's MAR, dated April 2022, the MAR indicated, on 4/1/22 at 8 a.m. LN documented Resident 45 was not administered tube feeding formula when she ate 0% of her meal. The MAR indicated, on 4/4/22, at 1 p.m. and 6 p.m. LN documented Resident 45 was not administered tube feeding formula when she ate 25% of her meal. The MAR indicated, on 4/16/22, at 1 p.m. LN documented Resident 45 was not administered tube feeding formula when she ate 25% of her meal. During a review of the professional reference titled, Lippincott Manual of Nursing Practice 11th edition dated 2020, page 15 indicated, . Standards of Practice . General Principles . 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable . b. These standards provide patients with a means of measuring the quality of care they receive . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: . follow physician orders . document appropriate information in the medical record . and follow physician's orders . Failure to implement a physician's . order properly . 2. During a review of Resident 63's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/21/22, the AR indicated, admission Date 7/18/18 .Diagnosis Information . Pneumonia (lung inflammation caused by bacterial or viral infection) . Dysphagia (difficulty swallowing) . Unspecified Dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) . Neuroleptic Induced Parkinsonism (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) . During a review of Resident 63's Order Summary Report (OS), dated 4/21/22, the OS indicated, .May crush or pull apart medications unless contraindicated . carbidopa-levodopa (medication used to treat Parkinson's Disease) Tablet 25-100 mg (milligrams- unit of measurement) give 1 tablet via (by) G-tube every 6 hours for Dx: Parkinson Disease . hydrocodone-acetaminophen (medication used to treat moderate to severe pain) Tablet 10-325 mg Give 1 tablet via G-tube every 6 hours related to OTHER CHRONIC PAIN . During an observation on 4/20/22, at 12:54 p.m., RN 1, prepared Resident 63's medication and enteral feeding. RN 1 crushed Resident 63's hydrocodone-acetaminophen tablet and poured the crushed pill into a medication cup. RN 1 crushed Resident 63's carbidopa-levodopa tablet and poured it into the same cup with the hydrocodone-acetaminophen. RN 1 poured water into the medication cup and mixed it. RN 1 opened the end of Resident 63's G-tube and inserted the tip of the syringe. RN 1 poured the water mixed with two medications into the syringe and allowed the medications to drain into the G-tube by gravity. LVN 5 stated there were two medications mixed in the medication cup and administered at the same time. LVN 5 stated medications should always be administered separately in G-tubes because medication interactions and clogging the G-tube from too much of the crushed medication at the same time. During an interview on 4/21/22, at 12:29 p.m., with the DON, the DON stated when G-tubes were clogged it was usually from ineffective administration of medication. During a review of the facility's P&P titled Medication Administration Enteral Tubes, dated 2007, the P&P indicated, .Policy . The nursing care center assures the safe and effective administration of enteral formulas and medications . 10. Crushed medications are not mixed together. The powder from each medication is mixed with water before administration. The souffle cup (measurement cups that are used for dispensing medications) is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose . 12. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19052281/, titled Medication administration through enteral feeding tubes, undated, the professional reference indicated, .Purpose: An overview of enteral feeding tubes, drug administration techniques . Summary: Enteral (passing through the intestine through an artificial opening) nutrition through a feeding tube is the preferred method of nutrition support in patients who have a functioning gastrointestinal tract (organs that food and liquids travel through when they are swallowed, digested, absorbed) but who are unable to be fed orally. This method of delivering nutrition is also commonly used for administering medications when patients cannot swallow safely. However, several issues must be considered with concurrent administration of oral medications and enteral formulas. Incorrect administration methods may result in clogged feeding tubes, decreased drug efficacy, increased adverse effects, or drug-formula incompatibilities . Liquid medications, particularly elixirs and suspensions, are preferred for enteral administration . Before solid dosage forms are administered through the feeding tube, it should be determined if the medications are suitable for manipulation, such as crushing a tablet or opening a capsule . 3. During a review of Resident 73's AR, dated 4/21/22, the AR indicated, admission Date 3/30/22 .Diagnosis Information . Cerebral Infarction (a stroke-the result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) . Hypertensive Chronic Kidney Disease (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys) . Unspecified Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) . During a review of Resident 73's OS, dated 4/21/22, the OS indicated, . Metoprolol Tartrate (medication to lower blood pressure) Tablet 25 MG Give 1 tablet by mouth two times a day related to HYPERTENSIVE CHRONIC KIDNEY DISEASE . (Hold for SBP [systolic blood pressure-(the first number) - indicates how much pressure your blood is exerting against your artery walls when the heart beats] <(less than) 100 or Apical Pulse <60) . During an observation on 4/20/22, at 4:15 p.m., with LVN 1, LVN 1 was at the doorway of Resident 73's room with the medication cart. LVN 1 reviewed a sheet with vital signs on it. LVN 1 stated the CNAs checked the resident's vital signs (VS-clinical measurements that include heart rate, respiration rate, temperature, oxygen level, and blood pressure that indicate the status of the body's vital functions) around 3 p.m. LVN 1 stated she would use the vital signs taken by the CNA to determine if a resident's VS met the parameters to administer blood pressure medications. LVN 1 stated the physician's order indicated if Resident 73's systolic blood pressure (SBP) was below 100, or apical pulse (AP) was less than 60 beats per minute (BPM), Resident 73's metoprolol would not be given. LVN 1 took a blood pressure cuff and stethoscope into Resident 73's room. LVN 1 checked Resident 73's blood pressure and stated it was 128/70. LVN 1 turned and walked through the doorway of Resident 73's room to administer the medication to Resident 73 and was stopped. LVN 1 stated she forgot to check Resident 73's AP. LVN 1 stated if she would have administered the metoprolol to Resident 73 without the AP checked, Resident 73's heart would slow down more, which could affect her circulation, and could cause the resident to pass out (become unconscious). During a review of Resident 76's AR, dated 