**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accident hazards for one of three final sampled residents (Resident 4) reviewed for accident hazards. * The facility failed to implement the bilateral floor mats as per the plan of care for Resident 4. This failure had the potential risk for injury to Resident 4. Findings: Review of the facility's P&P titled Care Plan Comprehensive dated 8/25/21, showed the care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. Medical record review for Resident 4 was initiated on 2/11/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's plan of care showed a care plan problem dated 7/29/24, addressing Resident 4's risk for falls/injuries. The interventions included may have floor mats to both sides of the bed. Review of Resident 4's MDS quarterly assessment dated [DATE], showed Resident 4 had severe cognitive impairment. On 2/11/25 at 1630 hours, Resident 4 was observed awake and lying position in a low bed. Resident 4's bilateral floor mats were observed leaning against the wall of Resident 4's room instead of both sides of the bed. On 2/11/25 at 1637 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 4's floor mats were leaning against the wall of Resident 4's room instead of on the floor. LVN 4 stated the floor mats were needed because Resident 4 might fall and she was a high risk for fall. On 2/18/25 at 1211 hours, the DON and Interim Administrator were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services related to the use of the GT for three of three final sampled residents (Residents 55, 58, and 74) reviewed for the GT management. * The facility failed to ensure the licensed staff managed the GT feeding for Resident 55. CNA 14 had resumed the GT feeding after providing incontinent care to Resident 55. In addition, the facility failed to ensure Resident 55's enteral feeding formula was labeled with the time and the Kangaroo (enteral feeding pump machine) water bag was labeled with the time and name of contents inside the bag. * The facility failed to ensure LVN 2 auscultated the resident to check the GT placement prior to the administration of the GT medication for Resident 58. In addition, the facility failed to ensure Resident 58's abdominal binder (compression band around the abdomen used to provide support and safety) was applied as per the care plan. * The facility failed to ensure Resident 74's HOB was elevated at a 30 degree angle or above when Resident 74 was receiving the enteral feeding via the GT. These failures posed the risk for complications related to the use of the GT for Residents 55, 58, and 74. Findings: Review of the facility's P&P titled Enteral Feeding-Close dated 5/26/21, showed enteral feedings will be administered via pump as ordered by the attending physician. The head of the bed should be elevated 30 degrees during feedings. The formula may hang for 24-48 hours, depending on the manufacturer guidelines. To label the formula with the date and the time hung only. To change the feeding formula and tubing every 24-48 hours or as required by manufacturer guidelines. Review of the facility's P&P titled Enteral Tube Medication Administration dated 10/2017 showed to verify the tube placement, use the following procedures: a. Insert a small amount of air into the tube with the syringe and listen to the stomach with the stethoscope for the gurgling sounds. b. Aspirate stomach contents with the syringe to check for residual feeding. 1. Medical record review for Resident 55 was initiated on 2/10/25. Resident 55 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 55's MDS dated [DATE], showed Resident 55 had a feeding tube. a. On 2/10/25 at 0927 hours, Resident 55 was observed lying in bed. An enteral feeding pump was observed with Nepro 1.8 (enteral formula) bottle hanging from the feeding pump pole. The enteral formula bottle was observed not labeled with the date or start time. The Kangaroo brand bag was observed with a clear liquid inside. The label on the bag was observed without the date, time, and name of contents inside the bag. Review of Resident 55's Order Summary Report dated 2/13/25, showed the following orders: - dated 1/15/25, to administer water flush at 150 ml every four hours for 20 hours per day, and start the GT feeding at 1200-1300 hours. - dated 1/16/25, to administer Nepro via pump at 50 ml per hour for 20 hours per day, to provide 1000 ml, 1000 kcals, and start at 1200-1300 hours, and continue until the total volume infused. On 2/11/25 at 1155 hours, an interview and concurrent observation was conducted with LVN 2. Resident 55's enteral feeding formula was observed not labeled with the name, date, room, and rate. The Kangaroo bag containing the clear liquid was not labeled with the time and name of contents inside the bag. LVN 2 verified the findings and stated she did not know when the enteral feeding formula was hung and the label on the Kangaroo bag should be labeled with the name of content inside the bag. On 2/12/25 at 1052 hours, an interview was conducted with the DON. The DON stated the enteral feeding formulas and the water bags should be labeled with the resident's name, room, date, time, rate, and name of content inside the bag. b. On 2/12/25 at 0800 hours, Resident 55 was observed in bed and CNA 14 was observed with another CNA providing care to Resident 55. The resident's enteral feeding pump was observed on hold. On 2/12/25 at 0807 hours, an observation and concurrent interview was conducted with CNA 14. Resident 55 was observed in bed, with the enteral feeding pump infusing Nepro 1.8 at 50 ml/hr. When asked, CNA 14 stated he resumed the enteral feeding after he had provided incontinent care to Resident 55. CNA 14 acknowledged there was a potential risk of the GT dislodgment during the turning and repositioning of Resident 55. When asked how CNA 14 was able to verify the GT placement prior to resuming the enteral feeding, CNA 14 stated he did not know. On 2/12/25 at 1052 hours, an interview was conducted with LVN 2. LVN 2 stated only the licensed nurses were responsible for putting the enteral feeding devices on hold and resuming the enteral feedings. LVN 2 stated there was a risk of dislodgment of the GT during care, therefore, the licensed nurses should check the GT placement after the care was rendered and prior to resuming the enteral feeding. LVN 2 further stated the CNAs should not touch the enteral feeding device. On 2/12/25 at 1052 hours, an interview was conducted with the DON. The DON stated the licensed nurses were responsible for holding and/or resuming the enteral feedings. The DON stated the CNAs were not trained to put the enteral feedings on hold or to resume the enteral feedings. 2. Medical record review for Resident 58 was initiated on 2/10/25. Resident 58 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 58's MDS dated [DATE], showed Resident 58 had a feeding tube. a. On 2/11/25 at 0918 hours, a medication administration observation for Resident 58 was conducted with LVN 2. LVN 2 failed to check the GT placement via auscultation prior to the administration of the GT medications. On 2/11/25 at 0958 hours, an interview was conducted with LVN 2. LVN 2 verified she did not check the GT placement prior to the administration of the GT medications. LVN 2 further stated she should check the GT placement to ensure for proper placement of the GT prior to administering the GT medications. On 2/12/25 at 1052 hours, an interview was conducted with the DON. The DON stated when administering the medications via the GT, she expected the licensed nurses to check for the GT placement via auscultation and checking for gastric residual. b. Review of Resident 58's plan of care showed a care plan problem dated 10/17/24, addressing Resident 58's requirement for the GT feeding to meet the nutritional and hydration needs. The care plan showed Resident 58 had episodes of pulling out/dislodgment off the GT. The interventions showed to apply the abdominal binder to prevent pulling out the GT. On 2/11/25 at 0945 hours, during a medication administration observation with LVN 2, Resident 58 was observed not wearing an abdominal binder. On 2/12/25 at 1100 hours, an interview, observation, and concurrent medical record review for Resident 58 was conducted with LVN 2. Resident 58 was observed not wearing an abdominal binder. LVN 2 verified Resident 58 was not wearing an abdominal binder and stated Resident 58 had a history of pulling out her GT and was sent to the acute care hospital. LVN 2 verified Resident 58 was not wearing an abdominal binder during the medication administration observation on 2/11/25. LVN 2 reviewed Resident 58's plan of care and verified the above findings. LVN 2 stated the care plan intervention to apply the abdominal binder should be implemented to prevent Resident 58 from pulling out her GT. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings. 3. Medical record review for Resident 74 was initiated on 2/11/25. Resident 74 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 74's MDS dated [DATE], showed Resident 74 had moderately impaired cognitive skills for daily decision making. Review of Resident 74's Order Summary Report dated 2/11/25, showed a physician's order dated 1/15/25, to administer Glucerna (enteral feeding) 1.5 calorie continuous via pump at 55 ml/hr for 20 hours per day; and to start the infusion at 1400 hours, and continue until the total volume is infused. On 2/12/25 at 1555 hours, Resident 74 was observed lying in bed and receiving the enteral tube feeding with the HOB elevated less than 30 degrees . On 2/12/25 at 1600 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 74's HOB was elevated less than 30 degrees while the resident was receiving the enteral tube feeding. LVN 1 stated Resident 74's HOB should have been elevated at 30 degrees to prevent aspiration (inhaling food, liquid or other material into the lungs). On 2/18/25 at 0831 hours, an interview was conducted with the DON. The DON acknowledged the above findings. The DON stated when the resident was receiving the GT feeding, the HOB should be at least 30 to 45 degrees to prevent aspiration pneumonia (lung infection when food, liquid or other material are inhaled into the lungs).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care to the meet the needs for two of two final sampled residents (Residents 55 and 816) reviewed for respiratory care. * The facility failed to administer the oxygen as per the physician's order to Resident 816. * The facility failed to ensure Resident 55's sterile water for the humidifier was labeled with an opened date. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed under the preparation section, to verify there is a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. During the initial tour of the facility on 2/10/25 at 1057 hours, an observation was conducted in Resident 816's room. Resident 816 was observed lying in bed receiving oxygen by nasal cannula at three liters per minute. Resident 816 stated she had a hard time breathing. On 2/10/25 at 1115 hours, an observation and concurrent interview was conducted with the IP in Resident 816's room. The IP verified Resident 816 was receiving an oxygen at three liters per minute. Resident 816 stated she was short of breath and needed her oxygen saturation level to be between 95 - 97%. On 2/10/25 at 1123 hours, Resident 816 was observed to press her call light. On 2/10/25 at 1125 hours, an observation was conducted with LVN 8 in Resident 816's room. LVN 8 was observed to check Resident 816's oxygen saturation level with a vital signs monitor. The monitor showed Resident 816's oxygen saturation level was at 92%. LVN 8 verified Resident 816 was on oxygen at three liters per minute and would increase it. LVN 8 stated the physician's order was for up to six liters per minute. LVN 8 stated she would need to switch to a different oxygen machine because the one Resident 816 was using could only delivered five liters per minute. Medical record review for Resident 816 was initiated on 2/10/25. Resident 816 was admitted to the facility on [DATE]. Review of Resident 816's Nursing Documentation Note dated 2/7/25, showed Resident 816 was on six liters per minute of oxygen with an oxygen saturation level at 97%. Review of Resident 816's Nursing Documentation Notes dated 2/8 and 2/9/25, showed Resident 816 was breathing with oxygen at six liters per minute via nasal cannula. The resident's respirations were even/unlabored, with no shortness of breath, cough, congestion, or complaints of pain/discomfort when asked. Further review of Resident 816's medical record failed to show a rationale for Resident 816 to have the administration of the oxygen decreased to three liters per minute. Review of Resident 816's Order Summary Report dated 2/10/25, showed a physician's order dated: - 2/8/25 at 0309 hours, for oxygen at six liters per minute via nasal cannula continuously to keep the oxygen saturation level greater than 92%. - 2/10/25 at 1600 hours, for oxygen at three liters per minute via nasal cannula continuously to keep the oxygen saturation level greater than 92% as per the family request. Review of Resident 816's General Note dated 2/10/25, showed Resident 816 was complaining of difficulty breathing and the CNA called the LVN. The LVN went to Resident 816's room and checked the resident's oxygen, and the oxygen saturation level was at 93% at three liters per minute with nasal cannula. The LVN increased the oxygen to six liters per minute with nasal cannula and the oxygen saturation level was at 95 - 96%. On 2/12/25 at 0936 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged the above findings and stated the staff should be following the physician's order for the oxygen administration. 2. Review of the facility's P&P titled Respiratory Care; Equipment Care and Handling updated 11/2018 showed the respiratory equipment is handled in a manner that maintains good working order and promotes proper infection control. The P&P also showed to use only sterile medications, diluents, and solutions that have been dispensed aseptically and to date medication containers when opened and refrigerate as necessary per the manufacturer's recommendations. Medical record review for Resident 55 was initiated on 2/10/25. Resident 55 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 55's Order Summary Report dated 2/13/25, showed a physician's order dated 1/16/25, to administer the oxygen at three liters per minute via nasal cannula, may titrate up to 10 liters per minute as needed for shortness of breath, comfort, or if the oxygen saturation level less than 90%. On 2/10/25 at 0927 hours, Resident 55 was observed lying in bed and receiving oxygen via nasal cannula between two and three liters per minute. The nasal cannula was observed connected to the oxygen concentrator with a bottle of sterile water used for humidification. The sterile water was not observed with an opened date. On 2/11/25 at 1145 hours, an interview and concurrent observation was conducted with LVN 2. LVN 2 stated Resident 55 was currently on continuous oxygen at three liters per minute via nasal cannula. LVN 2 verified the above findings and stated the sterile water should be dated with the opened date when opened. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for one of two final sampled residents (Resident 818) reviewed for pain management. The facility failed to ensure Resident 818 was administered pain medication as per the physician's order. Additionally, the facility failed to consistently provide the NPI for pain prior to the administration of a narcotic pain medication to Resident 818. These failures had the potential for not effectively managing the resident's pain. Findings: Review of the facility's P&P titled Pain Management revised 10/2022 showed the staff will continually observe and monitor the residents for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices related to pain management. The nurse will notify the physician as appropriate and obtain treatment orders as indicated. The residents receiving interventions for pain will be monitored for the effectiveness and/or side effects/adverse drug reactions. To document non-pharmacological interventions and effectiveness. Medical record review for Resident 818 was initiated on 2/10/25. Resident 818 was admitted to the facility on [DATE]. Review of Resident 818's MDS dated [DATE], showed Resident 818 was cognitively intact. Review of Resident 818's plan of care showed a care plan focus initiated on 1/25/25, to address Resident 818's actual pain and discomfort related to status post open reduction and internal fixation (ORIF, an orthopedic surgical procedure used to repair a broken bone) with external fixation (an external device used to keep the bone stabilized) to the right foot and right heel infection. The interventions included to offer non-pharmacologic interventions prior to PRN pain medication. Review of Resident 818's MAR for January 2025 showed a physician's order dated 1/24/25, to administer morphine (narcotic pain medication) 15 mg one tablet by mouth every four hours as needed for severe pain (pain level of 8-10, on a 0-10 pain scale with 0=no pain and 10=worst pain). Resident 818 was administered the morphine medication as follows: - on 1/25/25 at 0720 hours, for a pain level of 10; at 1120 hours, for a pain level of 10; at 1530 hours, for a pain of level 8; and at 2000 hours, for a pain of level 8; - on 1/26/25 at 0035 hours, for a pain of level 8; at 0635 hours, for a pain of level 8; and at 1500 hours, for a pain of level 8; - on 1/27/25 at 0100 hours, for a pain of level 8; at 0500 hours, for a pain of level 8; 1600 hours, for a pain of level 7; and at 2000 hours, for a pain of level 7; - on 1/28/25 at 0000 hours, for a pain of level 8; at 0500 hours, for a pain of level 8; at 1230 hours, for a pain of level 8; at 1742 hours, for a pain of level 6; and at 2143 hours, for a pain of level 6; - on 1/29/25 at 0500 hours, for a pain of level 0; at 1000 hours, for a pain of level 8; at 1724 hours, for a pain of level 6; and at 2130 hours, for a pain of level 6; - on 1/30/25 at 0130 hours, for a pain of level 8; at 0830 hours, for a pain of level 8; at 1250 hours. for a pain of level 8; and at 1810 hours, for a pain of level 9; and - on 1/31/25 at 0715 hours, for a pain of level 10 and at 1430 hours, for a pain of level 8. Review of Resident 818's MAR for January 2025 showed a physician's order dated 1/24/25, to administer hydrocodone-acetaminophen (narcotic pain medication) 10-325 mg one tablet by mouth every four hours as needed for moderate pain (a pain level of 5 - 7). The MAR further showed the PRN hydrocodone-acetaminophen medication was not administered to the resident. Review of Resident 818's MAR for January 2025 showed documentation for the physician's order dated 1/24/25, for the NPI used before the administration of the PRN pain medication every six hours as needed: - on 1/25/25, no administrations; - on 1/26/25, no administrations; - on 1/27/25 at 0044 hours, with 1,6,7 NPI provided, at 0436 hours, with NA NPI provided; and at 2340 hours, with 1,6,7 NPI provided; - on 1/28/25 at 0449 hours, with 6,7 NPI provided; - on 1/29/25 at 0704 hours, with NA NPI provided and at 0930 hours, with 1,6,7 NPI provided; - on 1/30/25 at 0110 hours, with 6,7 NPI provided; at 0800 hours, with 6,7 NPI provided; and at 1220 hours, with 6,7 NPI provided; and - on 1/31/25 at 1400 hours, with 1,2,3,4 NPI provided. The MAR failed to show a legend on what 1, 2, 3, 4, 6, 7, and NA meant. Further review Resident 818's MAR for January 2025 showed a physician's order dated 1/24/25, to document the NPI, which were coded as follows: A. Heat; B. Repositioning; C. Relaxation breathing; D. Food/fluid; E. Massage; F. Exercise; G. Immobilization of joint; and H. Other - write in progress note as needed: - on 1/24/25 at 2000 hours, with B, C, D provided; - on 1/25/25 at 1500 hours, with A, B, D provided; - on 1/26/25 at 1430 hours, with A, B, C, D provided; and - on 1/27/25 at 1900 hours, with B, C, H provided. However, the MAR failed to show documented evidence the NPI were provided prior to the administration of the PRN morphine 15 mg on the following dates and times: - on 1/25/25 at 0720, 1120, and 2000 hours; - on 1/26/25 at 0035 and 0635 hours; - on 1/27/25 at 0100, 0500, and 1600 hours; - on 1/28/25 at 0000, 0500, 1230, 1742, and 2143 hours; - on 1/29/25 at 0500, 1000, 1724, and 2130 hours; - on 1/30/25 at 0130, 0830, 1250, and 1810 hours; and - on 1/31/25 at 0715 and 1430 hours. Further review of Resident 818's medical record failed to show documented evidence the NPI were provided with each of the PRN pain medication administration listed above. On 2/11/25 at 0902 hours, an interview was conducted with Resident 818. Resident 818 stated she had agonizing pain after her surgery. Resident 818 stated she took the morphine 15 mg medication every four hours for the pain. On 2/18/25 at 0841 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the facility's process for pain medications was to asses for pain and the licensed nurse would give the pain medication based on the pain scale. RN 1 verified the morphine 15 mg was administered to Resident 818 outside of the pain scale parameter on multiple occasions. RN 1 stated the NPI were offered for the PRN pain medication and verified the NPI were not provided to Resident 818 prior to the pain medication administration listed above. On 2/18/25 at 1106 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON verified the morphine 15 mg medication PRN order was administered outside of the pain scale and verified the medication should have been offered based on the pain scale. The DON stated for the PRN pain medications, the licensed nurse assessed the level of pain and offered the NPI and if the NPI did not work, then the licensed nurse would give the prescribed PRN pain medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two final sampled residents (Resident 21) reviewed for dialysis care. * The facility failed to ensure Resident 21's scheduled medications on the dialysis days were held as per the physician's order. In addition, the facility failed to ensure Resident 21's AV shunt was assessed after the dialysis treatment and fluid restriction was monitored . These failures had the potential to negatively affect Resident 21's physical well-being, which potentially would result in the resident having an excess of fluid which could lead to negative health consequences. Findings: Review of the facility's P&P titled Hemodialysis Care and assessment dated 2/2025 showed the process for documentation for residents receiving dialysis services should include the following: a. The licensed nurse completes the pre-dialysis form prior to the resident leaving for dialysis. b. Upon return, the pos-dialysis assessment portion of the form is completed and attached to the resident's medical record. c. If no documentation or new order is received from the dialysis center, no new orders will be implemented. If a post dialysis weight is not received from the dialysis center, a weight is obtained in the center and documented on the form. Residents who require hemodialysis are provided ongoing assessment and monitoring of the resident's condition before and after dialysis treatments including monitoring for complications and interventions as part of nursing standards of practice. Issues are documented, as noted, by the licensed nurse and medical providers are notified. Medical record review for Resident 21 was initiated on 2/10/25. Resident 21 readmitted to the facility on [DATE]. Review of Resident 21's H&P examination dated 5/27/24, showed Resident 21 had the capacity to make and understand decisions. Review of Resident 21's Order Summary Report dated 2/18/25, showed the following physician's orders: - dated 7/2/24, for hemodialysis every Tuesday, Wednesday, Thursday, and Saturday; - dated 7/2/24, to auscultate for bruit and palpate for thrill; and notify the physician for the absence of bruit/thrill; - dated 7/2/24, to administer hydralazine Hcl (medication to treat high blood pressure 50 mg one tablet by mouth every eight hours for hypertension, and to hold if the SBP less than 110 mmHg; - dated 7/2/24, to administer nifedipine (medication to treat high blood pressure) ER 20 mg one tablet by mouth every 24 hours for hypertension; and to hold if the SBP less than 110 mmHg, - dated 7/2/24, for fluid restriction of 1200 ml per day as follows: nursing department: 0700-1500 hours shift = 120 ml, 1500-2300 hours shift = 120 ml, and 2300-0700 hours shift =120 ml; and dietary department: breakfast tray = 360 ml, lunch tray = 120 ml, and dinner tray = 60 ml. - dated 9/8/24, to assess the AV fistula site for infection, edema, bleeding upon return from dialysis; and - dated 12/12/24, to hold hypertension medications (used to treat blood pressure greater than 140/90 mmHg) prior to dialysis. Review of Resident 21's Hemodialysis Communication Record for January and February 2025 showed Resident 21 had received dialysis treatment on 1/2, 1/4, 1/7, 1/8, 1/9, 1/11, 1/14, 1/15, 1/16, 1/18, 1/21, 1/22, 1/23, 1/25, 1/28, 1/29, 1/30, 2/1, 2/4, 2/5, 2/6, and 2/8/25. Review of Resident 21's Hemodialysis Communication Record dated 1/8/25, failed to show documented evidence Resident 21's AV shunt was assessed by the facility staff after the dialysis treatment. Review of Resident 21's Hemodialysis Communication Record dated 1/14/25, showed the recommendation by the dialysis center for fluid restriction less than 2000 ml per day between dialysis treatments. Additionally, the communication record showed 3.8 liters of IDWG was removed from Resident 21 during dialysis treatment. Review of Resident 21's Hemodialysis Communication Record dated 1/18/25, showed Resident 21 had a BP of 107/43 mmHg upon arrival to the dialysis center. The dialysis center was unable to remove the IDWG due to Resident 21's low BP. Additionally, the communication record showed the dialysis center's recommendation was to limit Resident 21's fluid intake and monitor the resident for signs and symptoms of fluid overload over the weekend. Further review of Resident 21's medical record failed to show documented evidence the physician was notified of the new recommendations from the dialysis center and/or when the resident had significant status changes on the above dates. Review of Resident 21's MAR for January and February 2025 showed the following: - hydralazine hcl 50 mg tablet was administered at 0600 hours, on 1/1 to 1/17, 1/19 to 1/27, 1/30, 1/31, and 2/1 to 2/10/25, which included the dialysis days. - nifedipine ER 30 mg tablet was administered at 0900 hours, on 1/14, 2/1, 2/3, 2/6, and 2/9/25, which included the dialysis days. - there was no documentation of the total amount of the resident's daily fluid intake. Further review of Resident 21's medical record failed to show documented evidence the physician was notified when Resident 21 received the hydralazine hcl and nifedipine medications on the dialysis days. On 2/13/25 at 1320 hours, an interview and concurrent medical record review was conducted with LVN 11 for Resident 21. When asked about the process when a resident returned from a dialysis treatment, LVN 11 stated the AV shunt should be assessed for bruit, thrill, bleeding, and signs and symptoms of infection; and the assessment should be documented on the resident's Hemodialysis Communication Record. LVN 11 stated if the Hemodialysis Communication Record showed any orders and/or recommendations from the dialysis center or resident status changes, the LVN was expected to notify the resident's physician. LVN 11 verified there was no documented evidence of the assessment of Resident 21's AV shunt after dialysis treatment on 1/8/25. Additionally, LVN 11 verified there was no documented evidence Resident 21's physician was notified of the new recommendations and/or when the resident had significant status changes on 1/14 and 1/18/25. When asked about Resident 21's fluid restriction, LVN 11 stated the LVNs were responsible for monitoring Resident 21's fluid intake during meals and medication administrations and documenting in the MAR. LVN 11 verified there was no documentation to show the total amount of Resident 21's fluid intake each shift. On 2/18/25 at 0945 hours, an interview and concurrent medical record review was conducted with RN 1 for Resident 21. When asked about Resident 21's hydralazine hcl and nifedipine ER medications, RN 1 verified there was a physician's order to hold Resident 21's hydralazine hcl and nifedipine ER medications on the days of the dialysis treatment. RN 1 verified the hypertension medications were not held as ordered on the above dates. RN 1 verified there was no documented evidence the physician was notified when Resident 21 was routinely administered the hypertension medications on the days of the dialysis treatment. On 2/18/25 at 1534 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of two final sampled residents (Residents 50 and 58). * The facility failed to ensure the physician's orders for Resident 58 were accurate. The medication route was ordered to be oral instead of GT. This failure had the potential for the medications to be administered in error. * One of five licensed nurses (LVN 2) who was observed during the medication administration was found to have an error. LVN 2 failed to administer the complete dose of one of Resident 58's medications when significant residual of the multivitamin (supplement) medication was observed in the medication cup after administering the medication via GT to Resident 58. * The facility failed to ensure LVN 1 documented the administration of the sodium chloride (supplement) medication to Resident 50 in the electronic MAR and/or in the resident's progress notes. These failures had the potential to negatively affect the residents' health conditions and posed the risk for possible complications or delay in interventions. Findings: Review of the facility's P&P titled Medication Administration- General Guidelines dated 10/2017 showed medications are administered as prescribed in accordance with good nursing principles and practices and only by the persons legally authorized to do so. Prior to the administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines. If a resident is tube-fed, medications are crushed finely to prevent clogging the tube. Further review of the facility's P&P showed medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the pharmacy provider for clarification prior to the administration of the medication or if necessary, contacts the prescriber for clarification. The interaction with the pharmacy and/or the prescriber and the resulting order clarification is documented in the nursing notes and elsewhere in the medical record as appropriate. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR to ensure the necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. 1.a. On 2/11/25 at 0918 hours, a medication administration observation for Resident 58 was conducted with LVN 2. LVN 2 was observed administering all the medications via the GT to Resident 58. Medical record review for Resident 58 was initiated on 2/10/25. Resident 58 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 58's MDS dated [DATE], showed Resident 58 had an enteral feeding tube. Review of Resident 58's Order Summary Report dated 2/11/25, showed the following physician's orders dated 1/28/25: - to administer polyethylene glycol (laxative) 3350 powder, 17 gm by mouth daily for constipation in four to eight ounces of fluid if the resident has not had a bowel movement in the past 72 hours and hold for loose stool. - to administer multiple vitamins-mineral (supplement) one tablet by mouth daily for supplement. On 2/11/25 at 0958 hours, an interview and concurrent medical record review for Resident 58 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 58 had a GT, and all of the resident's medications should be administered via GT. LVN 2 further stated the ordered route for the above medications should be changed to accurately reflect the care that the resident was receiving. On 2/13/25 at 1441 hours, an interview and concurrent medical record review for Resident 58 was conducted with the DON. The DON stated the licensed nurses who responsible for putting the physician's orders into the resident's medical record and carrying out the physician's orders. The DON further stated if there were any discrepancies in the physician's orders, the licensed nurses were responsible for clarifying the discrepancies. The DON reviewed Resident 58's medical record and verified the above findings. The DON stated the licensed nurse should have clarified the physician's order to accurately reflect the medication route. b. On 2/11/25 at 0918 hours, a medication administration observation for Resident 58 was conducted with LVN 2. LVN 2 prepared and administered Resident 58's medications which included the following: - one tablet of aspirin (antiplatelet) 81 mg, - one tablet of memantine (dementia medication, used to treat symptoms of Alzheimer's disease, a brain disease that slowly destroys the memory and the ability to think, learn, communicate and handle daily activities) 5 mg, - one tablet of metoprolol tartrate (antihypertensive) 25 mg, - one tablet of multivitamin with mineral, and - 17 gm of polyethylene glycol 3350 in five ounces of water. LVN 2 was observed administering the above medications to Resident 58 via the GT. After administering the medication, one medication cup was observed with a significant amount of yellow-colored medication residue. On 2/11/25 at 0955 hours, an interview and concurrent observation was conducted with LVN 2. LVN 2 verified the above findings and identified the medication cup contained the multivitamin with mineral medication. LVN 2 stated when there was significant residue in the medication cup she should add more water, stir the contents, and administer the complete dose of the medication to the resident. On 2/18/25 at 1428 hours, an interview was conducted with the DON. The DON stated during the administration of the medications, the licensed nurses were expected to ensure the medications were administered as per the physician's orders, including the correct route and complete dose. The DON stated when there are medication residue in the medication cup, the licensed nurses were expected to add water, mix the contents, and administer the complete dose as ordered by the physician. 2. On 2/12/25 at 0857 hours, a medication administration observation for Resident 50 was conducted with LVN 1. LVN 1 prepared and administered Resident 50's medications. LVN 1 stated Resident 50 had a physician's order for sodium chloride (supplement) 1 gm orally scheduled at 0900 hours; however, she could not administer the medication as it was not available in her medication cart. On 2/12/25 at 1005 hours, an interview was conducted with LVN 1. LVN 1 stated when the medication was not available in the medication cart, she would check the central supply for the medication. If the medication was not in the central supply stock, she would call the pharmacy and order the medication. LVN 1 was asked and stated she had not checked the central supply for sodium chloride medications. LVN 1 further stated she would attempt to obtain and administer the medication to Resident 50 as soon as possible. On 2/12/25 at 1058 hours, a follow-up interview was conducted with LVN 1. LVN 1 stated she had obtained the sodium chloride medication from the central supply and planned to administer the sodium chloride medication to Resident 50. Review of Resident 50's MAR for February 2025 showed the sodium chloride 1 gm tablet was held on 2/12/25 at 0900 hours. Review of Resident 50's Progress Notes failed to show the licensed nurse's documentation on 2/12/25, for the reason the sodium chloride 1 gm tablet was held and failed to show the documentation LVN 1 administered the sodium 1 gm tablet on 2/12/25. On 2/18/25 at 0907 hours, a follow-up interview was conducted with LVN 1. LVN 1 stated she had administered the sodium chloride 1 gm tablet medication to Resident 50 on 2/12/25. LVN 1 verified she did not document the administration of the medication in Resident 50's MAR or the progress notes. On 2/18/25 at 1428 hours, an interview was conducted with the DON. The DON stated during the administration of medications, if the medication was not available in the medication cart, the licensed nurses were expected to follow up with the central supply/pharmacy to obtain the medication and administer the medication as soon as possible. The DON further stated if the medication was held, she expected the licensed nurse to inform the physician and document in the progress notes the reason the medication was held. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. According to the Lexicomp, an online reference for clinical drug information, showed apixaban was an anticoagulant and may increase the risk of bleeding (hemorrhage), including severe and potential fatal major bleeding. Medical record review for Resident 60 was initiated on 2/10/25. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's Order Summary Report dated 2/13/25, showed a physician's order dated 1/17/25, to administer apixaban 5 mg one tablet by mouth two times a day for the treatment/prevention of blood clots. The physician's orders for the apixaban medication did not include the monitoring for the side effects. Review of Resident 60's MAR for February 2025 showed Resident 60 was administered the apixaban medication by mouth two times a day from 2/1/25 to 2/12/25 at 0900 and 1700 hours, except on 2/6/25 at 0900 hours. Further review of Resident 60's MAR for February 2025 failed to show documentation Resident 60 was being monitored for the signs and symptoms of bleeding related to the use of the apixaban medication. Review of Resident 60's plan of care showed a care plan problem dated 1/22/25, addressing Resident 60's potential for easy bruising, skin tears, ecchymosis and bleeding related to the adverse reaction of the apixaban medication. The interventions included to monitor for the signs and symptoms of bleeding: discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, muscle joint pain, diarrhea, lethargy, bruising, sudden changes in mental status and or vital signs, shortness of breath or nose bleeds; and to notify the physician for any changes in condition. On 2/13/25 at 1024 hours, an interview and concurrent medical record review for Resident 60 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated for the use of the anticoagulant medication, there should be the monitoring for the signs and symptoms of bleeding and bruising every shift. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings. Based on interview and medical record review, the facility failed to ensure two of five final sampled residents (Residents 60 and 110) reviewed for unnecessary medication were properly monitored for the signs and symptoms of bleeding related to the use anticoagulant (prevents blood clots) medication. * The facility failed to ensure Resident 110 was monitored for the signs and symptoms of bleeding for the use of enoxaparin (anticoagulant medication) medication. * The facility failed to monitor for signs and symptoms of bleeding related to Resident 60's use of the apixaban (anticoagulant medication) medication. These failures had the potential for the residents to develop significant side effect of bleeding and negatively affect the resident's health condition and well-being. Findings: According to DailyMed, the enoxaparin medication's most common adverse effect was the increased risk of bleeding. 