4/21/22, the AR indicated, admission Date 3/31/22 .Diagnosis Information . Fracture of Left Pubis (broken pelvis) . Type 2 Diabetes Mellitus (impairment in the way the body regulates and uses sugar (glucose) as a fuel) . Chronic Kidney Disease . Hypertensive Heart and Chronic Kidney Disease (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys) . During a review of Resident 76's OS, dated 4/21/22, the OS indicated, . Carvedilol Tablet [medication to lower blood pressure] Tablet 12.5 MG Give 1 tablet by mouth two times a day related to HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE . (Hold for SBP <100 or Apical Pulse <60) . During an observation on 4/20/22, at 4:42 p.m., with LVN 1, LVN 1 was at the medication cart outside of Resident 76's doorway. LVN 1 stated Resident 76 was due to receive carvedilol (medication used to lower blood pressure) and the physician ordered VS parameters was to hold the medication if SBP was less than 100 or the AP was less than 60. LVN 1 stated around 3 p.m., the CNAs would check the VS of residents she needed to pass medication to and turn them in to her. LVN 1 stated it had been approximately an hour and a half since the CNA checked Resident 76's VS. LVN 1 stated the VS could change within that amount of time and stated, oh, maybe I better check them [VS] again. During a concurrent interview on 4/20/22, at 4:53 p.m., with Resident 76 and LVN 1, Resident 76 stated when CNAs checked her pulse, she would hold up my wrist and the CNAs check my pulse, they don't listen to my heart. LVN 1 stated the physician order was to hold if the resident's apical pulse was less than 60. LVN 1 stated Resident 76's physician ordered parameters were not followed because the CNAs checked a peripheral pulse (pulses that are palpable at the hand) instead of an apical pulse. LVN 1 stated it was important to check an apical pulse when she administered anti-hypertensives because the AP was more accurate. During an interview on 4/21/22, at 12:29 p.m., with the DON, the DON stated when a nurse administered medications, and an apical pulse was required, the nurse should check the apical pulse themselves. The DON stated the apical pulse should be taken when the nurse gave the medication for an accurate and current reading. During a review of the facility's P&P titled, Administering Medications, dated April 2019, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders . 11. The following information is checked/verified for each resident prior to administering medications . b. Vital signs, if necessary . During a review of the professional reference titled Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . 4. During an observation on 4/19/22, at 11:11 a.m., LVN 3 prepared Resident 71's medication, walked into Resident 71's room and pulled the privacy curtain closed. The medication cart was left unlocked by LVN 3 while she was in Resident 71's room. During an interview on 4/19/22, at 11:27 a.m., with LVN 3, LVN 3 stated the medication cart must be locked anytime it was out of her sight. LVN 3 stated leaving the medication cart unlocked was a safety issue for the residents because they could access other medications in the cart and could cause adverse side effects if they ingested other's medications. During a concurrent observation and interview on 4/20/22, at 12:44 p.m., with LVN 5 and RN 1, LVN 5 and RN 1 entered Resident 53's room and closed the privacy curtain. The medication cart was left unlocked at the doorway and out of the nurse's eyesight. LVN 5 stated when she returned to the cart, she saw it was left unlocked and stated she should have locked it. LVN 5 stated an unlocked cart was a risk to the residents and anybody could take medication from an unlocked cart. During an interview on 4/21/22, at 12:29 p.m. with the DON, the DON stated her expectation was for the nurses to lock the medication cart any time it was out of their eyesight. The DON stated it was a standard of practice to lock the medication cart when unattended. The DON stated there were many people in the hallway and drugs could easily be diverted from an unlocked medication cart. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . The cart must be clearly visible to the personnel administering medications . During a professional reference review retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/lewingroup.pdf, titled, CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services Long-Term Care Pharmacy Primer, dated December 30, 2004, the professional reference review indicated, .C. Administration of Medications by Nursing Facility Personnel . Nursing facility personnel administer medications pursuant to the prescription order. The personnel designated to administer medications must be trained by the nursing facility . Medication Carts. Medication carts are most often provided by the LTCP. The carts contain locked, non-removable drawers for each resident's medications . Medication carts must be supervised at all times by the nurse administering medications. When medication carts are not in use, they must be stored in a designated locked area with all drawers locked .Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality when: 1. The facility's pain assessment tool for cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) residents, Pain Assessment in Advanced Dementia (impairment of at least two brain functions, such as memory loss and judgment) (PAINAD), was not used for one of 22 sampled residents (Resident 67). This failure had the potential to result in Resident 67's pain going unnoticed and untreated, which could delay healing time, disturb sleep and activity patterns, reduce function, and reduce quality of life. 2. One of four sampled licensed nurses (Registered Nurse [RN] 1) administered two medications crushed together in Resident 63's gastrostomy tube (G-tube- a tube surgically inserted through the abdominal wall that brings nutrition directly to the stomach) at the same time, against the facility's policy and procedure (P&P) titled, Medication Administration Enteral Tubes. This failure had the potential to result in Resident 63 to experience drug interactions when mixed and clogging of the G-tube. 3. Licensed Vocational Nurse (LVN) 1 did not follow physician's orders for two of three sampled residents (Resident 73 and Resident 76) when the apical pulse (AP-the pulse site over the apex [pointed end] of the heart and is the most accurate, non-invasive way of assessing cardiac health) was not checked prior to administering a medication. This failure had the potential to result in Resident 73 and Resident 76 to experience adverse effects of the medication, such as bradycardia (slow heart rate) and cardiac arrest (when the heart stops). 