1. Medical record review for Resident 110 was initiated on 2/10/25. Resident 110 was admitted to the facility on [DATE]. Review of Resident 110's H&P examination dated 1/25/25, showed Resident 110 had the capacity to understand and make decisions. Review of Resident 110's Order Summary Report dated 2/13/25, showed a physician's order dated 1/15/25, to administer enoxaparin 40 mg/0.4 ml injection subcutaneously one time a day to prevent clotting. Review of Resident 110's plan of care showed a care plan problem dated 1/15/25, addressing the resident's potential for easy bruising, skin tears, ecchymosis and bleeding related to adverse reaction of the enoxaparin medication. The care plan interventions included to monitor for the signs and symptoms of bleeding: discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, nose bleeds; and to notify the physician for any changes in the condition. Review of Resident 110's medical record did not show documented evidence Resident 110 was monitored for the signs and symptom of bleeding. On 2/13/25 at 1307 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified there was no monitoring documented to show Resident 110 was assessed for the adverse effects related to the use of the enopaxarin medication. On 2/18/25 at 1212 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the monitoring for the use of the antipsychotic medications (medications that affect brain activities associated with mental process and behavior) for three of five sampled residents (Residents 4, 41, and 60) reviewed for unnecessary medications were completed when: * The facility failed to ensure Resident 41 was monitored accurately for orthostatic hypotension as ordered by the physician for the use of Seroquel (antipsychotic medication). In addition, the facility failed to ensure Resident 41's informed consent for the use of the Seroquel medication included the indication for its use and the date for the Seroquel medication to be stopped. * The facility failed to ensure Resident 60's informed consent had documentation of the frequency and behavior manifestations for the use of the Risperdal (antipsychotic) medication and to monitor Resident 60 for orthostatic hypotension for the use of the Risperdal medication. In addition, the facility failed to ensure the physician documented the justification for the continued daily use and no-stop date for the PRN use of the Risperdal medication for Resident 60. * The facility failed to ensure Resident 4 was monitored for orthostatic hypotension as ordered by the physician for the use of Seroquel medication. These failures had the potential for adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dosage of psychotropic medication. Findings: Review of the facility's P&P titled Blood Pressure, Measuring Assessments and Care Planning (undated) showed orthostatic (postural) hypotension is defined as a 20 mmHg or greater decline in systolic blood pressure (the blood pressure during the contraction of the heart) or a 10 mmHg or greater decline in diastolic blood pressure (the pressure in the arteries when the heart rests between beats) upon standing. 1. a. Medical record review for Resident 41 was initiated on 2/10/25. Resident 41 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 41's H&P examination dated 5/7/24, showed the resident had no capacity to understand and make decisions. Further review of Resident 41's H&P examination showed the resident had a diagnosis of unspecified psychosis. Review of Resident 41's Order Summary Report dated 2/18/25, showed the following physician's orders: - dated 3/21/22, to monitor for significant side effects from the Seroquel medication usage including postural hypotension; - dated 3/31/22, to monitor for orthostatic hypotension while sitting one time a day every Saturday; - dated 3/31/22, to monitor for orthostatic hypotension while lying one time a day every Saturday; - dated 3/31/22, to monitor for orthostatic hypotension while standing one time a day every Saturday; and - dated 8/23/24, to administer Seroquel 25 mg one-half tablet of by mouth twice a day for psychosis manifested by increased yelling/screaming. Review of Resident 41's MAR for January through 2/12/25, showed the following medications were administered to Resident 41: - Seroquel 25 mg, half of a tablet daily at 0900 hours, from 1/1 to 2/12/25; and - Seroquel 25 mg, half of a tablet daily at 1700 hours, from 1/1 to 2/11/25. Further review of Resident 41's MAR for January through 2/12/25, showed the orthostatic BP (lying, sitting, and standing) were scheduled to be monitored every Saturday. However, the blood pressure readings for the three positions were the same as follows: - On 1/4/25, the blood pressure readings was 98/74 mmHg for the lying, sitting, and standing position. - On 1/11/25, the blood pressure readings was 132/79 mmHg for the lying, sitting position, and 132, and standing position. - On /18/25, the blood pressure readings was 110/54 mmHg for the sitting position, lying position, and standing position. - On 1/25/25, the blood pressure readings was 128/67 mmHg for the sitting position, lying, and standing position. - On 2/1/25, the blood pressure readings was 120/68 mmHg for the lying position and standing position. - On 2/8/25, the blood pressure readings was 124/70 mmHg for the lying position and sitting position. On 2/12/25 at 1014 hours, an interview and concurrent medical record review for Resident 41 was conducted with LVN 1. When asked about the procedure for taking the orthostatic blood pressure readings, LVN 1 stated the BP was taken while the resident was sitting or lying down. A second BP reading was taken a few minutes after changing the resident's position to sitting or standing. LVN 1 stated the orthostatic BP readings should not be the same for the lying, sitting, and standing position. LVN 1 stated Resident 41 could be at risk for the low blood pressure not being identified if the orthostatic BP readings were not taken using the proper procedure. LVN 1 verified the orthostatic BP readings for Resident 41 were the same for the above dates. On 2/13/25 at 1041 hours, an interview and concurrent medical record review for Resident 41 was conducted with RN 1. RN 1 verified Resident 41 had a physician's order to monitor for orthostatic hypotension as a side effect of the Seroquel medication administration. RN 1 stated the blood pressure readings should not be the same for the lying, sitting, and standing position. RN 1 stated Resident 41 was at risk for injury and adverse consequences because of the inaccurate monitoring of the orthostatic hypotension. RN 1 verified the orthostatic BP readings for Resident 41 were the same for the above dates. b. Review of the facility's P&P titled Consent for Psychotropic Drugs revised 9/2017 showed when the physician had ordered the use of antipsychotic, antidepressant, antianxiety, and/or hypnotic drug, the Center obtains, per Federal and State Regulations and Center policy, informed consent from the resident or resident representative. An informed consent is obtained before the drug prescribed is administered. The Procedure was described as follows: 1. The licensed nurse reviews/completes the following with the resident and/or responsible party: a. The drug, dosage, and frequency. b. Discuss the rationale/benefits for the orders as directed by the physician. c. Discuss the potential risk factors (side effects/symptoms) of taking the prescribed drug. d. Review the content with them and obtain their signature if they agree to take the prescribed drug. Review of Resident 41's Psychotropic Medication Administration Informed Consent dated 8/23/24, showed to increase the Seroquel medication dosage to 12.5 mg by mouth twice a day. However, the consent did not show the documentation of the behavioral indications for the recommended increase of the Seroquel medication dosage. On 2/13/25 at 1041 hours, an interview and concurrent medical record review was conducted with RN 1 for Resident 41. When asked about the procedure for obtaining the informed consent prior to the administration of psychotropic medications, RN 1 stated the written consent form should include the name of the medication, dosage, frequency, indications for the medication (behavioral manifestations), and date for the medication to be stopped. Resident 41's Psychotropic Medication Administration Informed Consent dated 8/23/24, was reviewed with RN 1. RN 1 verified Resident 41's consent form did not show the documentation of the behavioral indications for the recommended increase of the Seroquel medication or the date for the medication to be stopped. On 2/18/25 at 1534 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 4 was initiated on 2/11/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS quarterly assessment dated [DATE], showed Resident 4 had severe cognitive impairment. Review of Resident 4's Order Summary Report dated 2/11/25, showed the physician's order dated 7/25/24, to take the orthostatic blood pressure. Direction for orthostatic BP: Enter BPs in Weights and Vitals tab directly. Take the BP while lying, then take BP while standing every seven days. Evaluate both recording for potential orthostatic hypotension indicated if the systolic drops by 20 units or diastolic drops by 10 units. Document occurrence and action taken in the Progress Note. Further review of Resident 4's medical record did not show documentation of Resident 4's orthostatic BP readings. On 2/14/25 at 1010 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified the orthostatic BP was not done for Resident 4 as ordered by the physician. RN 3 stated the LVN should have taken Resident 4's BP. RN 3 further stated Resident 4's BP might drop when the resident stood up or sat up too quickly. RN 3 stated Resident 4's BP should be monitored for the psychotropic and BP medications. On 2/14/25 at 1135 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the orthostatic BP for Resident 4 was not done as ordered by the physician. LVN 3 stated she did not read Resident 4's physician's order clearly. LVN 3 further stated the licensed nurse usually entered the orthostatic BP in the MAR. LVN 3 stated the physician's order for the monitoring of Resident 4's orthostatic BP was documented differently from the usual physician's order. LVN 3 stated the orthostatic BP should have been done so the licensed nurse could monitor the side effect of the Seroquel medication to Resident 4. On 2/18/25 at 0826 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the above findings. The DON stated the orthostatic BP should have been done by the licensed nurse because the Seroquel medication might induce orthostatic hypotension associated with dizziness. 2. Review of the facility's P&P titled Antipsychotic Medication Use revised 7/2022 showed antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. PRN orders for the antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. The duration of the PRN order will be indicated in the order. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: b. cardiovascular: orthostatic hypotension, arrhythmias. Review of the facility's P&P titled Medication Redimen Review (Monthly Report) dated 6/2021 showed recommendations are acted upon and documented by the facility staff and or the prescriber. The physician accepts or acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit. Medical record review for Resident 60 was initiated on 2/10/25. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's MDS dated [DATE], showed Resident 60 had modified independence (some difficulty in new situations) in cognitive skills for the daily decision making. Further review of Resident 60's MDS showed Resident 60 had the diagnosis of PTSD and was on an antipsychotic medication. Review of Resident 60's Order Summary Report dated 2/13/25, showed the following physician's orders: - dated 1/18/25, to report to the physician if any side effects were present: sedation, drowsiness, dry mouth, constipation, blurred vision, weight gain, edema, postural hypotension, sweating, loss of appetite, tardive dyskinesia (facial, tongue movement), cognitive behavior (decreased mental status), akathisia (inability to sit still), Parkinsonism (tremors, drooling from the mouth, muscle rigidity), every shift, - dated 1/21/25, to administer Risperdal 2 mg ½ (half) tablet by mouth two times a day for PTSD manifested by restlessness as evidenced by irritability towards others, and - dated 1/21/25, to administer Risperdal 2 mg ½ (half) tablet by mouth every four hours as needed for PTSD manifested by restlessness as evidenced by irritability towards others. No stop date per the physician. Review of Resident 60's MAR for February 2025 showed the following: - Resident 60 was administered Risperdal 2 mg ½ tablet by mouth two times a day from 2/1 to 2/12/25 at 0900 and 2100 hours, - Resident 60 was administered Risperdal 2 mg ½ tablet by mouth every four hours as needed on 2/12/25 at 0557 hours, and - Resident 60 was monitored for: free of significant side effects from Risperdal medication usage, to report to the physician if any side effects are present: sedation, drowsiness, dry mouth, constipation, blurred vision, weight gain, edema, postural hypotension, sweating, loss of appetite, tardive dyskinesia , cognitive behavior (decreased mental status), akathisia (inability to sit still), Parkinsonism. The MAR showed a check mark from 2/1 to 2/12/25 for the day, evening, and night shifts. Further review of Resident 60's MAR failed to show Resident 60 was monitored for the orthostatic hypotension related to the use of the Risperdal medication. Review of Resident 60's plan of care showed a care plan problem dated 1/22/25, addressing Resident 60's antipsychotic drug use of the Risperdal medication for PTSD manifested by restlessness as evidenced by irritability towards others. The interventions showed to monitor for the side effects and consult the physician and/or pharmacist as needed. Review of Resident 60's Psychotropic Medication Administration Informed Consent dated 1/20/25, showed a consent was obtained for Risperdal 1 mg PO tablet. The consent failed to indicate the frequency or manifestations for the use of the Risperdal medication. Review of the facility's documents for Resident 60's pharmacy recommendation dated 1/28/25, showed the following: 1. Resident 60 was admitted with orders for the Risperdal medication and to ensure the physician (or Psych physician) documentation was available to support the continued use of the current psychotropic. The section for Physician/Prescriber Response showed the physician selected AGREE and documented per Psych. 2. The Pharmacist noted Resident 60 had an order for the the use of the Risperdal medication PRN. The Pharmacist documented Per the new CMS regulations, PRN psychotropic orders are limited to 14 days. If longer duration of this PRN antipsychotic order was required, please include the documentation in the clinical record. The facility document showed the physician selected No stop date. Update the current PRN order to include no stop date per MD. The section for Physician/Prescriber Response showed the physician selected AGREE and documented per Psych. Review of the facility's document titled Consultant Pharmacist's Medication Regimen Review for the recommendations created between 1/1 and 1/28/25, for Resident 60 showed the following: - The Pharmacist recommended (for Resident 60's Risperdal medication) to ensure the physician documentation was available to support the continued use of the current psychotropic. The section for Follow-Through showed, note written to the secondary physician. - The Pharmacist recommended (for Resident 60's Risperdal PRN medication) the PRN psychotropic orders are limited to 14 days. If longer duration of this PRN antipsychotic order was required, please include the documentation in the clinical record. The section for Follow-Through showed, note written to physician. Review of Resident 60's Physician's Progress Notes dated 1/21/25, failed to show documentation to support the continued use of the Risperdal medication for Resident 60. Further review of Resident 60's medical record failed to show any progress notes by the physician to support Resident 60's continued use of the Risperdal medication and the documentation for Resident 60 to have the Risperdal PRN medication for more than 14 days. On 2/13/25 at 1024 hours, an interview and concurrent medical record review for Resident 60 was conducted with RN 1. RN 1 stated an informed consent must be obtained for the use of antipsychotic medication. RN 1 further stated the informed consent for the use of antipsychotic should include the name of the medication, dose, route, frequency, and indications for the use of the medication. RN 1 stated for the residents on antipsychotics, the monitoring of behaviors was conducted every shift, as well as the monitoring for the potential side effects related to the use of the antipsychotic medication. RN 1 stated the monitoring of the side effects for the use of the antipsychotic medications was documented in the MAR. RN 1 reviewed Resident 60's informed consent for the use of the Risperdal medication and verified the consent was missing the frequency and indication of the medication. RN 1 further reviewed Resident 60's medical record and verified there was no documentation the licensed nurses were monitoring Resident 60 for orthostatic hypotension. On 2/13/25 at 1555 hours, an interview and concurrent medical record review for Resident 60 was conducted with the DON. The DON stated she designated two licensed nurses to be responsible for the recommendations made by the Pharmacist on the monthly drug regimen reviews. The DON stated the recommendations by the Pharmacist should be addressed as soon as possible. The DON reviewed the Pharmacist's recommendations for Resident 60's Risperdal medication use and stated there were no documentation by the physician in Resident 60's medical record to indicate the continued use of the Risperdal medication and the justification for the PRN Risperdal medication with no stop date. The DON stated the Pharmacist's recommendations for Resident 60 were not followed-up and should have been followed up timely. On 2/18/25 at 1428 hours, an interview was conducted with the DON. The DON stated she expected the Pharmacist's recommendations for the drug regimen review to be addressed as soon as possible. The DON further stated, if the recommendations were addressed with the physician or were not resolved, then she expected the licensed nurses to document in the resident's progress notes. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 11.54%. Three of five licensed nurses (LVNs 1, 2, and 10) were found to have made errors during the medication administration observations. * Resident 50 had a physician's order for zinc (supplement) for wound healing. LVN 1 failed to administer the zinc medication as ordered due to the unavailability of the medication. * LVN 2 failed to check Resident 58's last bowel movement and if Resident 58 had loose stool prior to administering the polyethylene glycol 3350 (laxative medication) medication. * LVN 10 failed to check whether Resident 109 had a bowel movement in the last 72 hours prior to administering the polyethylene glycol medication. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines dated 10/2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with the written orders of the attending physician. 