4. Three of four licensed nurses (LVN 3, LVN 5 and RN 1) failed to lock the medication cart when it was out of sight, per the facility's P&P titled, Administering Medications. This failure had the potential for staff or residents to access an medications from the unlocked medication cart. 5. Licensed nurses did not follow the physician's order for one of 22 sampled residents (Resident 45), when Resident 45 had a meal intake of 50% or less, and the facility did not administer Resident 45's tube feeding formula. This failure resulted in Resident 45 to not receive her tube feeding formula on 4/1/22, 4/4/22 and 4/16/22, and had the potential for Resident 45 to not receive adequate nutrition. Findings: 1. During a review of Resident 67's pain assessments dated 4/1/22 through 4/20/22, ordered for every shift, Resident 67's pain assessments indicated, Resident 67 had zero pain every shift from 4/1/22 through the morning of 4/18/22 and then was documented as a pain of six out of 10 on a numeric scale. During an interview on 4/20/22, at 11:41 a.m., with LVN 8, LVN 8 stated Resident 67 was alert, but could not communicate her needs. LVN 8 stated Resident 67 spoke mostly Armenian, very little English, and was sometimes non-responsive. LVN 8 stated she used the FACES scale (self-report measure of pain intensity using pictures of faces) to assess Resident 67's pain but documented it as assessing the pain on a Numeric scale (self-reported measure of pain intensity using numbers 0-10) by accident. LVN 8 was unable to explain how to properly use the FACES scale. LVN 8 stated she associated the look on Resident 67's face to the faces on the scale. LVN 8 stated Resident 67 was resting in bed, so she documented a zero for pain. During an interview on 4/20/22, at 2:30 p.m., with RN 2, RN 2 stated she was new and on orientation with RN 3 and they took care of Resident 67 on 4/18/22. RN 2 stated she assessed Resident 67's pain, Resident 67 was grimacing, so she documented a pain of six out of 10 on the numeric scale. During a concurrent interview and record review on 4/20/22, at 2:30 p.m., with RN 3, Resident 67's pain assessment scale was reviewed. RN 3 stated Resident 67 was fine on 4/18/22, was sitting up in chair, and visiting with her son. RN 3 validated Resident 67's pain assessment was documented as six out of 10 on a numeric scale. RN 3 stated Resident 67 could sometimes communicate in English if she was in pain. RN 3 stated she used the FACES scale to assess Resident 67's pain. RN 3 stated it was important to use the same pain assessment scale/tool each time a resident's pain was assessed to ensure proper pain management. During a concurrent observation and interview on 4/20/22, at 2:50 p.m., with the Assistant Director of Nursing (ADON), Resident 67 was observed in activities. The ADON stated Resident 67 could verbalize her pain on a numeric scale. The ADON asked Resident 67 if she was having any pain. Resident 67 did not answer intelligibly. The ADON stated, she thought Resident 67 might have said no, but nurses should be using the FACES scale to assess Resident 67's pain and not the numeric scale. During a concurrent observation and interview on 4/20/22, at 2:53 p.m., with LVN 6 and the ADON, the documentation of a pain assessment in the electronic medical record (EMR) was reviewed. LVN 6 stated the PAINAD assessment tool needed to be used on non-verbal, confused, and residents with dementia. LVN 6 demonstrated how to document with the PAINAD scale in the EMR. LVN 6 stated the numeric and PAINAD pain scales were the only two pain assessment scales to choose from when documenting pain. During an interview on 4/20/22, at 3:17 p.m., with the Director of Nursing (DON), the DON stated, if a resident was unable to speak or not able to understand a question, the nurses should use the FACES/grimace scale to monitor pain. During an interview on 4/21/22, at 8:25 a.m., with LVN 7, LVN 7 stated Resident 67 could verbalize her pain on a numeric scale, most times for LVN 7. LVN 7 was unable to describe how to use the PAINAD assessment tool or who it was appropriate to use it on. During a review of the facility's P&P titled, Pain - Clinical Protocol, revised March 2018, the P&P indicated, Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident' cognitive level. During a review of the professional reference of Wong-Baker FACES Foundation the FACES Pain Rating Scale, indicated, This self-assessment tool must be understood by the patient, so they are able to choose the face that best illustrates the physical pain they are experiencing. It is not a tool to be used by a third person, parents, healthcare professionals, or caregivers, to assess the patient's pain. There are other tools for those purposes. During a review of the professional reference of The Hartford Institute for Geriatric Nursing the article titled, Assessing Pain in Older Adults with Dementia, dated 2018, indicated, Pain in older adults is very often undertreated .Changes in a patient's ability to communicate verbally present special challenges in treating pain .Untreated pain in cognitively impaired older adults can delay healing, disturb sleep and activity patterns, reduce function, reduce quality of life, and prolong hospitalization .The PAINAD scale is reported to have moderate to high concurrent validity .The use of a standardized pain assessment tool is important in measuring pain. It enables health care providers to document their assessment, measure change in pain, evaluate treatment effectiveness, and communicate to other health care providers, the patient, and the family.

4. During a review of Resident 55's AR, dated 4/20/22, the AR indicated, admission Date 3/15/22 .Diagnosis Information . Other Pulmonary Embolism (blood clot in the lungs) . Shortness of Breath . During a review of Resident 55's OS, dated 4/20/22, the OS indicated, .Oxygen at 2L/min via nasal cannula every shift related to SHORTNESS OF BREATH . During a concurrent observation and interview on 4/18/22, at 2:30 p.m., with Certified Nursing Assistant (CNA) 1, Resident 55 was lying in bed with oxygen tubing on and an oxygen concentrator at bedside. The oxygen concentrator's humidifier and tubing were undated. CNA 1 stated the tubing and humidifier should have been dated. CNA 1 stated she was unable to tell when the humidifier and tubing were changed, and she did not know when they were due for replacement. CNA 1 stated the date was used to determine when it would need to be replaced. CNA 1 stated if they were not replaced timely, it could cause a bacterial infection (organisms that cause illness) and the residents could become very sick. CNA 1 stated Department of Transportation (DT) was responsible to change the humidifier and tubing. During an interview on 4/19/22, at 3:11 p.m., with LVN 4, LVN 4 stated the oxygen humidifier and tubing should be dated otherwise there was no way to know when it needed to be changed. LVN 4 stated the humidifier and tubing needed to be changed every 24 to 72 hours. LVN 4 stated if the humidifier and tubing were not changed frequently enough, it could cause a respiratory infection. During an interview on 4/20/22, at 11:09 a.m., with LVN 3, LVN 3 stated the oxygen humidifiers and tubing were changed daily. LVN 3 stated DT checked the oxygen concentrators daily, and would let her know which humidifiers and tubing were due to be changed. 