1. On 2/12/25 at 0857 hours, a medication administration observation for Resident 50 was conducted with LVN 1. LVN 1 prepared and administered Resident 50's medications. LVN 1 stated Resident 50 had a physician's order for zinc (supplement) 220 mg orally scheduled at 0900 hours, however she could not administer the medication as it was not available in her medication cart. On 2/12/25 at 1005 hours, an interview was conducted with LVN 1. LVN 1 stated when the zinc medication was not available in the medication cart, she would check the central supply for the medications. If the medication was not in the central supply stock, she would call the pharmacy and order the medication. LVN 1 was asked and stated she had not checked the central supply for the zinc. LVN 1 further stated she would attempt to obtain and administer the medication to Resident 50 as soon as possible. On 2/12/25 at 1058 hours, a follow-up interview was conducted with LVN 1. LVN 1 stated the central supply did not have the zinc medication and she had placed an order for the zinc medication with the pharmacy. Review of Resident 50's Order Summary Report dated 2/13/25, showed a physician's order dated 2/10/25, to administer zinc 220 mg orally once a day for wound healing. Review of Resident 50's MAR for February 2025 showed the zinc 220 mg tablet was held on 2/12/25 at 0900 hours. On 2/18/25 at 1428 hours, an interview was conducted with the DON. The DON stated during the administration of medications, if the medication was not available in the medication cart, the licensed nurses were expected to follow up with the central supply/pharmacy to obtain the medication and administer the medication as soon as possible. The DON further stated if the medication was held, she expected the licensed nurse to inform the physician and document in the progress notes the reason the medication was held. 2. On 2/11/25 at 0918 hours, a medication administration observation for Resident 58 was conducted with LVN 2. LVN 2 administered five medications to Resident 58, including the polyethylene glycol 3350 powder 17gm in five ounces of water via the GT. Review of Resident 58's Order Summary Report dated 2/11/25, showed a physician's order dated 1/28/25, to administer polyethylene glycol 3350 17 gm by mouth daily for constipation, in four to eight ounces of fluid, if the resident had no bowel movement in the past 72 hours; and to hold for loose stools. On 2/11/25 at 0958 hours, an interview and concurrent medical record review for Resident 58 was conducted with LVN 2. LVN 2 reviewed Resident 58's medical record and stated Resident 58 had a GT, thus the ordered route for the polyethylene glycol 3350 medication was incorrect. Additionally, LVN 2 stated the physician's order for the polyethylene glycol 3350 medication was to administer to Resident 58, if the resident had no bowel movement in the last 72 hours and to hold the medication for loose stools. LVN 2 stated she did not check Resident 58's last bowel movement and consistency prior to the administration of the polyethylene glycol 3350 medication. LVN 2 reviewed Resident 58's medical record and stated Resident 58's last bowel movement was on 2/10/25 at 0330 hours (less than 72 hours) and the consistency of the bowel movement was documented as loose stools. LVN 2 stated she should not have administered the polyethylene glycol 3350 medication. 3. On 2/11/25 at 0856 hours, a medication administration observation for Resident 109 was conducted with LVN 10. LVN 10 administered two medications orally to Resident 109, including the polyethylene glycol 3350 powder 17gm in five ounces of water. Review of Resident 109's Order Summary Report dated 2/11/25, showed a physician's order dated 1/13/25, to administer polyethylene glycol 3350 17 gm by mouth daily for constipation, in four to eight ounces of fluid, if the resident had no bowel movement in the past 72 hours. On 2/11/25 at 0912 hours, an interview and concurrent medical record review for Resident 109 was conducted with LVN 10. LVN 10 verified the physician's order was to administer the polyethylene glycol 3350 medication if the resident had no bowel movement in the past 72 hours. LVN 10 reviewed Resident 109's medical record and stated Resident 109 had a bowel movement on 2/9/25 at 2200 (less than 72 hours). LVN 10 further stated she should not have administered the polyethylene glycol 3350 medication. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aide 1 was unable to correctly demonstrate how to test the chemical concentration of the sanitizing solution used to sanitize the food contact surfaces. * Dietary Aides 1 and 2 were unable to correctly describe how to manually wash the dishes. These failures had the potential to lead to foodborne illnesses in a highly susceptible population of the residents who received food prepared in the kitchen. Findings: Review of the facility's Diet Type Report dated 2/12/25, showed 107 of the 111 residents residing in the facility as of 2/12/25, received foods prepared in the kitchen. On 2/12/25 at 1050 hours, the CDM stated she was unable to provide the Diet Type Report for 2/10/25. Review of the facility's P&P titled Environment revised 9/2017 showed the Dining Services Director will ensure that all the employees are knowledgeable in the proper procedures for cleaning and sanitizing of all the food service equipment and surfaces. Review of the Ecolab Oasis 146 Multi-Quat Sanitizer manufacturer's instructions dated 2015 showed the directions for sanitation range testing. The instructions stated to withdraw and tear off approximately two inches of test paper from the dispenser. Dip test paper for 10 seconds in test solution. Don't shake. Under the section showing the direction for use, showed to expose all surfaces of equipment, ware, or utensils to the sanitizing solution for a period of not less than one minute. 1. According to the USDA Food Code 2022, 4-501.116, Warewashing Equipment, Determining Chemical Sanitizer Concentration showed the effectiveness of chemical sanitizers is determined primarily by the concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution. On 2/10/25 at 0810 hours, an observation and interview was conducted with Dietary Aide 1 and the CDM who provided the translation. Dietary Aide 1 was asked to demonstrate how to check the sanitizing solution in the sanitation bucket. Dietary Aide 1 was observed to use a quaternary test strip and dipped and swishes the strip for four seconds into a red bucket filled with sanitizer. The testing strip color changed. When asked how long she dipped the test strip in the sanitizer for, the Dietary Aide stated one or two seconds. The CDM and Dietary Aide 1 verified she should have dipped the test strip in the sanitizer for 10 seconds per the guideline. Dietary Aide 1 stated the color changes too much. 2. According to the USDA Food Code 2022, 4-703.11 Hot Water and Chemical showed efficacious sanitation depends on the warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning. Review of the facility's document titled Manual Warewashing undated showed the dishwashing - two-sink method for pots, pans and cooking utensils. For sink one, showed to wash in a clean detergent solution and rinse with clean water in sink one. For sink two, showed to sanitize using hot water or chemical sanitizer. To sanitize with hot water, dishes must be immersed in hot water of not less than 171 degrees F for 30 seconds and to sanitize using chemical sanitizers, a chemical sanitizing solution used according to manufacturer's instructions. a. On 2/12/25 at 0821 hours, a concurrent interview and observation was conducted with Dietary Aide 2. Dietary Aide 2 was asked for the procedure for manual dishwashing in their two-compartment sink. Dietary Aide 2 stated they washed the dishes at 110 degrees F, rinsed, and then sanitized. Dietary Aide 2 stated to sanitize, she would mix the sanitizer and water in the second sink. Dietary Aide 2 stated she would leave the items in the solution with the chemicals at 171 degrees F for 30 seconds. b. Dietary Aide 1 was summoned and asked the procedure for manual dishwashing with Dietary Aide 2 who was translating. Dietary Aide 1 stated she would scrub the dishes in another sink away from the two-compartment sink, then would sanitize and leave the dishes for three to five seconds in the sanitizer, then would put the items in the wash, then air dry. The CDM was informed the two staff members were unable to verbalize the correct process for manual dishwashing. The CDM acknowledged the findings and stated they would need to be re-educated.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the labeling and dating of the food items in the freezer used for the residents food. * The facility failed to ensure the maintenance tools were stored properly. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's Diet Type Report dated 2/12/25, showed 107 of the 111 residents residing in the facility as of 2/12/25 received foods prepared in the kitchen. On 2/12/25 at 1050 hours, the CDM stated she was unable to provide the Diet Type Report for 2/10/25. 1. Review of the facility's P&P titled Food Receiving and Storage undated showed all the foods stored in the refrigerator or freezer are covered, labeled, and dated. During the initial tour of the kitchen conducted with the CDM on 2/10/25 at 0754 hours, the following was observed: - an opened bag of veggie vegan patties observed unlabeled and undated; - one opened package of French toast unlabeled and undated; and - one bag of hamburger buns unlabeled and undated. The CDM verified the above findings. 2. According to the USDA Food Code 2022 Section 6-501.113, .Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be (B)Stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools. On 2/12/25 at 0832 hours, a concurrent observation and interview was conducted with the CDM. The CDM stated their cleaning materials were kept outside of the kitchen. There were three brooms observed to be stored on the ground outside of the kitchen. The CDM verified the cleaning materials should be kept hanging on the wall.

Based on interview and facility P&P review, the facility failed to ensure the education was provided to the staff on safe food handling of outside food. This failure had the potential to cause foodborne illnesses to the medically vulnerable residents population who consumed food brought from the outside sources. Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further shows the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Food Brought in by Family or Visitors revised 3/2024 showed the residents' family members will be educated to inform nursing staff of their desire to bring food into the facility. Family/visitors are asked to prepare and transport food using safe food handling practices. The responsible facility staff member will be responsible for reheating foods in the unit microwave. On 2/9/25 at 0825 hours, an interview was conducted with the IP. The IP stated the residents sometimes had food brought in from the outside and did not let the residents to have leftovers. The IP stated they did not have a resident refrigerator due to infection control issues. The IP stated she would tell the family members to take the leftovers home. The IP stated they would reheat food in a microwave in the employee lounge labeled for the resident's family to use only. The IP then went to the employees lounge and verified there was no microwave labeled for family use only. On 2/10/25 at 1016 hours, a concurrent observation and interview was conducted with Family Member 1 in Resident 46's room. There were several unlabeled containers of food on Resident 46's bedside tables. Family Member 1 stated he would bring Resident 46 food from home and if the food was cold, he would ask the staff to heat it up. On 2/11/25 at 1417 hours, an interview was conducted with CNA 3. CNA 3 stated Family Member 1 would bring Resident 46 food from home and would ask him to heat up the food. CNA 3 stated Family Member 1 told him how long to warm the food for. When asked if he received safe food handling education, CNA 3 stated he had to make sure Resident 46 was able to eat and swallow the food before it was provided to the resident. On 2/12/25 at 0852 hours, an interview was conducted with LVN 2. LVN 2 was asked if she received education regarding safe food handling. LVN 2 was unable to recall if she received the education. On 2/12/25 at 0907 hours, an interview was conducted with the DSD. The DSD stated she had not provided education to the staff on safe food handling. When asked what education would be provided, the DSD stated how to assist the resident during meals, how to handle the food, prepare the residents, hand hygiene, and a microwave was available and would remind the staff the food heated should not be very hot. The DSD provided the past in-service titled Food-Handling given to staff on 9/17/24, however, the DSD was unable to provide the lesson plan and verified she did not know what education was provided. The DSD verified the in-service was only provided to the CNAs. On 2/12/25 at 1050 hours, an interview was conducted with the CDM, DSS, and Regional Dietitian. The CDM verified they were not responsible for providing safe food handling education to the facility staff not working in the kitchen. On 2/13/25 at 0847 hours, an interview was conducted with CNAs 4 and 6. CNA 6 assisted with the translation of the questions that were asked. When asked about the food brought in by the visitors, CNA 4 stated the resident's family would ask to reheat the food for one minute and she would cover the food and put it in the microwave. CNA 4 stated she made sure the food was not too hot for the residents. CNAs 4 and 6 were asked what temperature the food should be to safely reheat it. The CNAs were unable to answer. CNAs 4 and 6 stated they had not received any education on safe food handling. On 2/18/25 at 1140 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the CMS's QSO-24-08-NH Enhanced Barrier Precautions in Nursing Homes dated 3/20/24, and effective 4/1/24, showed, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The QSO further showed the EBP recommendations now included the use of EBP for the residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. The indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Medical record review for Resident 616 was initiated on 2/12/25. Resident 616 was admitted to the facility on [DATE]. Review of Resident 616's Order Summary Report showed a physician's order dated 2/5/25, for enhanced barrier precautions for Resident 616's right knee surgical wound. On 2/12/25 at 0831 hours, a medication administration observation for Resident 616 was conducted with LVN 4. A sign outside of Resident 616's room showed the providers and staff must wear a gown and gloves with high contact care activities. A yellow sticker was indicated next to Resident 616's name on the door. LVN 4 was observed entering Resident 616's room to administer Resident 616's medications. LVN 4 was not observed donning a gown. LVN 4 was observed touching Resident 616's arm to check her identification band. LVN 4 was then observed administering enoxaparin (anticoagulant) 30 mg subcutaneously into Resident 616's right lower abdomen. On 2/12/25 at 0841 hours, an interview was conducted with LVN 4. LVN 4 stated the yellow sticker next to the resident's name indicated the resident was under enhanced barrier precautions. LVN 4 stated the enhanced barrier precautions meant the staff should wear the gown and gloves when making contact with the resident to prevent the transmission organism. LVN 4 stated Resident 616 was on enhanced barrier precautions for her wound. LVN 4 verified she did not wear a gown during the medication administration and stated she should have worn a gown. On 2/18/25 at 1428 hours, an interview was conducted with the DON. The DON stated for the residents with wounds and on enhanced barrier precautions, the staff were expected to don appropriate PPEs consisting of gown and gloves when entering the room to administer medications or provide care. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings. 4. Medical record review for Resident 55 was initiated on 2/10/25. Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 55's MDS dated [DATE], showed Resident 55 had severe cognitive impairment. Review of Resident 55's Order Summary Report dated 2/13/25, showed a physician's order dated 1/16/25, to administer oxygen at three liters per minute via nasal cannula, may titrate up to 10 liters per minute as needed for shortness of breath, comfort, or if the oxygen saturation level less than 90%. On 2/11/25 at 1145 hours, an interview and concurrent observation of Resident 55 was conducted with LVN 2. Resident 55 was observed lying in bed, receiving continuous oxygen via nasal canula at three liters per minute. Resident 55's nasal canula tubing connected to the oxygen concentrator was observed touching the ground, and the trash can was observed on top of the nasal canula tubing. LVN 2 verified the above findings. LVN 4 stated the tubing should not touch the ground due to infection control risks. LVN 4 was then observed fixing the nasal canula tubing and stated she the tubing should be changed. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented as evidenced by: * The facility failed to record all the residents with infection on the facility's infection surveillance tool. The facility's infection surveillance tool did not include all the residents identified with infections. The facility only documented on the surveillance log the residents who were prescribed with antibiotics were identified as having infection. * The facility failed to ensure the staff used proper PPE upon entering the resident's room for one nonsampled resident (Resident 88) who had Covid. * The facility failed to ensure LVN 7 donned the proper PPE during high-contact care for Resident 616 who was on enhanced barrier precautions. * The facility failed to ensure Resident 55's nasal cannula tubing was not touching the ground and under the trash can. These failures posed a risk for transmission of disease-causing microorganisms and infections. Findings: Review of the facility's P&P titled Infection Prevention and Control Program Description revised 11/15/20, showed the IPCP is a comprehensive process that addresses preventing, identifying, reporting, investigating, and controlling of infections and communicable diseases for patients, staff, volunteers, visitors, and other individuals providing services under a contractual agreement. The major activities of the program are: * Surveillance of Infections which includes ongoing monitoring to identify possible communicable diseases or infections before they can spread to others in the Center and to whom they should be reported. * Process Surveillance to review infection prevention and control practices directly related to patient care. * Implementation of Control Measures and Precautions which includes basics such as hand hygiene, Standard and Transmission Based Precautions (including the use of PPE), cleaning/disinfecting equipment and measures to protect persons (as listed above) from communicable diseases or infections. 1. Review of the facility's Infection Prevention and Control Surveillance Log did not show a record of all the residents with infection. The surveillance log showed only the residents who were prescribed with the antibiotics. On 2/12/25 at 0953 hours, an interview and record review was conducted with the IP. The IP stated she was responsible for the infection control surveillance in the facility. When asked if the facility included on their infection surveillance log all the residents with signs and symptoms of infections but were not prescribed antibiotic, the IP stated they were only tracking the residents who were prescribed with antibiotic on the surveillance log. The IP acknowledged the infection surveillance log did not include all the residents identified with infection, and only the residents who were prescribed with antibiotic were listed on the infection surveillance form. The IP stated she did not have a surveillance log for the residents with signs and symptoms of infection but they addressed the residents' change of condition. On 2/18/25 at 0752 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the above findings. The DON stated the IP should have tracked also the residents who have signs and symptoms of infection but were not prescribed antibiotic to make sure they would be able to know if the residents were really infected. On 2/18/25 at 1211 hours, the Interim Administrator and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Covid-19 Management, Infection Control (undated) showed to provide a safe environment and to prevent the development and transmission of Covid- 19; Covid-19 transmission-based precautions the staff will use the following PPE: N95 respirator, gloves, gown, and eye protection. On 2/10/25 at 1004 hours, during the initial tour of the facility, Room A showed a sign outside the door stop, Novel Respiratory Precaution to clean hands-on room entry, wear gown on room entry, wear a N-95 and face shield or goggles, wear gloves on room entry and clean hands when exiting. On 2/11/25 at 0816 hours, CNA 15 was observed donning PPE gown, N-95, and gloves, then went inside the room and remove a breakfast tray, don off PPE gloves, gown, and N-95 mask. CNA 15 was observed with no face shield nor goggles. On 2/12/25 at 0759 hours, CNA 15 was observed answering the call light in Room A, sanitized the hands, and don on PPE, gown, N-95 and gloves. The CNA was observed with no face shield nor goggles. On 2/12/25 at 1342 hours, an interview was conducted with CNA 15. The CNA 15 verified no face shield or goggles was used during the care with Resident 88. On 2/13/25 at 0929 hours, an interview was conducted with the IP. The IP verified Resident 88 was a Covid positive and while doing resident care for the staff to don proper PPE consist of wearing gown, N-95 and face shield or goggle and gloves. The IP was informed and acknowledged CNA 15 did not use the goggle or face shield during care with Resident 88. On 2/18/25 at 1212 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Medical record review for Resident 816 was initiated on 2/10/25. Resident 816 was admitted to the facility on [DATE]. Review of Resident 816's eINTERACT SBAR Summary for Providers dated 2/8/25, showed the resident's change in condition related to decreased appetite and fluid intake. The provider recommendation included to administer one liter of IV fluids 0.9% normal saline at 50 ml/hr for hydration. The document showed a 24 gauge PIV was inserted into Resident 816's right hand. Review of Resident 816's Physician Orders for Infusion Therapy dated 2/8/25, showed a physician's order to place a PIV, if there was no venous access. On 2/10/25 at 1057 hours, an observation of Resident 816 was conducted in the resident's room. Resident 816 was observed with a single-lumen PIV line to the right hand with undated and unlabeled dressing. On 2/10/25 at 1115 hours, a concurrent observation and interview was conducted with the IP. The IP verified Resident 816's PIV line dressing was not dated or labeled. The IP stated the PIV line dressing should be labeled with the date it was started and initialed by whoever started the PIV. On 2/11/25 at 0906 hours, an observation of Resident 816 was conducted in the resident's room. Resident 816 was observed with a single-lumen PIV line to the right hand with an undated and unlabeled dressing. On 2/10/25 at 0949 hours, an observation and concurrent interview was conducted with RN 2. RN 2 verified Resident 816's PIV line dressing was not dated or labeled. RN 2 stated the PIV line dressing should be labeled with the date when the PIV line was inserted. 6. Medical record review for Resident 818 was initiated on 2/10/25. Resident 818 was admitted to the facility on [DATE]. Review of Resident 818's Physician Orders for Infusion Therapy dated 1/24/25, showed a physician's order for the following: - Zosyn (antibiotic medication) 3.375 gm every eight hours for 28 days for right foot cellulitis (skin infection). - To provide midline care for the right upper arm midline; to measure the external catheter length of the PICC and midlines upon admission and with each dressing change; and include the arm circumference for the midlines upon admission. Further review of Resident 818's medical record failed to show documented evidence the measurement of the external catheter length or arm circumference for Resident 818's right upper arm midline was obtained upon admission to the facility. On 2/12/25 at 1426 hours, an interview and concurrent medical record review was conducted with RNs 1 and 2. RN 1 verified the RN was responsible for the maintenance of the IV in the facility. RNs 1 and 2 verified Resident 818's medical record did not show the midline external catheter and arm circumference measurements were obtained upon admission as per the facility's P&P and physician's orders. On 2/18/25 at 1140 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for six of six final sampled residents (Residents 60, 83, 110, 716, 816, and 818) reviewed for IV care. * The facility failed to ensure the initial PICC line external catheter measurements were documented in the medical record and confirmed the baseline measurements of the PICC line external catheters and arm circumferences prior to the administration of IV antibiotics for Resident 83. In addition, the facility failed to ensure Resident 83's PICC dressing was labeled with the date and a care plan was developed for the use of Resident 83's right upper arm PICC. * The facility failed to ensure accurate documentation of the monitoring and documentation of Resident 60's right arm midline. In addition, the facility failed to develop a care plan for the use of Resident 60's right upper arm midline. * The facility failed to ensure the midline dressing for Resident 716 was changed. * The facility failed to ensure Resident 110's PIV site was dated and labeled. * The facility failed to ensure Resident 816's PIV site was labeled with the date and the licensed nurse's initials to show when it was inserted. * The facility failed to ensure Resident 818's midline external catheter and arm circumference measurements were performed and documented in the medical record upon admission to the facility. These failures had the potential to delay the identification of catheter related complications for the residents. Findings: Review of the facility's P&P titled PICC Dressing Change dated 3/2023 showed the length of the external catheter is obtained upon admission, during dressing changes, and if signs or symptoms of complications are present. To measure the external catheter length (from the insertion site to the hub). To label the dressing with the date and time, and the nurse's initials. Further review of the facility's P&P showed documentation in the medical record includes, but is not limited to: - date and time; - site assessment; - length of external catheter; - Resident response to procedure and/or medication; and - Resident teaching. Review of the facility's P&P titled Midline Catheter Dressing Change dated 3/2023 showed the dressing changes using the transparent dressings are performed: upon admission (if not dated or site is not visible for assessment), at least weekly, and if the integrity of the dressing has been compromised (wet, loose, or soiled). To measure the upper arm circumference: upon admission and when clinically indicated to assess the presence of edema and possible deep vein thrombosis (DVT, condition where a blood clot forms in a deep vein). Further review of the facility's P&P showed documentation in the medical record includes, but is not limited to: - date and time; - site assessment; - length of external catheter; - upper arm circumference; - Resident response to procedure and/or medication; and - Resident teaching. 1. On 2/10/25 at 0915 hours, Resident 83 was observed in bed with a PICC line with a two-port external catheter to the right upper arm . A transparent dressing was observed undated on the PICC line site. Medical record review for Resident 83 was initiated on 2/10/25. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's MDS dated [DATE], showed Resident 83 was admitted from an acute care hospital and received the antibiotic medications and IV medications at the facility. Review of Resident 83's Nursing Documentation - V11 dated 1/2/25, showed Resident 83 was admitted for IV therapy, management of diabetes (body has trouble controlling the blood sugar), and wound care. Further review of the admission documentation failed to show any documentation of the measurements for Resident 83's arm circumference and external catheter length of right upper arm PICC line. Review of Resident 83's Order Summary Report dated 2/13/25, showed a physician's order dated 1/3/25, to administer ceftriaxone (antibiotic) 2 gm intravenous every 24 hours until 2/10/25, for cellulitis (bacterial infection of the skin and underlying tissues). Review of Resident 83's Intravenous Therapy Medication Record for January and February 2025 showed Resident 83 was administered ceftriaxone 2 gm intravenous on the following dates and times: - on 1/3/25 at 2000 hours, - on 1/4/25 at 2030 hours, - on 1/5/25 at 2000 hours, and - from 1/6/25 to 2/10/25 at 1800 hours. Further review of Resident 83's Intravenous Therapy Medication Record for January 2025 showed Resident 83's PICC dressing was changed on 1/4/25, with the external catheter length measurement of 1.5 cm. However, there was no documentation of Resident 83's baseline arm circumference and external catheter length upon admission to the facility on 1/2/25. Review of Resident 83's medical record failed to show documented evidence of Resident 83's baseline arm circumference and external length of the PICC line measurements upon admission to the facility. In addition, Resident 83's medical record failed to show the licensed nurse had confirmed the baseline measurements of Resident 83's arm circumference and PICC line external length measurements prior to the use of the PICC line. Review of Resident 83's plan of care failed to show a care plan problem to address the use of Resident 83's right upper arm PICC line. On 2/11/25 at 1136 hours, Resident 83 was observed in bed. Resident 83's right upper arm PICC dressing was observed with a transparent dressing dated 2/9/25. On 2/11/25 at 1440 hours, an interview was conducted with RN 2. RN 2 verified on 2/10/25, Resident 83's right upper arm PICC dressing was not dated. RN 2 stated on 2/10/25, he noted the dressing was not labeled so he checked the Intravenous Therapy Medication Record and documentation showing the PICC dressing was changed on 2/9/25, so he dated Resident 83's PICC dressing for 2/9/25, even though he did not perform the dressing change. RN 2 stated the licensed nurse who changed the dressing should date the dressing. On 2/13/25 at 1310 hours, a follow-up interview and concurrent medical record review for Resident 83 was conducted with RN 2. RN 2 stated for the residents admitted to the facility with a PICC line, the RN was responsible for verifying the placement of the PICC line by measuring the arm circumference and external catheter length of the PICC and verifying/comparing the measurements with the reports from the acute care hospital, prior to the use of the PICC line. RN 2 further stated the nurse should document the baseline measurements and verification in the resident's progress notes. RN 2 reviewed Resident 83's medical record and verified the above findings. On 2/18/25 at 1428 hours, an interview was conducted with the DON. The DON stated the PICC dressings were changed every seven days and as needed, and the dressing should be labeled with the date. The DON stated on admission, there should be the baseline measurements of the arm circumference and external catheter of the PICC line catheter. In addition, the DON stated she expected the licensed nurse to review the resident's medical record from the acute care hospital to verify the baseline measurements. The DON further stated the licensed nurse should verify and document the verification of the baseline measurements in the resident's progress notes before the use of the PICC. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings. 2. On 2/10/25 at 1131 hours, Resident 60 was observed in bed with the right upper arm midline (a small, thin tube that is inserted into a vein in the upper arm). Medical record review for Resident 60 was initiated on 2/10/25. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's MDS dated [DATE], showed Resident 60 was admitted from an acute care hospital and received the antibiotic medications and IV medications while a resident at the facility. Review of Resident 60's Midline Insertion Record dated 1/27/25, showed a midline catheter was inserted in Resident 60's right basilic vessel. The record showed the internal length was 14 cm, external length was 0 cm, and arm circumference was 31 cm. Review of Resident 60's Intravenous Therapy Medication Record for January and February 2025 showed Resident 60's right arm midline dressing was changed on the following dates with the external catheter length measurements: - on 1/27/25, 0 cm. - on 2/3/25, 2 cm. - on 2/9/25, 2 cm. Further review of Resident 60's Intravenous Therapy Medication Record for February 2025 showed the current IV site was the right upper arm midline, inserted on 1/27/25. The internal and external midline length were left blank. Review of Resident 60's Progress Notes showed the following nursing documentations: - dated 1/27/25 at 1518 hours, the resident's midline was replaced and the new IV site was on the left arm. - dated 1/28/25 at 0400 hours, and 1/29/25 at 0640 hours, the licensed nurse monitored for the new midline on the resident's left arm and observed the site intact with no signs of infiltration/infection. Review of Resident 60's plan of care failed to show a care plan problem was developed to address the use of Resident 60's right upper arm midline. On 2/13/25 at 1248 hours, an interview and concurrent medical record review for Resident 60 was conducted with RN 2. RN 2 stated Resident 60 had a midline inserted on 1/27/25, in the right arm. RN 2 stated the dressing changes were done weekly and as needed, and the external catheter length was measured and documented with each dressing change. RN 2 reviewed Resident 60's medical record and verified the above findings. RN 2 stated the documented external catheter length measurements of 2 cm were inaccurate, and the documentation of the monitoring for Resident 60's IV access should be for the right arm. On 2/18/25 at 1428 hours, an interview was conducted with the DON. The DON stated the purpose of measuring the external catheter length was to determine any dislodgment of the catheter. The DON stated if there were any discrepancies in the external catheter length measurements, the RN should address the discrepancy and inform the physician. The DON further stated the residents should have a care plan developed for the use of a PICC or midline IV catheter. On 2/18/25 at 1505 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON were informed and acknowledged the above findings. 3. Review of the facility's P&P titled Peripheral Venous Catheter Insertion dated 3/2023 showed to write the date, time and initials on the dressing label. Medical record review for Resident 716 was initiated on 2/10/25. Resident 716 was admitted to the facility on [DATE]. Review of Resident 716's Physician Order for Infusion Therapy dated 2/4/25, showed for the RUA midline, to change all the central line, PICC, and midline transparent dressings per sterile technique upon admission (if not dated or site not visible for assessment), every seven days and PRN if wet, loose, or soiled. Review of Residents 716's MDS dated [DATE], showed the resident had a BIMS score of 15 (meaning cognitively intact). On 2/10/25 at 0938 hours, Resident 716 was observed awake and lying in bed with a midline with one lumen (channel or tube within a catheter) to the right upper arm and the midline dressing dated 2/2. On 2/10/25 at 1021 hours, an observation and concurrent interview was conducted with RN 2 for Resident 716. RN 2 verified and acknowledged the midline dressing for Resident 716 was dated 2/2. RN 2 stated Resident 716's RUA midline dressing should have been done on 2/9/25. 4. Medical record review for Resident 110 was initiated on 2/10/25. Resident 110 was admitted to the facility on [DATE]. Review of Resident 110's Order Summary Report dated 2/13/25, showed a physician's order to administer metronidazole (antibiotic medication) 500 mg IVPB every eight hours for cerebral abscess (collection of pus in the brain tissue). Review of Residents 110's MDS dated [DATE], showed the resident had a BIMS score of 14 (meaning cognitively intact). On 2/10/25 at 0907 hours, Resident 110 was observed awake and lying in bed with a single-lumen PIV line to the right hand, not labeled with the date, time and initial of the facility staff. On 2/10/25 at 1014 hours, an observation and concurrent interview was conducted with RN 2 for Resident 110. RN 2 verified Resident 110's right hand PIV was not labeled with the date, time, and initial of the facility staff. On 2/18/25 at 1212 hours, an interview was conducted with the Interim Administrator and DON. The Interim Administrator and DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed as evidenced by: * Residents were served the yellow cake instead of the carrot cake with cream cheese frosting as shown on the posted menu. * Residents 97 and 466 were not served the chocolate ice cream as per the menu. * Resident 66 who was on a renal diet was not provided a renal diet per the menu. In addition, Resident 66 was not served a double portion of the protein per the diet order. These failures had the potential for the residents to not receive an adequate nutrition and appropriate servings to meet the residents' individual needs. Findings: Review of the facility's Diet Type Report dated 2/12/25, showed 107 of 111 residents residing in the facility received foods prepared in the kitchen. On 2/12/25 at 1050 hours, the CDM stated she was unable to provide the Diet Type Report for 2/10/25. Review of the facility's P&P titled Menus revised 10/2022 showed the menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas. Review of the facility's P&P titled Substitutions revised 4/2007 showed all the substitutions are noted on the menu and filed in accordance with established dietary policies. 1. Review of the facility's Diet Guide Sheet printed 2/12/25, showed for Week 2: Monday lunch menu, the residents were to be served with the carrot cake with cream cheese frosting. However, during the lunch observation, the residents were not served the carrot care with cream cheese frosting as per the diet guide and menu. For example: a. On 2/10/25 at 1214 hours, an observation was conducted for Resident 51. Resident 51's meal ticket showed there resident was to receive a regular dysphagia advanced diet. Review of the facility's Diet Guide Sheet for 2/10/25, showed Resident 51 was to receive one square of carrot cake with cream cheese frosting on her meal tray; however, Resident 51 was served one square of the yellow cake. b. On 2/10/25 at 1222 hours, an observation was conducted for Resident 43. Resident 43's meal ticket showed the resident was to receive a carbohydrate controlled - dysphagia advanced diet. Review of the facility's Diet Guide Sheet for 2/10/25, showed Resident 43 was to receive one-half square of the carrot cake with cream cheese frosting on his meal tray; however, Resident 43 was served one square of the yellow cake. c. On 2/10/25 at 1221 hours, an observation was conducted for Resident 76. Resident 76's meal ticket showed the resident was to receive a regular - dysphagia advanced diet. Review of the facility's Diet Guide Sheet for 2/10/25, showed Resident 76 was to receive one square of the carrot cake with cream cheese frosting on his meal tray; however, Resident 76 was served one square of the yellow cake. On 2/10/25 at 1228 hours, the CDM and DSS. The CDM stated they did not have the carrot cake so they substituted with the yellow cake and provided the document titled Menu Substitution Log noting the substitution. When asked if the menu was changed and if the residents were notified of the change, the CDM stated they would have to change the menu outside and that was how the residents would know of the change. The CDM stated they failed to change the menu to show the substitution and verified the residents were not notified of the change in the menu. 2. Review of the facility's Diet Guide Sheet printed 2/12/25, showed for Week 2: Tuesday, the residents were to be served one chocolate ice cream. a. On 2/11/25 at 1220 hours, during the trayline observation, Resident 466's meal ticket showed the resident was to receive a regular - dysphagia pureed diet. There were no restrictions on the texture of the liquids consistency. Resident 466's tray was observed to have a vanilla pudding on the tray and no chocolate ice cream. The meal cart which contained Resident 466's tray was sent out of the kitchen. b. On 2/11/25 at 1252 hours, an observation was conducted for Resident 97. Resident 97's meal ticket showed the resident was to receive a regular - dysphagia puree diet. There were no restrictions on the texture of the liquids consistency. Resident 97's tray was observed to have a vanilla pudding on the tray and no chocolate ice cream. On 2/12/25 at 1050 hours, an interview was conducted with the CDM, DSS, and Regional Dietician. The CDM verified the above findings. 