5. During a concurrent interview and record review on 4/20/22, at 11:25 a.m., with the CS, the facility's P&P titled, Oxygen Concentrator dated 12/30/21 was review. The CS stated she followed the facility's policy and replaced the humidifiers and tubing every 72 hours. The CS stated she would date the humidifier but did not date the tubing. The facility's P&P titled, Oxygen Concentrator, dated 12/30/21, indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators . 5. Care of the Concentrator . c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. ii. Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer . The CS stated she performed the humidifier bottle and tubing changes herself. The CS stated DT trained her to set up the oxygen concentrators, change the humidifier bottles and tubing before he changed job positions. The CS stated she was not aware the P&P indicated only the nurses were responsible for the humidifier and tubing change. During a concurrent interview and record review at 4/20/22, at 11:41 with the Director of Nurses (DON), the facility's P&P titled, Oxygen Concentrator, dated 12/30/21 was reviewed. The facility's P&P indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators . 5. Care of the Concentrator . c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. ii. Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer . The DON stated the way the P&P was written, it indicated the nurses were responsible to change the humidifiers and tubing. The DON stated the P&P should include the CS since she was trained and responsible to perform the humidifier and tubing changes. The DON stated according to the P&P, the CS should not change the humidifiers and tubing. Based on observation, interview and record review, the facility failed to provide respiratory (network of organs and tissues that help you breathe) care and services in accordance with professional standards of practice for four of five sampled residents (Residents 25, 39, 52, and 55) when: 1. Resident 25 had a humidifier (a container with sterile water used to prevent dry airway when breathing oxygen) with an outdated label (3/9/22); 2. Resident 39 had a humidifier with an outdated label (4/7/22); 3. Resident 52 had a humidifier with an outdated label (4/10/22); 4. Resident 55's oxygen humidifier and tubing were not dated; and 5. A non-licensed staff member (Central Supply [CS]) routinely changed residents' oxygen humidifiers and tubing, against the facility's policy and procedure titled, Oxygen Concentrator. These failures resulted in a non-licensed staff to perform duties they were not supposed to perform and had the potential for contamination of oxygen equipment for Residents 25, 39, 52, 55 that could lead to illness, or even death. Findings: 1. During a review of Resident 25's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 12/19/20 .Diagnosis Information . Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) . During a review of Resident 25's Order Summary Report (OS), dated 12/19/20, the OS indicated, .Oxygen at 2L/min (liters per minute- units of measurement) via nasal cannula (device used to deliver oxygen that is placed in a resident's nose) as needed for Shortness of Breath related to COPD . During an observation on 4/18/22, at 10:39 a.m., in Resident 25's room, there was an oxygen concentrator (a medical device that gives extra oxygen) near Resident 25's bed, with a date written on the humidifier of 3/9/22. During an interview on 4/19/22, at 3:11 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the humidifier and tubing needed to be changed every 24 to 72 hours. LVN 4 stated if the humidifier and tubing were not changed frequently enough, it could cause a respiratory infection. During a review of the facility's P&P titled, Oxygen Concentrator dated 12/30/2021, the P&P indicated, .5. Care of the Concentrator .c .i .Change oxygen tubing and mask/cannula weekly and as needed .ii. Change humidifier bottle when empty, every seventy-two hours . 2. During a review of Resident 39's AR dated 4/20/22, the AR indicated, admission Date 11/13/19 .Diagnosis Information . Pulmonary Fibrosis (PF-lung disease that occurs when lung tissue becomes damaged and scarred) . During a review of Resident 39's OS, dated 11/14/19, the OS indicated, .Oxygen at 2L/min via nasal cannula every shift for Shortness of Breath . During an observation on 4/18/22, at 10:23 a.m., in Resident 39's room, there was an oxygen concentrator near Resident 39's bed with a date written on the humidifier of 4/7/22. Resident 39 was using the oxygen via nasal cannula. During an interview on 4/19/22, at 3:11 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the humidifier and tubing needed to be changed every 24 to 72 hours. LVN 4 stated if the humidifier and tubing were not changed frequently enough, it could cause a respiratory infection. During a review of the facility's P&P titled, Oxygen Concentrator dated 12/30/2021, the P&P indicated, .5. Care of the Concentrator .c .i .Change oxygen tubing and mask/cannula weekly and as needed .ii. Change humidifier bottle when empty, every seventy-two hours . 3. During a review of Resident 52's AR, dated 4/20/22, the AR indicated, admission Date 7/2/21 .COPD . During a review of Resident 52's Order Summary Report (OS), dated 7/9/21, the OS indicated, .Oxygen at 2L/min via nasal cannula at bedtime for shortness of breath (SOB) . During a review of Resident 52's Minimum Data Set Section C Cognitive Patterns (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 3/14/22, the MDS indicated, .BIMS (Brief Interview for Mental Status) Summary Score .15 [indicating normal level of cognition] . During a concurrent observation and interview on 4/18/22, at 10:43 a.m., with Resident 52, Resident 52 had an oxygen concentrator near her bed with a date written on the humidifier of 4/10/22. Resident 52 stated she did not know when the humidifier had been changed, nor did she know how often it should have been changed. During an interview on 4/18/22, at 11:06 a.m., with LVN 2, LVN 2 stated the Department of Transportation (DT) staff was responsible for changing out the oxygen tubing and humidifier once a week. LVN 2 stated the nurses would only change out the tubing and humidifier if they were to become soiled or dislodged. During an interview on 4/19/22, at 3:11 p.m., with LVN 4, LVN 4 stated the humidifier and tubing needed to be changed every 24 to 72 hours. LVN 4 stated if the humidifier and tubing were not changed frequently enough, it could cause a respiratory infection. During a review of the facility's P&P titled, Oxygen Concentrator dated 12/30/2021, the P&P indicated, .5. Care of the Concentrator .c .i .Change oxygen tubing and mask/cannula weekly and as needed .ii. Change humidifier bottle when empty, every seventy-two hours .