3. Review of the facility's Diet Guide Sheet printed 2/12/25, showed for Week 2: Tuesday, the residents on a carbohydrate controlled renal diet were to be served with pork carnitas, marinated cucumber salad, mashed potatoes or black beans, and one sugar cookie. On 2/11/25 at 1254 hours, an observation was conducted for Resident 66. Resident 66's meal ticket showed the resident was to receive a renal - dysphagia puree and honey-thick liquids diet. The meal ticket also showed Resident 66 was to receive a double portion of protein, fish and chicken only. Resident 66's tray was observed to have one portion of pureed protein, pureed green beans, pureed black beans, and pureed starch. On 2/11/25 at 1258 hours, a concurrent observation of Resident 66's meal tray and interview was conducted with the CDM and [NAME] 2. [NAME] 2 verified Resident 66 did not receive a double portion. The CDM verified the cucumber salad was not prepared. The Regional Dietician and CDM verified Resident 66 did not receive the renal diet as per the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 2) was provided a floor mat as per the resident's care plan to prevent or minimize the injury in case of a fall. This failure had the potential to place the resident at risk for serious injury. Findings: Review of the facility's P&P titled Falls Management revised 3/15/24, showed the residents will be assessed for risk of falling as part of the nursing assessment process, interventions to reduce risk and minimize injury will be implemented as appropriate and implement and document the resident-centered interventions according to the individual risk factors in the resident's plan of care. On 6/4/24 at 1435 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed awake and sitting in her bed with the right side of the bed against the wall. Resident 2 was observed without a floor mat on the floor. Resident 2 stated she fell last month but could not recall the exact date. Resident 2 further stated she could not remember if she ever had a floor mat beside her bed. Medical record review for Resident 2 was initiated on 6/4/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 7/3/23, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's MDS dated [DATE], showed Resident 2 required substantial to maximal assistance with mobility and transfers. Review of Resident 2's Assessment Outcome for Admission/readmission dated 7/3/23, showed a fall risk was identified for the resident. Review of Resident 2's Care Plan initiated on 7/3/23, showed a care plan problem addressing Resident 2's risk for falls related to confusion, attempt to self-transfer multiple times, needed constant redirection, required substantial to maximum assistance with ADL care, and occasionally incontinence of bowel and bladder. The care planinterventions included to implement the floor mat to the right side of the bed. Review of Resident 2's Change of Condition Evaluation dated 5/14/24, showed Resident 2 had an episode of fall. The resident had a skin tear to the right hand. On 6/4/24 at 1500 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 stated he had been taking care of Resident 2 for a long time as he was permanently assigned to the station where Resident 2 had been staying. CNA 1 further stated Resident 2 had never had a floor mat in her room. On 6/4/24 at 1545 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated she had known Resident 2 for a while as she was assigned most of the time to the station where Resident 2 was. LVN 1 stated the care plan was person-centered and the interventions should be followed. LVN 1 stated Resident 2 had never used a floor mat in her room. On 6/4/24 at 1620 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 2's care plan interventions included to place the floor mat on the right side of the bed. RN 1 further stated Resident 2 should have the floor mat placed at the bedside. RN 1 was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the dignity was maintained for one of 22 final sampled residents (Resident 89). * The facility's staff was standing over Resident 89 when assisting the resident with the house supplement. This failure created the potential to affect the resident's well-being. Findings: Review of the facility's P&P titled Feeding a Resident revised date 6/1/21, showed to sit in chair at eye level with the resident. On 9/13/22 at 1250 hours, during dining observation, Resident 89 was observed in bed with the head of the bed elevated, and the bed was in a low position. CNA 7 was observed standing over Resident 89 while assisting Resident 89 with her nutritious juice drink (a house supplement to increase calories and protein in the diet). Resident 89's head was at the level of CNA 7's chest. On 9/13/22 at 1254 hours, a concurrent observation and interview was conducted with CNA 7. CNA 7 was observed tapping Resident 89's shoulder and instructing Resident 89 to drink the juice while CNA 7 holds a spoon close to Resident 89's lips. CNA 7 continued standing by Resident 89's bed side and looking down at Resident 89 while assisting the resident. When asked, CNA 7 stated she normally sat when assisting the residents with their meals but just passed by to assist Resident 89 with her nutritious drink since Resident 89 did not eat much of her lunch. CNA 7 verified she was standing over Resident 89 and should had been sitting at the same level as Resident 89. CNA 7 proceeded to grab a chair, sat beside Resident 89, and continued assisting and encouraging Resident 89 to drink the juice with a spoon. Medical record review for Resident 89 was initiated on 9/13/22. Review of Resident 89's Order Summary Report showed an order dated 7/14/22, for house supplement two times a day for oral supplement (nutritious juice drink). Review of Resident 89's MDS dated [DATE], showed Resident 89 had severe cognitive impairment and required one person's assistance for eating. On 9/13/22 at 1306 hours, an interview was conducted with the DON. The DON verified the above findings and stated the staff should be at the same level or eye level with the residents when assisting residents during feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical Record Review for Resident 55 was initiated on 9/16/22. Resident 55 was admitted on [DATE]. Review of the Order Summary Report for September 2022 did not show the physician's order for A&D ointment. Review of the plan of care did not show a care plan problem to address Resident 55's ability to self-administer the medications. On 9/15/22 at 1447 hours, an observation and concurrent interview was conducted with Resident 55 in his room. Resident 55 was observed with an open oval scratch mark on his left upper forehead, with ointment. Resident 55 stated he scratched his forehead when he was doing rehab. He put the ointment himself, and the therapist gave him the ointment packets. During the observation, Resident 55 wheeled himself towards his bedside drawer. He pulled out the small packets of A&D ointment. On 9/15/22 at 1504 hours, an interview was conducted with RN 3. RN 3 stated the A&D ointment packets were not supposed to be in Resident 55's bedside drawer. RN3 stated sometimes, the resident asked for the ointment. RN 3 verified there was no order for A&D ointment. On 9/15/22 at 1556 hours, a follow-up interview was conducted with RN 3. RN 3 stated Resident 55 did not have a self- administration assessment. Based on observation, interview, medical record review, and facility P&P review, the facility failed to assess two of 22 final sampled residents (Residents 55 and 745) for their ability to self-administer the medications. * Resident 745 had a bottle of over-the-counter analgesic cream at the bedside and LVN 6 took it out from the drawer and gave to the resident to self-administer. Resident 745 did not have the assessment and physician's order for the self-administration of medications. * Resident 55 had a packet of A&D ointment (skin protective barrier) at bedside which was provided to self-administer by a facility staff member. Resident 55 did not have the assessment and physician's order to self-administer the A&D ointment. These failures had the potential for poor health outcomes to these residents. Findings: 1. Review of the facility's P&P titled Medications: Self-administration revised 3/1/22, showed it is the facility's policy to provide a safe, effective process for patient self-administration of medication. On 9/13/22 at 0955 hours, an observation and concurrent interview was conducted with Resident 745. Resident 745 was observed lying in bed with a bottle of topical pain reliever on her chest area. Resident 745 stated she used the topical pain reliever on her arms or shoulders for pain. Review of the medical record for Resident 745 was initiated on 9/13/22. Resident 745 was admitted to the facility on [DATE], with a diagnosis of osteoarthritis. Review of Resident 745's Progress Notes dated 9/14/22, showed Resident 745 had the capacity to understand and make decisions. Review of the medical record failed to show documented evidence of the physician's order for the topical pain reliever, nor an assessment was completed for Resident 745 to self-administer the medications. On 9/13/22 at 1010 hours, an observation and concurrent interview was conducted with CNA 6. A bottle of topical pain reliever was observed on top of Resident 745's over bed table. CNA 6 stated Resident 745 used the topical pain reliever on her arms or shoulders. On 9/13/22 at 1034 hours, an interview was conducted with LVN 6. LVN 6 stated she took out the topical pain reliever from Resident 745's drawer because Resident 745 asked for it. LVN 6 further stated the medications should not be at bedside and needed to have a physician's order. On 9/13/22 at 1612 hours, an interview was conducted with RN 4. RN 4 acknowledged and verified Resident 745 was not assessed to safely self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services related to GT were provied to one of 22 final sampled residents (Resident 46) and one of 11 nonsampled residents (Resident 91). * Resident 91's enteral water bag was unlabeled and undated. * The facility failed to ensure Resident 46's GT syringe was rinsed and dried prior to storing as per the facility's P&P. These failures posed the risk for complications related to the GT for the residents. Findings: 1. Review of the facility's P&P titled Enteral Feeding: Administration by Pump revised date 6/15/22, showed to label administration bag and tubing with the resident's name, room number, date, start time, and flow rate. Medical record review for Resident 91 was initiated on 9/13/22. Resident 91 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed an enteral feed order dated 7/19/22, to flush GT with water 40 milliliters per hour for 20 hours. On 9/13/22 at 0803 and 1002 hours, Resident 91 was observed in bed. An undated and unlabeled enteral bag filled with fluid was observed on Resident 91's enteral pump. On 9/13/22 at 1545 hours, an observation and concurrent interview was conducted with LVN 9 and RN 4. Both of them verified Resident 91's enteral water bag was undated and unlabeled. LVN 9 stated the enteral water bag should have been labeled with Resident 91's name, room number, date, time, and rate. 2. Review of the facility's P&P titled Enteral Feeding: Administration by Pump revised date 6/15/22, showed to rinse and dry syringe, separately store syringe and barrel prior to storing in the labeled and dated plastic bag or container. Medical record review for Resident 46 was initiated on 09/13/22. Resident 46 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 3/4/22, for Glucerna (a meal or snack replacement to help minimize blood sugar spikes) five times a day, 1.5 calories, administer bolus one carton (240 ml) to provide daily a total of 1200 ml/1800 kilocalories. On 09/15/22 at 0947 hours, after administration of Glucerna, LVN 1 was observed holding the GT syringe barrel (the cylindrical part of a syringe that holds fluid) with one hand and used her other hand to insert the GT syringe plunger (the component of the syringe that when depressed pushes the liquid out of the GT syringe barrel). The GT syringe barrel was observed with white liquid residue still inside. LVN 1 proceeded to store the GT syringe in a plastic bag without rinsing, drying, and separately storing the GT syringe as per the facility's P&P. On 09/15/22 at 0957 hours, an interview and concurrent record review of the facility's P&P was conducted with LVN 1. LVN 1 acknowledged she did not rinse and dry the GT syringe. LVN 1 stated she should have rinsed and dried the GT syringe prior to storing it in a plastic bag. On 09/20/22 at 0929 hours, an interview was conducted with the DON. The DON verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Oxygen: Nasal Cannula revised 6/15/22, showed under gather supplies section that nasal cannula labeled with date of initial set-up. Review of Resident 743's medical record was initiated on 9/14/22. Resident 743 was admitted to the facility on [DATE], with a diagnosis of asthma among others. Review of the H&P examination dated 9/11/22, showed Resident 743 had the capacity to understand and make decisions. Review of the Order Summary report dated 9/15/22, showed an order for oxygen at two liters per minute via nasal cannula as needed for shortness of breath and/or to keep oxygen saturation level more than 92%. On 9/13/22 at 0809 hours, during an initial tour of the facility, an observation and concurrent interview was conducted with Resident 743. Resident 743 was observed in bed receiving oxygen at 2 liters per minute via nasal cannula. Resident 743 stated he used the nasal cannula. Resident 743 further stated he needed oxygen to help him breathe better. On 9/13/22 at 0935 hours, an observation was conducted with Resident 743. Resident 743 was observed sitting up in a wheelchair receiving oxygen at 2 liters per minute via nasal cannula. On 9/13/22 at 0938 hours, an observation and concurrent interview was conducted with LVN 6. Resident observed sitting up in a wheelchair receiving oxygen at 2 liters per minute via nasal cannula which was undated. When asked if Resident 743 needed supplemental oxygen, LVN 6 stated Resident 743 was on oxygen as needed. LVN 6 acknowledged and verified the above findings. LVN 6 further stated the nasal cannula tubings should be dated for infection control reasons. On 9/20/22 at 0903 hours, an interview with the DON was conducted. The DON acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of 22 final sampled residents (Residents 693 and 743). * The facility failed to ensure a physician's order for supplemental oxygen therapy was obtained prior to the oxygen administration for Resident 693. This failure had the potential for Resident 693 receiving unnecessary oxygen. * The facility failed to ensure Resident 743's nasal cannula tubing was dated as per the facility's P&P. This had the potential for increased risks of infection. Findings: 1. Review of the facility's P&P titled Oxygen: Nasal Cannula (medical device to provide supplemental oxygen therapy) revised 6/15/22, showed to verify order. Review of the facility's P&P titled Oxygen: Concentrator revised 6/15/22, showed to verify order. On 9/13/22 at 0759 and 1102 hours, Resident 693 was observed in bed receiving oxygen via nasal cannula at 1.5 liters per minute. Medical record review for Resident 693 was initiated on 9/13/22. Resident 693 was admitted to the facility on [DATE]. Review of the H&P examination dated 9/11/22, showed a diagnosis of pneumonia. Review of the Order Summary Report did not show a physician's order for oxygen administration. Review of the Admission/ readmission Nursing Documentation dated 9/8/22, showed the following: - on oxygen at two liters/minute via nasal cannula - oxygen saturation level: 98% - method: oxygen via nasal - respiratory care needs: oxygen at two liters/minute via nasal cannula/mask Review of the Nursing Documentation Note showed the following entries: - 9/9/22 at 0334 hours, the resident was on oxygen at two liters/minute via nasal cannula. - 9/9/22 at 0800 and 2342 hours, the resident had no shortness of breath, received oxygen via nasal cannula, and had labored breathing with exertion. - 9/10/22 at 2122 hours, 9/11/22 at 2226 hours, and 9/12/22 at 0333 hours, showed the resident had no shortness of breath, received oxygen via nasal cannula, and had labored breathing with exertion. Review of Resident 693's plan of care showed a care plan problem revised 9/13/22, addressing Resident 693's risk for respiratory complications with the intervention to administer oxygen as ordered via nasal cannula. On 9/13/22 at 1320 hours, an observation and concurrent interview and medical record review was conducted with LVN 6. When asked why Resident 693 was on supplemental oxygen therapy, LVN 6 stated she would like to check Resident 693's medical record. LVN 6 checked Resident 693's physician's orders and stated Resident 693 had no physician's order for supplemental oxygen therapy. LVN 6 proceeded to Resident 693's room and Resident 693 was observed lying in bed with an oxygen concentrator at bedside and nasal cannula tubing was on Resident 693. LVN 6 acknowledged the oxygen concentrator was set on 1.5 liters per minute and checked Resident 693's oxygen saturation which was at 98%. LVN 6 further stated a physician's order was needed to place the resident on the supplemental oxygen therapy. On 9/20/22 at 0903 hours, an interview with the DON was conducted. The DON verified and acknowledged the above findings. The DON stated there should be a physician's order for the residents to be on the supplemental oxygen therapy.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 11 nonsampled residents (Resident 78) was administered the medication at the correct time as ordered. * LVN 1 was observed administering the medication to Resident 78 after a meal instead of before meals as ordered. Failure to administer the medication at the right time posed the risk of poor health outcome for this resident. Findings: Review of the facility's P&P titled General Dose Preparation and Medication Administration revised 4/1/22, showed to verify each time a medication is administered at the correct time among others. On 9/15/22 at 0748 hours, a medication pass observation was conducted with LVN 1. Empty meal trays were observed being placed back in the meal carts. LVN 1 was observed administering Insulin Aspart FlexPen (a short acting insulin that to help control blood glucose spikes that happen when eating) 5 units subcutaneously (beneath or under all the layers of skin) to Resident 78. Review of Resident 78's Order Summary Report showed a physician's order dated 4/5/22, to administer Novolog FlexPen Solution Pen-Injector 100 unit per milliliter (Insulin Aspart) inject 5 units subcutaneously before meals related to type 2 diabetes mellitus. On 9/15/22 at 0822 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 78 already had her breakfast at 0730 hours, and acknowledged the Insulin Aspart was administered to the resident after breakfast. LVN 1 stated Resident 78 should have received the Insulin Aspart before meals. On 9/15/22 at 0929 hours, an interview was conducted with the DON. The DON verified the above findings and stated the breakfast trays were delivered around 0715 to 0730 hours, and the insulin medication should have been given prior to Resident 78's eating breakfast.