Based on interview and record review, the facility failed to ensure 20 of 22 licensed nursing staff (LN) possessed the competencies required to provide for residents' needs, when annual competency evaluations were not documented as completed in 2021. This failure had the potential for staff to not possess the appropriate skills and competencies to assure residents' safety and provide appropriate care. Findings: During a concurrent interview and record review on 4/21/22, at 2:25 p.m., with Accounts Payable (AP), employee files and staffing schedules were reviewed for compliance with staffing regulations. The AP validated orientation check off lists were kept in the employee files, but there were no recent annual competencies to be found in three of three sampled nursing staff files (Licensed Vocational Nurse [LVN] 7, LVN 8, and Registered Nurse [RN] 3. LVN 7's employee file indicated, LVN 7 started working at the facility on 2/10/2022. The orientation check off was completed and competencies were checked on abuse and reporting abuse. No other competency was in the file. LVN 8's employee file indicated, LVN 8 started working at the facility on 3/2/22. The orientation check off was completed and competencies were checked on abuse and reporting abuse. No other competency was in the file. RN 3's employee file indicated, RN 3 worked at the facility since 4/6/2005. Individual competencies checked for 2021 included Medication Administration, Hand Hygiene, and Wound Care. Annual competency checks for 2014, 2016, 2019, and 2020 were in the file. No annual competency for 2021 was in RN 3's employee file. During an interview on 4/21/22, at 3:02 p.m., with the Assistant Director of Nursing (ADON), the Director of Staff Development (DSD), and the Interim Director of Staff Development (IDSD), the DSD stated, nursing staff have orientation with the ADON, Director of Nursing (DON), or shift leads, and the former DON or ADON checked annual competencies for nursing staff. The ADON stated she had not completed any competencies for nursing staff since the former DON left, but the former DON checked annual competencies for nursing staff before then. During an interview on 4/21/22, at 3:57 p.m., with the ADON, the ADON stated the previous DON had worked on the 2021 nursing competencies, but the ADON did not know where she had kept them. The ADON stated she had not given any in services (education or training) or checked any competencies for LNs since starting with the facility. During a concurrent interview and record review on 4/21/22, at 4:02 p.m., with the DSD, the yearly in-service binders for LNs was reviewed. The DSD validated seven of 22 LNs completed the Medication Administration competency for 2021, five of 22 LNs completed the Wound Care competency for 2021, 12 of 22 LNs completed the Hand Hygiene competency for 2021, one of 22 nurses completed the Nephrostomy (artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system) Competency for 2021, and one of 22 nurses completed the Suprapubic (drains urine from the bladder; it is inserted into your bladder through a small hole in the belly) Competency for 2021. During a concurrent interview and record review on 4/21/22, at 4:24 p.m., with the ADON, the yearly in-service binders for LNs were reviewed. The ADON stated the binder being reviewed was the only nurse competency binder she could find. The ADON validated there were only two completed annual competency evaluations completed for LNs in 2021. The ADON stated the competency binder for LNs was not complete for 2021 and needed to be kept complete and current to keep track of the competencies and ensure all nursing staff were competent in their practices. During a review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, revised October 2017, the P&P indicated, .licensed nurses .will: participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care .The following factors are considered in the creation of the competency-based staff development and training program .A method to track, assess, plan, implement and evaluate the effectiveness of training .The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population .Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment .Inquiries concerning staff competency evaluations should be referred to the Director of Nursing Services or to the Personnel Director. During a review of the facility's P&P titled, On-the-job Training, revised January 2008, the P&P indicated, .Department directors will be responsible for on-the-job training to assure that our established training schedules are followed .All training programs and classes attended by an employee shall be entered on his/her Employee Training Attendance Record. Training records will be filed in the employee's personnel file or may be maintained by the department supervisor.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards, when: 1. The mechanical soft (chopped to make the food soft and easy to eat) salad located on the lunch assembly line was 56 degrees Fahrenheit (F- scale used to measure temperature) (acceptable temperature is below 41 degrees F) when measured with a food thermometer. This failure had the potential to place residents at risk for complications from foodborne illness (sickness caused by bacteria, viruses, parasites, or toxins). 2. Individually wrapped cookies and crackers were stored in three easily accessible snack bins. The individually wrapped cookies and crackers and the bins were not labeled with a use-by date. This failure had the potential for residents to consume foods that may have been compromised (quality and taste) and for residents to have a decrease in their nutritional intake. Findings: 1. During a concurrent observation and interview on 4/18/22, at 11:27 a.m., with the Certified Dietary Manager (CDM), the tray line assembly for lunch preparation was measured with a food thermometer. The mechanical soft salad was in a cup, over ice. The salad's temperature was measured with the food thermometer, and thermometer indicated 56 degrees F. The CDM stated, the serving temperature of the mechanical soft salad should be 41 degrees or less to minimize foodborne illness. During a concurrent interview and record review on 4/18/22, at 11:30 a.m., with the CDM, the facility document titled, Food: Temperature Log, dated April 18, 2022 was reviewed. The Food Temperature Log indicated, Suggested serving temperature .Cold food maximum 40 degrees F. Record. The Food Temperature log dated 4/18/22 for lunch meal service did not contain a temperature collected for the salad. The CDM stated the cooking staff did not check the temperature on the vegetables (salad). During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2018, the P&P indicated, .Policy: Employees will prepare food in a clean and safe manner to protect residents/patients and staff from foodborne illness .Procedures .12. Prepared food will be stored at proper temperature until serving time. Temperature forms will be utilized .c. Cold foods at less than or equal to 41 degrees F . During a review of the professional reference retrieved from https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-industry-guide-minimize-microbial-food-safety-hazards-fresh-cut-fruits-and-vegetables, titled, Guidance for Industry: Guide to Minimize Microbial Food Safety Hazards of Fresh-cut Fruits and Vegetables, dated February 2008, the professional reference indicated, Processing fresh produce into fresh-cut products increases the risk of bacterial growth and contamination by breaking the natural exterior barrier