b. On 9/15/22 at 1037 hours, during the inspection of Intravenous Medication Cart with RN 2, one outdated heparin lock flush 50USP (United States Pharmacopeia - a reference of uniform preparations for the most used drugs) units/5ml was observed. The heparin lock flush showed an expiration date of 8/31/22. RN 2 acknowledged the above findings and stated the expired medications should have been removed and discarded from the cart. On 9/15/22 at 1243 hours, a follow-up interview and concurrent medical record review was conducted with RN 2. RN 2 stated the heparin lock flushes were used to flush Resident 492's PICC line. Resident 492's Central Vascular Access Device (CVAD) Physician/Licensed Independent Practitioner (LIP) Order Sheet dated 8/31/22, showed an order for minimum flush/lock/unused lumens, flush with 5 ml of heparin 10units/ml every 12 hours. The Treatment Record for September 2022 showed the PICC non-valved catheter was flushed with 5 ml of heparin every 12 hours and was signed by the staff. RN 2 acknowledged and verified above findings. On 9/20/22 at 0903 hours, an interview was conducted with the DON. The DON acknowledged the above findings and further stated the expired medications should be discarded for safety reasons. Based on observation, interview, and facility document review, the facility failed to follow their controlled medication destruction P&P. This failure posed the risk of drug diversion. Findings: Review of the facility's P&P titled Disposal/ Destruction of Expired or Discontinued Medication revised 5/4/22, showed destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional who should record signature of the registered nurse and licensed professional among others. On 9/16/22 at 1451 hours, an interview and concurrent facility document review were conducted with the DON. The DON stated the process for controlled medication destruction was for controlled medications to be destroyed by the DON and Pharmacy Consultant and both parties should sign the controlled medication count sheet when the medications were destroyed. Review of the controlled medication count sheets showed 9 count sheets that were not signed by the DON. The DON acknowledged the controlled medication count sheets were signed by the Pharmacy Consultant only. The DON stated she and the Pharmacy Consultant performed the controlled medication destruction, but she forgot to sign the controlled medication count sheets. The DON verified the above findings and stated the count sheets should have been signed by her upon destruction of the controlled medications. 2. Review of the facility's P&P titled LTC Facility's Pharmacy Services and Procedures Manual - Storage and Expiration Dating of Medications, Biologicals revised 7/21/22, showed the facility should ensure the medications and biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. a. On 9/15/22 at 1200 hours, an observation and concurrent interview was conducted with the Central Supply Clerk in the Central Supply Room. Medications were observed in the locked cabinets including three eight ounce bottles of pink bismuth regular strength. The expiration date on the three bottles was 6/22. The bottles were observed in the same area as the non-expired medications. The Central Supply Clerk stated he must have missed those expired medications when he last checked the medications.

Based on observation, interview, medical record review, and facility P&P review, LVN 1 failed to follow the facility's P&P on hand hygiene practices and infection prevention during contact with two residents (Residents 46 and 78). * LVN 1 did not perform hand hygiene during Resident 78's medication administration. * LVN 1 did not perform hand hygiene before GT medication administration for Resident 46. These failures had the potential to spread infectious organisms to the residents. Findings: Review of the facility's P&P titled General Dose Preparation and Medication Administration revised date 4/1/22, showed prior to preparing or administering medications, authorized and competent facility staff should follow the facility's infection control program (for example handwashing). Review of the facility's P&P titled Hand Hygiene revised date 11/28/17, showed to perform hand hygiene before resident care, after resident care, and after contact with the resident's environment among others. 1. On 9/15/22 at 0812 hours, a medication administration observation was conducted with LVN 1. LVN 1 was observed placing individual medication cups on a medication tray. LVN 1 donned a pair of clean gloves without performing hand hygiene. LVN 1 administered Resident 78's medications. LVN 1 doffed gloves and with one CaviWipes, LVN 1 proceeded to clean the medication tray, top of the medication cart, then the thermometer with the same wipe. On 09/15/22 at 0822 hours, an interview was conducted with LVN 1. LVN 1 acknowledged she did not perform hand hygiene before donning gloves and she used the same CaviWipes wipe to disinfect the medication tray, top of the medication cart, and thermometer. LVN 1 stated hand hygiene was performed before donning gloves to administer medications and after doffing gloves. LVN 1 stated she should have used a different wipe to disinfect the medication tray, medication cart, and thermometer. On 09/15/22 at 0929 hours, an interview was conducted with the DON. The DON verified the above findings and stated the staff should have performed hand hygiene before and after removal of gloves. Furthermore, the DON stated they had plenty of CaviWipes and the staff should have thrown the dirty wipe and used a new one to clean the other items. 2. On 9/15/22 at 0912 hours, a medication administration observation was conducted with LVN 1. LVN 1 prepared Resident 46's medications for administration. LVN 1 donned a pair of gloves for the GT medication administration and cleaned the stethoscope (a medical instrument used in listening to sounds produced in the heart, lungs or gastrointestinal tract) with alcohol swab. LVN 1 adjusted Resident 46's bed height, pulled the privacy curtain, and touched Resident 46's footboard. Without changing the gloves and performing hand hygiene, LVN 1 proceeded to auscultate Resident 46's bowel sounds, aspirate (to draw by suction) gastric contents, and administer medications. On 09/15/22 at 0929 hours, an interview was conducted with the DON. The DON verified the above findings and stated the staff should have changed gloves after touching other surfaces prior to enteral feeding administration.

Based on observation, interview, and facility document review, the facility failed to ensure the patient care equipment was maintained in a safe operating condition when two of five glucometers were not checked for quality control. This failure put the residents at risk for inaccurate blood sugar readings. Findings: Review of the Assure Platinum Blood Glucose Monitoring System User Instruction Manual showed to use Assure dose control solutions to check if the meter and test strips are working correctly as a system, and ensure you are testing correctly. Perform a control solution test before testing with the Assure Platinum system for the first time, when you open a new bottle of test strips, to check your technique, and each time the batteries are changed. a. On 9/15/22 at 1218 hours, an observation, interview, and concurrent facility document review was conducted with RN 3. The Assure Platinum blood glucose monitor with the serial number 1040-4057618 was observed in Medication Cart A. RN 3 was asked to show documentation of the quality control check using the control solution for the blood glucose monitor machine. Review of the facility's document title Assure Platinum Blood Glucose Monitoring System: Quality Control Record for Medication Cart A dated 9/22 showed the Assure Platinum Meter serial number 1040-4743645. RN 3 was unable to explain why the serial numbers did not match and was unable to show documentation the Assure Platinum Meter in use had the quality control check done. b. On 9/15/22 at 1225 hours, an observation, interview, and concurrent record review was conducted at Medication Cart B with RN 3. The Assure Platinum Blood Glucose Meter was observed in the cart with the serial number 1040-4057623. RN 3 was asked to show documentation of the quality control check for the Assure Platinum Meter in use. Review of the facility's document titled Assure Platinum Blood Glucose Monitoring System: Quality Control Record for Medication Cart B dated 9/22 showed Assure Platinum Meter serial number 1040-4133272. RN 3 was unable to explain why the serial numbers did not match and was unable to show documentation the Assure Platinum Meters in use had the quality control check done.

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed as evidenced by: * Residents were served the canned sliced peaches instead of peach shortcake as shown on the posted menu. These failures had the potential for the 91 residents receiving food prepared in the kitchen to not meet their nutritional needs which might lead to nutritional related health complications. Findings: Review of the facility's CMS 672 form dated 9/13/22, showed 91 of 108 residents were served food from the kitchen. Review of the facility's P&P titled Menu Substitutions revised 10/27/19, showed the director of dining services or designees revised the day's menu program components (Week-At-A-Glance, Display Menu, Selective Menu, Diet Guide and Production Sheet) to reflect the change. The policy also showed substitutions are communicated to the residents and other department employees, as appropriate. Review of the facility's Diet Guide Sheet for Tuesday (Day 10) Lunch showed all residents were to be served peach shortcake for dessert. Review of the facility's Week-At-A-Glance Week 2 menu showed the residents were to be served peach shortcake at lunch. However, during the observations, the residents were not served peach shortcake as per the diet guide and menu. For example: 1. On 9/13/22 at 1210 hours, an observation and concurrent interview was conducted with RNA 1. Resident 3's meal ticket showed he was to receive a regular dysphagia advanced diet. Review of the facility's Diet Sheet Guide for 9/13/22 showed Resident 3 was to receive one square of peach shortcake in his meal tray; however, Resident 3 was served the canned sliced peaches. RNA 1 verified the finding. 2. On 9/13/22 at 1215 hours, an observation was conducted for Resident 84. Resident 84's meal ticket showed she was to receive a regular dysphagia advanced diet. Review of the facility's Diet Sheet Guide for 9/13/22, showed Resident 84 was to receive one square of peach shortcake in her meal tray; however, Resident 84 was served the canned sliced peaches. 3. On 9/13/22 at 1244 hours, an observation and concurrent interview for Residents 22 and 32. Resident 22 and 32's meal tickets showed they were to receive a regular dysphagia advanced diet. Review of the facility's Diet Sheet Guide for 9/13/22 showed Resident 3 was to receive one square of peach shortcake in his meal tray; however, Resident 3 was served the canned sliced peaches. The DON verified the findings. Further review of the facility's posted Week-At-A-Glance Week 2 menu failed to show the peach shortcake was substituted with the sliced canned peaches for lunch service on 9/13/22. On 9/13/22 at 1228 hours, an interview was conducted with the Dietary Manager. The Dietary Manager verified the above findings and stated the facility was not able to serve peach shortcake to any residents and substituted it with canned sliced peaches. The Dietary Manager also verified she did not inform the residents of the change before serving their meals. The Dietary Manager acknowledged the posted menu and diet sheet guide did not reflect the changes made to the residents' lunch meal.