of the produce (Ref. 6).The release of plant cellular fluids when produce is chopped or shredded provides a nutritive medium in which pathogens, if present, can survive or grow (Ref. 6). Thus, if pathogens are present when the surface integrity of the fruit or vegetable is broken, pathogen growth can occur and contamination may spread. The processing of fresh produce without proper sanitation procedures in the processing environment increases the potential for contamination by pathogens (see Appendix B, Foodborne Pathogens Associated with Fresh Fruits and Vegetables.) .The potential for pathogens to survive or grow is increased by the high moisture and nutrient content of fresh-cut fruits and vegetables, the absence of a lethal process (e.g., heat) during production to eliminate pathogens, and the potential for temperature abuse during processing, storage, transport, and retail display (Ref. 6). Importantly, however, fresh-cut produce processing has the capability to reduce the risk of contamination by placing the preparation of fresh-cut produce in a controlled, sanitary facility . During a professional reference review of the Food Code - U.S. (United States) Food & Drug Administration 2017, dated 2017, the professional referenced indicated, .Historical Record of Cold Holding Temperature Provisions .41°F became the standard for cold holding . 2. During a concurrent observation and interview on 4/20/22, at 2:25 p.m., with the CDM, a bin stored individually wrapped graham crackers [brand name] (removed from its original packaging) and did not contain a label with a used by date. Two bins with individually wrapped cookies and chips [brand names] did not contain a used by date (removed from its original packaging) in the facility's kitchen pantry. The individually wrapped snacks did not contain a manufacturer's used by date as they were removed from the original packaging. The CDM stated there should have been an opened date and use by date on a label, on each snack bin, to ensure the snacks were within the recommended manufacturer's guideline to ensure the nutritional value, taste, and quality of the snacks During a concurrent interview and record review of the facility's P&P titled, Sanitation and Infection Control Subject: Canned and Dry Goods Storage, dated 2018, the P&P indicated, .All open food items will have an open date and use-by-date per manufacturer's guidelines. During a review of the professional reference retrieved from https://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely titled, Are You Storing Food Safely? Storing food properly can help prevent foodborne illnesses. Here are tips for safely storing food in your refrigerator, freezer, and cupboards, dated 2/9/21, the professional reference review indicated, Check expiration dates. A 'use by' date means that the manufacturer recommends using the product by this date for the best flavor or quality. The date is not a food safety date. At some point after the use-by date, a product may change in taste, color, texture, or nutrient content, but, the product may be wholesome and safe long after that date. If you're not sure or if the food looks questionable, throw it out .

Based on observation, interviews, and record review, the facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of communicable disease and infections when: 1. One of five sampled residents' (Resident 68) nasal cannula (device used to deliver oxygen that is placed in a resident's nose) was observed on the floor in Resident 68's room. This failure had the potential to result in transmission of organisms (germs) from the floor, onto the nasal cannula and to Resident 68. 2. Two of four Licensed Nurses (Licensed Vocation Nurse [LVN] 1 and LVN 3) failed to perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizer) prior to the administration of medications for three of 11 residents (Residents 69, 71 and 428). This failure had the potential to expose Residents 69, 71, and 428 to communicable diseases. Findings: 1. During an observation on 4/18/22, at 10:28 a.m., in Resident 68's room, a nasal cannula was attached to an oxygen concentrator (medical device that gives extra oxygen). The nasal cannula was on the floor, next to Resident 68's bed. There was no plastic bag available to store the nasal cannula. During a concurrent observation and interview on 4/18/22, at 10:40 a.m., with LVN 2, in Resident 68's room, LVN 2 stated there should have been a plastic bag on the oxygen concentrator to store the nasal cannula. LVN 2 validated the nasal cannula was on the floor. LVN 2 stated the nasal cannula should be stored in bag to keep it from getting contaminated with germs from the floor. LVN 2 stated the nasal cannula belonged to Resident 68. During a concurrent interview and record review, on 4/20/22, at 10:21 a.m., with the Infection Preventionist (IP), the facility's policy and procedure, titled, Oxygen Concentrator, dated 2022, was reviewed. The IP stated there should be a disposable bag on the oxygen concentrator and the nasal cannula tubing coiled up and stored in the bag. The IP stated the nasal cannula tubing should not be on the floor. The IP stated if the nasal cannula tubing from the floor was placed back on a resident, it could potentially introduce a pathogen (germ) into their nose, mouth or around their face, and there was a potential for infection. During a review of the facility's policy and procedure (P&P) titled, Oxygen Concentrator, dated 2022, the P&P indicated, .4. Use of the concentrator: . l. Keep delivery devices covered in a plastic bag when not in use . During a professional reference review retrieved from https://www.cdc.gov/infectioncontrol/spread/index.html, titled How Infections Spread, dated January 7, 2016, the professional reference indicated, .An infection occurs when germs enter the body, increase in number, and cause a reaction of the body. Three things are necessary for an infection to occur: Source: Places where infectious agents (germs) live (e.g., sinks, surfaces, human skin) Susceptible (vulnerable) Person with a way for germs to enter the body Transmission: a way germs are moved to the susceptible person . Transmission refers to the way germs are moved to the susceptible person . Germs don't move themselves. Germs depend on people, the environment, and/or medical equipment to move in healthcare settings. A Source is an infectious agent or germ and refers to a virus, bacteria, or other microbe. In healthcare settings, germs are found in many places. People are one source of germs including . Germs are also found in the healthcare environment. Examples of environmental sources of germs include: Dry surfaces in patient care areas (e.g., bed rails, medical equipment, countertops, and tables) Wet surfaces, moist environments, and biofilms (e.g., cooling towers, faucets and sinks, and equipment such as ventilators) . 2. During an observation on 4/19/22, at 11:08 a.m., with LVN 3, LVN 3 prepared Resident 69's medication for administration. LVN 3 touched the medication cart and did not perform hand hygiene before she prepared the medication. During an observation on 4/19/22, at 11:11 a.m., with LVN 3, LVN 3 did not perform hand hygiene before she prepared Resident 71's medication and donned (put on) gloves. LVN 3 entered Resident 71's room and administered Resident 71 oral medication and eye drops with the same gloves on. LVN 3 did not perform hand hygiene between the oral medication and eye drops. LVN 3 did not clean her hands after she removed the gloves. During an interview on 4/19/22, at 11:27 a.m., with LVN 3, LVN 3 stated hand hygiene must be performed before medication administration to prevent illness. LVN 3 stated she should have washed her hands before and after Resident 71's eye drops. LVN 3 stated she did not want bacteria to enter Resident 71's eyes and cause an eye infection. During an observation on 4/20/22, at 4:15 p.m., with LVN 1, LVN 1 pushed the medication cart to Resident 428's room. LVN 1 did not perform hand hygiene and prepared Resident 428's medication. During an interview on 4/21/22, at 12:29 p.m., with the Director of Nursing (DON), the DON stated all nurses needed to Gel [hand sanitizer to kill bacteria and viruses] in and gel out when they prepared and administered medication. The DON stated if the hand gel was not easily accessed, the expectation would be for the nurses to wash their hands in the room before and after they prepared and administered the medication. The DON stated her expectation was the nurse to have washed their hands before and after they administered eye drops. During a review of the facility's P&P titled, Administering Medications, dated April 2019, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed . 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves .) for the administration of medications, as applicable .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement and ensure their policy and procedure (P&P) titled, Mandatory COVID-19 (communicable, respiratory disease that can cause severe illness in some people) Employee Vaccination Policy was followed, when the facility did not follow their process for granting non-medical exemptions, four of 19 staff members were inaccurately documented as having a non-medical exemption, and one nursing student was marked as having a non-medical exemption, without documentation of the exemption. This failure resulted in 93.8% (percent- unit of measurement) of staff being vaccinated for COVID-19, which placed residents at risk of being exposed and contracting COVID-19 from staff. Findings: During a concurrent interview and record review, on [DATE], at 9:44 a.m., with the Infection Preventionist (IP), the facility's COVID-19 staff Vaccination Status for Providers, updated [DATE], and proof of employee granted exemptions, were reviewed. The IP stated the facility accepted both Request for a Religious Exemption to the COVID-19 Vaccination Requirement and Declination of COVID-19 Vaccination forms for vaccine exemptions. The IP stated there were five Request for a Religious Exemption to the COVID-19 Vaccination Requirement on file, but only one of the five staff members had answered the three questions on the exemption request form. The IP stated the facility had not required staff to answer the questions on the form because of employee rights, and the facility had no process of validating an employees' religious exemption request. During a concurrent interview and record review, on [DATE], at 10:13 a.m., with the IP, the facility's P&P titled Mandatory COVID-19 Employee Vaccination Policy, dated [DATE], was reviewed. The IP validated the P&P indicated employees needed to submit a Religious Accommodate Request Form and describe the basis for their religious belief to be eligible for a religious belief exemption. The IP stated the facility was not following the P&P. During a concurrent interview and record review, on [DATE], at 3:16 p.m., with the IP, the facility's staff immunization tracker titled, COVID-19 staff Vaccination Status for Providers, updated [DATE], and proof of employee granted exemptions, were reviewed. The IP validated there were 17 employees with granted (approved) non-medical exemptions (GN) and two employees with pending non-medical exemption (PN) on the tracker. The IP stated Housekeeping (HK) 1 received her first COVID-19 vaccination on [DATE], but was listed as GN. HK 1 had filled out a Request for a Religious Exception to the COVID-19 Vaccination Requirement, did not answer the questions, but wrote in at the bottom of the form, I haven't gotten it done yet but I'm planning on getting it soon. But it's against my religious reasons. HK 1's COVID-19 vaccination card was reviewed, the card indicated HK 1 received her fist dose of [name of COVID-19 vaccine] on [DATE]. The IP indicated he had not updated the vaccination tracker yet. The IP stated Medical Record Assistant (MRA) 1 was also listed as GN but had a temporary delay with a medical note and no Declination or Exemption request filed. The IP stated he should have marked MRA 1 as having a temporary delay on the tracker. The IP validated there were ten other staff members marked as GN who only had a vaccination declination on file. The IP stated four of the five Request for a Religious Exception to the COVID-19 Requirement forms submitted did not have the questions answered for religious exception. The IP stated, Nursing Student (NS) 1 had not been into the facility yet and he had no documentation for her vaccine or exemption but had put her on the tracker as GN while he waited for the information. The IP stated, he had no paperwork for the two staff listed as PN. The IP stated the information on the tracker was incorrect. The IP stated he did not know who granted the exemptions or what the process was to determine if the exemptions were granted or not. During an interview on [DATE], at 11:47 a.m., with the Director of Nursing (DON), the DON stated she did not know what the process was for COVID-19 vaccination exemptions at the facility. The DON stated staff vaccination status should be maintained accurately. During a review of the facility's form titled, Request for a Religious Exception to the COVID-19 Vaccination Requirement, [undated], the form indicated, .All requests for a religious exception will be evaluated on an individual bases .Questions: 1. Please describe the nature of your objection to the COVID-19 vaccination requirement. 2. Would complying with the COVID-19 vaccination requirement substantially burden your religious exercise or conflict with your sincerely held religious beliefs, practices, or observances? If so, please explain how. 3. Please provide an additional information that you think may be helpful in reviewing your request. For example: How long you have held the religious belief underlying your objection; Whether your religious objection is to the use of all vaccines, COVID-19 vaccines, a specific type of COVID-19 vaccine or some other subset of vaccines; Whether you have received vaccines as an adult against any other diseases (such as a flu vaccine or a tetanus vaccine) . During a review of the facility's P&P titled Mandatory COVID-19 Employee Vaccination Policy, dated [DATE], the P&P indicted, .The policy is intended to safeguard the health of our employees and their families; our clients and visitors; and the community at large from COVID-19 .All staff are to be fully vaccinated or submit a valid exemption no later than [DATE] .Before the stated deadlines to be vaccinated have expired, employees will be required to provide either proof of vaccination or an approved reasonable accommodation to be exempted from the requirements .To be eligible for a Religious Beliefs exemption, the employee must submit a Religious Accommodate Request Form, signed by the employee, describing the basis for their religious belief. Additional documentation or evidence may be required .Employees who do not qualify for an exemption who nonetheless refuse get a vaccination will be separated from employment at [facility name] .If the worker is exempt, [facility name] must maintain all exemption forms .

Based on interview and record review, the facility failed to have an infection prevention and control program that included an antibiotic stewardship program that ensured residents who required antibiotics were prescribed the appropriate antibiotic, when the Infection Preventionist (IP) was unaware one of 21 sampled residents (Resident 67) who tested positive for extended spectrum beta-lactamase (ESBL- enzymes produced by a variety of gram negative bacteria with an increased resistance [not easily killed by] to commonly used antibiotics) and the physician was not notified of the lab results, and the resident was treated with an antibiotic her infection was resistant to. This failure had the potential for Resident 67's infection to not be treated with the appropriate medication and placed Resident 67 at risk to become septic (an infection spread throughout the body) and experience worsening of the infection. Findings: During a concurrent interview and record review, on 4/19/22, at 2:39 p.m., with the IP, the facility's antibiotic stewardship program was reviewed. The IP stated, part of the antibiotic stewardship program was to do daily audits of antibiotics ordered and laboratory tests, track residents on antibiotics, review culture and sensitivity (C&S- a test to determine what antibiotics will destroy the bacteria causing the infection) if it was ordered, and compare the antibiotic ordered to the C&S. The IP reviewed the antibiotic stewardship notebook and stated, Resident 67's information was placed in the notebook in February 2022. The IP validated the notebook indicated Resident 67 had a urinary tract infection (UTI- common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract) from a bacterium that tested positive for ESBL, the C&S was collected, and Resident 67 was put on the antibiotic, ciprofloxacin. During a concurrent interview and record review, on 4/21/22, at 8:41 a.m., with Licensed Vocational Nurse (LVN) 7, Resident 67's electronic and paper charts were reviewed. LVN 7 stated Resident 67 exhibited some symptoms of a UTI on 1/30/22 and had a urine sample sent off to test for infection. LVN 7 stated there was a nurses' note in Resident 67's electronic chart dated 2/1/22 that indicated, Resident 67's Medical Doctor (MD) 1 had been paged regarding Resident 67's lab results and MD 1 called back with orders to start Resident 67 on ciprofloxacin. LVN 7 stated there was a lab report in Resident 67's paper chart that indicated Resident 67, was ESBL positive and the bacteria responsible for her infection was resistant to ciprofloxacin. LVN 7 validated the handwritten note on the lab report indicating MD 1 was not made aware of the C&S until 2/15/22. LVN 7 stated, there was no documentation in Resident 67's electronic chart indicating MD 1 had been notified of the C&S. During an interview on 4/21/22, at 9 a.m., with the Administrator (ADM), the ADM stated he did not know what the process was for notifying the MD of lab results for antibiotic stewardship. During a concurrent interview and record review on 4/21/22, at 9:02 a.m., with the IP, the IP stated he was not aware Resident 67's C&S results because the results were received so late. The IP stated tracking lab reports was part of his job, but he was not responsible for it. The IP stated, Determining the proper antibiotic is not my job to determine but if the bacteria is not sensitive to the antibiotic the resident was on, he would tell the MD. The IP validated Resident 67's bacteria was resistant to ciprofloxacin, and Resident 67 was not given another antibiotic or a repeat urine test to ensure the UTI had been cured. The IP stated the risk in prescribing an antibiotic that a bacteria is resistant to, would be the infection not being treated and turning into septic infection and risk for interfacility transmission. The IP stated he was not sure if there was a policy and procedure (P&P) on notifying the MD of lab results and was not sure what the policy was for notifying the MD was, if there was one. The IP found the P&P titled, Culture Tests, revised January 2012, which indicated, IP and the Infection Control Committee (ICC) will review all cultures. The IP stated, he was not currently doing this practice [reviewing cultures] and had not reviewed Resident 67's C&S and was unaware the results came back so late. The IP stated Resident 67 did not have a follow up urine test or have any other antibiotics prescribed after the ciprofloxacin. The IP stated the facility did not follow the facility's P&P. During an interview on 4/21/22, at 9:22 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the nurses were responsible for checking residents' C&S when it came back and making sure the bacteria was sensitive (could be killed by) to the antibiotic the resident was prescribed. The ADON stated, she was on the ICC and the ICC did not review cultures. The ADON stated, she was unsure who was responsible for tracking C&S and making sure the residents were on the correct medication. The ADON stated the risk of not having the resident on the correct antibiotic would be residents becoming septic and dying. During a phone interview on 4/21/22, at 9:43 a.m., with MD 1, MD 1 stated he was very familiar with Resident 67 and did not recall receiving results of Resident 67's C&S. MD 1 stated if he had received Resident 67's C&S results, he would have run a repeat urine test and changed the antibiotic if the resident was still having symptoms. MD 1 stated he was going to order a follow up urine test for Resident 67 immediately. During an interview on 4/21/22, at 11:26 a.m., with the Director of Nursing (DON), the DON stated, she was not involved in antibiotic stewardship. The DON stated the IP brought recommendations during care plan and IDT meetings. The DON stated she believed the P&P made sure the IP was doing his job of tracking and reporting on antibiotics. The DON stated the risk for not being prescribed the correct antibiotic for an infection was that the infection would continue until it was septic and could possibly kill the resident. During a review of the facility's P&P titled, Culture Tests, revised January 2012, the P&P indicated, .Should the Attending Physician order cultures, they shall be obtained and completed as soon as practical. As test results shall be reported to the physician as soon as the results are obtained .Completed culture reports shall be reviewed by the Infection Preventionist and the Infection Control Committee and filed in accordance with established recordkeeping requirements . During a review of the facility's P&P titled, Test Results, revised April 2007, the P&P indicated, .The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results . During a review of the facility's P&P titled, Antibiotic Stewardship, revised December 2016, the P&P indicated, .The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents .When a C&S is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued .Appropriate i indications for use of antibiotics include: .Pathogen susceptibility, based on C&S, to antimicrobial (or therapy begun while culture is pending) .As part of the facility antibiotic Stewardship Program, all clinical infection treated with antibiotics will undergo review by the Infection Preventionist, or designee .The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situation that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: 1) The organism is not susceptible to antibiotic chosen .at the conclusion of the review, the provider will be notified of the review findings .The DON will monitor individual resident antibiotic regimens, including: a. Reviewing clinical documentation supporting antibiotic orders .The IP will audit and the DON will provide feedback to providers on antibiotic prescribing practices .The IP will monitor over time and report to the IPCC .Antibiotic susceptibility patterns .