Based on observation and interview, the facility failed to follow the proper sanitation and food storage practices. * The facility failed to ensure the prepared food items were properly dated and labeled. *The facility failed to ensure the resident and staff's personal food items were not stored in the walk-in refrigerator. * The facility failed to ensure the personal belongings were stored away from the kitchen preparation area. * The facility failed to ensure the food items in the resident's refrigerator were properly labeled and dated. These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's CMS 672 form dated 9/13/22, showed 91 of 108 residents were served food from the kitchen. 1. During the initial tour of the kitchen on 9/13/22 at 0730 hours, with the Dietary Manager, the following items were found in the walk-in refrigerator: - an undated white paper bag labeled with a resident's room number and last name containing prepared soup; - a box of a staff member's Spanish Serrano ham; - an unlabeled and undated purple container of prepared food; - an unlabeled and undated piece of tortilla wrapped in foil; and - an unlabeled and undated white foam cup with pureed substance. The Dietary Manager verified the above findings. The Dietary Manager stated the resident's prepared food should not be stored in the kitchen, staff personal food items should not be stored in the kitchen, and unlabeled and undated food items should be thrown away. The Dietary Manager also verified the purple container of food and tortilla wrapped in foil were the facility's staff food. 2. According to the USDA Food Code 2017, 6-501.110, personal belongings can contaminate, food, food equipment and food contact surfaces. On 9/19/22 at 0730 hours, an observation of the food preparation area was conducted with the Dietary Manager. A staff's cell phone was observed on top of a blue cooler in the food preparation area. The Dietary Manager verified the findings and stated the cell phone should not be there. 3. On 9/15/22 at 1432 hours, an observation of the residents' refrigerator was conducted with RN 2. The following items were found unlabeled and/or undated: - a black container of food - a gray plastic bag labeled with a resident's room number containing cheese, fruit, cherry tomatoes and cucumbers - a clear container covered with a paper towel containing slices of watermelon - a white bag with multiple packages of cheese - a clear container with a red top containing soup, unlabeled and undated;- a bag of chips - a bottle of fish sauce RN 2 was asked if she knew who owned any of the food items in the residents' refrigerator. RN 2 stated she did not know if they were the staff or residents' food items. RN 2 verified only the residents' food should be in the refrigerator and the items should be labeled and dated. On 9/19/22 at 1235 hours, an interview was conducted with the RD. The RD acknowledge the above findings. The RD stated food stored in the kitchen should be reserved for the residents only and no prepared resident's food should be in the walk-in refrigerator. The RD added no staff food should be stored in the kitchen. The RD also stated the personal items should be stored away and should not be in the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to develop a plan of care to reflect the individual care needs for one of 23 final sampled residents (Residents 40). The facility failed to ensure a care plan problem was developed to address Resident 40's bilateral lower extremity edema (swelling caused by a buildup of fluid within the tissues). This posed the risk of not providing appropriate, consistent, and individualized care to Resident 40. Findings: On 8/6/19 at 0812 hours, during the initial tour of the facility, Resident 40 was observed seated in bed with bilateral lower extremity edema. Medical record review for Resident 40 was initiated on 8/6/19. Resident 40 was readmitted to the facility on [DATE]. Review of the Progress Notes showed a nursing entry dated 7/23/19, showing Resident 40 had bilateral lower extremity pitting edema (when an indentation remains after the swollen skin is pressed). The description and location of the pitting edema were assessed and documented as +4 to the right foot and +3 to the left foot. Review of Resident 40's plan of care failed to show a care plan problem was developed to address the bilateral lower extremity edema until 8/6/19, which was 14 days after the edema was identified. On 8/7/19 at 1604 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 40 was readmitted to the facility with bilateral lower extremity edema, but a care plan problem was not developed to address the bilateral lower extremity edema until 8/6/19. Cross reference to F684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 23 final sampled residents (Resident 40) attained and maintained their highest practicable physical well-being. Resident 40 had a history of CHF (congestive heart failure - a condition where the heart is too weak to sufficiently pump blood to the body). The facility failed to ensure Resident 40's physician was notified when Resident 40 had bilateral lower extremity edema (swelling caused by a buildup of fluid within the tissues) until it had worsened. The posed the risk for delayed medical interventions. Findings: On 8/6/19 at 0812 hours, during the initial tour of the facility, Resident 40 was observed seated in bed with bilateral lower extremity edema. Medical record review for Resident 40 was initiated on 8/6/19. Resident 40 was readmitted to the facility on [DATE]. Review of the Progress Notes showed a nursing entry dated 7/23/19, showing Resident 40 had bilateral lower extremity pitting edema (when an indentation remains after the swollen skin is pressed). The description and location of the pitting edema were assessed and documented as +4 to the right foot and +3 to the left foot. Review of the Progress Notes failed to show Resident 40's physician was notified Resident 40 had bilateral lower extremity edema. Further review of Resident 40's Progress Notes showed nursing entries dated: - 8/4/19 at 2139 hours, showing a change in condition was noted for Resident 40, including worsening edema. The entry showed Resident 40's physician was notified and responded he was going to come in the morning to see the resident. - 8/5/19 at 0258 hours and 1258 hours, showing Resident 40 was being monitored for increased edema to both feet. - 8/5/18 at 1620 hours, showing a change of condition noted regarding the resident ' s left hand. The physician was called and returned the call at 1650 hours, giving orders for treatment of the left hand. There was no mention of the edema to the bilateral feet. - 8/6/19 at 0954 hours, showing Resident 40's physician came and examined Resident 40 at 0800 hours and gave new orders. On 8/7/19 at 1604 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated Resident 40 had a history of CHF and was readmitted with bilateral lower extremity edema. When asked if abnormal findings identified upon the resident's assessment should be reported to the physician, RN 2 replied yes. RN 2 stated the physician's response, including any new orders and what was reported to the physician, should have been documented. When asked what signs and symptoms were monitored for residents with CHF, RN 2 stated shortness of breath and signs and symptoms of fluid overload such as edema and weight gain. RN 2 verified there was no documentation to show Resident 40's physician was notified Resident 40 had bilateral lower extremity edema. On 8/8/19 at 0747 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 40's lower extremities were not swollen prior to being transferred to the acute care hospital. Family Member 1 stated Resident 40's lower extremity edema had not resolved since being readmitted . On 8/8/19 at 0801 hours, an interview was conducted with Physician 1. Physician 1 was asked if he was notified Resident 40 had bilateral lower extremity edema upon readmission. Physician 1 stated he was not notified regarding the edema. Physician 1 stated he was not a hospitalist (a physician who cares for patients in the hospital in place of their attending physician) and did not follow the residents when they were transferred to the acute care hospital. Cross reference to F656.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe environment for four rooms in the Dementia Unit. A metal lock was placed on the top portion of the glass slider door requiring a key to unlock, which was not readily accessible to the staff at the nurses' station. This had the potential to delay or prevent evacuation during an emergency. Findings: On 8/7/19 at 0740 hours, an observation and concurrent interview was conducted with CNA 2 and CNA 3. rooms [ROOM NUMBERS] were observed with metal locks attached on the top portion of the glass slider doors. CNA 2 and CNA 3 stated rooms [ROOM NUMBERS] had metal locks attached on the top portion of the glass slider doors, and a special key was needed to unlock the glass doors. There was no special key at the station. CNA 2 and CNA 3 stated not all doors needed to have the special key, just some of the doors, and staff would have to get the special key from maintenance. CNA 2 and CNA 3 stated the staff needed to keep the residents safe because they could wander out. On 8/7/19 at 0755 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified a key was needed to open the glass slider doors with special locks. The Maintenance Supervisor verified the key was in the maintenance office, and was not kept at the nurses' station. The Maintenance Supervisor verified slider doors in Rooms 48 (which housed two residents), 52 (which housed two residents), 53 (which housed two residents), and 54 (which housed two resident's) were locked, and were unable to be opened without the key from maintenance. When the Maintenance Supervisor was asked what would have happened in case of a fire, and the door was needed to exit the room, the Maintenance Supervisor stated he should give keys to everyone in the station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, medical record review, and facility P&P review, the facility failed to administer the medications appropriately and follow the physician's orders for medication administration for two of 23 final sampled residents (Residents 59 and 111). Findings: * The facility failed to ensure the appropriate administration of eyes drops for Resident 59. This failure posed the risk of the medication's effectiveness. * The facility failed to ensure injection sites were rotated for Residents 111. This had the potential for the residents to suffer adverse effects. Findings: 1. Review of the facility's P&P titled Medication Administration: Eye (drops and Ointments) revised 1/2/14, showed if the nurse administers multiple eye medications, the nurse should wait at least five minutes between medications. After administering medication, the nurse should instruct the resident to close the eyes gently without squeezing the lids shut. The nurse removes excess solution or ointment with tissue, and uses a fresh tissue for each eye. On 8/8/19 at 0920 hours, an observation of medication administration was conducted with LVN 3. LVN 3 was observed administering one drop of Artificial Tears to each eye of Resident 59. LVN 3 applied a tissue directly and immediately on each eye after administering the eyes drops, without instructing Resident 59 to close her eyes gently. Then LVN 3 proceeded to administer brimonidine (medication uses to treat glaucoma) within 30 seconds after administering the Artificial Tears. LVN 3 put the tissue on Resident 59's eyes without instructing Resident 59 to close her eyes gently after administering the brimonidine. On 8/8/19 at 1000 hours, an interview and concurrent facility P&P review was conducted with LVN 3. LVN 3 acknowledged she should have instructed Resident 59 to close her eyes gently after administering the eyes drops. LVN 3 also stated she should have waited for at least five minutes to administer the brimonidine after administering the Artificial Tears. LVN 3 verified the findings. 2. On 8/12/19, medical record review for Resident 111 was initiated. Resident 111 was readmitted to the facility on [DATE], with diagnoses including diabetes. Review of Resident 111's Medication Administration Record showed Resident 111 was administered Humalog (insulin) subcutaneously every six hours as per sliding scale with the direction to rotate the injection sites, Levemir (insulin) subcutaneously at bedtime with the direction to rotate the injection sites, and Novolog (insulin) subcutaneously every six hours as per sliding scale with the direction to rotate the injection sites. Review of Resident 111's Location of Administration Reports for May, June, and July 2019 showed Resident 111's insulin injection sites were not rotated a total of 16 times. On 8/12/19 at 1100 hours concurrent medical record review and interview was conducted with LVN 2. LVN 2 verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the Pharmacy Consultant failed to identify and report medication irregularities to the attending physician and the facility for one of 23 final sampled residents (Resident 109). The Pharmacy Consultant failed to identify a medication interaction between levothyroxine (medication to treat an underactive thyroid gland [hypothyroidism]) and Protonix (a proton pump inhibitor [PPI] to treat certain stomach and esophageal problems). This had the potential for Resident 109 to experience symptoms such as fatigue, cold sensitivity, dry skin, slow heart rate, and weight gain. Findings: Review of the American Thyroid Association's publication titled Clinical Thyroidology for the Public dated 6/15 showed patients with hypothyroidism are most often treated with levothyroxine in order to return their thyroid hormone levels to normal. Replacement therapy means the goal is a TSH (thyroid stimulating hormone) in the normal range. The levels of levothyroxine must be consistent for patients to experience the benefits of treatment. Several medications can interfere with levothyroxine by decreasing the absorption of levothyroxine from the gut or by slowing down its metabolism. Medications known to interfere with levothyroxine included PPIs. In patients treated with levothyroxine and PPI, an increase in serum TSH was observed. Review of the drug label information for levothyroxine as submitted to the Food and Drug Administration (FDA), showed many drugs can exert effects on thyroid hormone pharmacokinetics and metabolism (e.g., absorption, synthesis) and may alter the therapeutic response to levothyroxine. Administer levothyroxine at least four hours before or after drugs that are known to interfere with absorption. Concurrent use of PPIs may reduce the efficacy of levothyroxine by binding and delaying or preventing absorption of levothyroxine, potentially resulting in hypothyroidism. Medical record review for Resident 109 was initiated on 8/6/19. Resident 109 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of the Order Summary Report showed the physician's orders dated 7/20/19, to administer one tablet of levothyroxine 50 mcg one time a day at 0600 hours and to administer one tablet of Protonix 40 mg one time a day at 0600 hours. Review of Resident 109's Lab Results dated 7/11/19, showed the TSH was 10.700 (normal range 0.3 to 4.0). On 8/7/19 at 1020 hours, a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated the practice was to have a pharmacist remotely review any newly admitted resident's drug regimen within 72 hours of admission and make any needed recommendations. The Pharmacy Consultant stated Resident 109's drug regimen was reviewed on 7/22/19, but no recommendations were made regarding the levothyroxine and Protonix. The Pharmacy Consultant stated she used an online pharmacology database to check for medication interactions. When asked to check the pharmacology database for levothyroxine, the Pharmacy Consultant verified it showed a moderate severity interaction between levothyroxine and Protonix. The Pharmacy Consultant stated the TSH level was tested to determine the effectiveness of the levothyroxine dose. The Pharmacy Consultant stated when the TSH level was elevated (above the normal/reference range) it could mean Resident 109 was not getting enough dosage of the levothyroxine medication. On 8/7/19 at 1106 hours, an observation of Resident 109 was conducted with CNA 1. Resident 109 was observed lying in bed covered with two blankets and wearing a knit cap on his head. CNA 1 stated Resident 109 and Resident 109's family asked for the resident to be covered with extra blankets because the resident got cold easily. When asked about the knit cap, CNA 1 stated Resident 109 always wore the knit cap. On 8/7/19 at 1113 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the levothyroxine and Protonix were administered concurrently to Resident 109 in the mornings. LVN 1 stated the TSH result dated 7/11/19, was used as a baseline since it was recent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the security of medication and biologics for one of five medication carts, and failed to ensure the storage of drugs and biologics for one of 23 final sampled residents (Resident 92) and one nonsampled resident (Resident 6). * A medication cart on Station 2 was observed unlocked and unattended. This posed the risk of residents, unauthorized personnel, and visitors having access to the medications stored in the medication cart. * A medication for Resident 92 was discontinued, but the medication was not removed from the medication cart. This posed the risk of the medication being inadvertently administered to the resident. * Resident 6 had an expired order for a hypnotic medication; however, the medication remained in the medication cart. This posed the risk of the drug being diverted or inadvertently administered to the resident. Findings: 1. Review of the facility's P&P titled Medication Administration General revised date [DATE], showed medication practice standards required maintaining security of medication carts at all times. On [DATE] at 1039 hours, an observation and concurrent interview was conducted with LVN 4. Medication Cart 1 for Station 2 was observed in the hallway facing room [ROOM NUMBER]. Medication Cart 1 was observed to be unlocked. LVN 4 was observed in room [ROOM NUMBER] talking with a colleague. LVN 4 was asked if Medication Cart 1 was required to be locked. LVN 4 stated yes. 2. On [DATE] at 1039 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. Medication Cart 2 for Station 2 was observed to contain the medication clonidine (a blood pressure medication) 0.1 mg for Resident 92. Medical record review showed Resident 92 was readmitted to the facility on [DATE]. Review of the Order Summary Report dated [DATE], failed to show an order for the administration of clonidine. LVN 1 stated Resident 92 was transferred to the hospital on [DATE], and was readmitted on [DATE]. LVN 1 stated he was unsure how long a medication should remain in the medication cart once a resident is discharged . LVN 1 stated the medication should not be in the medication cart. 3. According to the facility's P&P tiled Disposal/Destruction of Expired or Discontinued Medication revised date [DATE], when an order to discontinue a medication is received, the facility staff should remove that medication from the resident's medication supply. The facility should place all discontinued or out-dated medication in a designated, secured location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. On [DATE] at 1152 hours, a medication reconciliation was conducted with LVN 3. A bubble pack of Ambien (a hypnotic used for sleep) for Resident 6 was observed in Medication Cart 3 without a label showing it was a discontinued medication. The label on the bubble pack of Ambien showed it was dispensed on [DATE]. Review of the Order Summary Report for Resident 6 showed the physician's order dated [DATE], to administer Ambien 5 mg, one tablet by mouth PRN (as needed) for insomnia for 14 days showed the end date was [DATE]. On [DATE] at 1508 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated the order for the PRN psychotropic medication was limited for 14 days. If the physician did not renew the order, that medication was considered discontinued. RN 2 stated the order for the PRN Ambien was not renewed, and the bubble pack should have been removed from the cart and turned in to the DON. RN 2 verified the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review showed Resident 717 was admitted to the facility on [DATE]. Review of Resident 717's Order Audit Report showed showed an entry date of 7/23/19, for a heart healthy diet, regular texture. Another entry dated 7/24/19, showed Dietetic Tech 1 added plant-based diet, no dairy, milk or cheese, no fried food. Review of Resident 717's Order Summary Report dated 8/12/19, showed a physician's order dated 8/7/19, for a no added salt (NAS) diet. On 8/8/19 at 1223 hours, an interview and observation of Resident 717 was conducted. Resident 717's lunch ticket showed no red meat, no dairy, no cheese, no milk. Resident 717 stated she liked cheese and all meat. Resident 717 was asked how it made her feel when she saw the meal ticket showing her preferences did not match the food preferences listed on the ticket. Resident 717 stated it made her feel like she was being ignored. On 8/12/19 at 0816 hours, an observation and interview was conducted with Resident 717. Resident 717's tray ticket showed no read meat, no dairy, no cheese, no milk. On 8/12/19 at 0947 hours, an interview was conducted with the DSS. The DSS stated Resident 717 has never had any restrictions for meat. The DSS stated Resident 717 was on a heart healthy diet and was able to receive meat as long as it was not fried. The DSS confirmed Resident 717 was not a vegetarian. The DSS confirmed Resident 717's diet orders had been changed to a low sodium diet. The DSS stated as of 8/12/19, Resident 717's meal ticket should not have shown no read meat, no dairy, no cheese, no milk. Based on observation, interview, medical record review, and facility document review, the facility failed to ensure food preferences were honored for two of 23 final sampled residents (Residents 31 and 717). This had the potential for poor meal intake, weight loss, and a negative impact on the residents' psychosocial well-being. Findings: 1. Medical record review for Resident 31 was initiated on 8/6/19. Resident 31 was readmitted to the facility on [DATE]. Review of the medical record showed Resident 31 weighed 99 pounds on 7/2/19, and weighed 94 pounds on 8/1/19, a weight loss of 5.05% over one month. Review of Resident 31's care plan showed a care plan problem with a revised date 6/10/19, titled Underweight related to poor oral intake secondary to selective eating. The interventions showed to honor food preferences, in order to accomplish a goal weigh between 142 - 185 pounds. On 8/6/19 at 1234 hours, an observation and interview was conducted with Resident 31. Resident 31 was observed lying in bed. Resident 31's lunch tray was observed on his bedside table. The lunch tray was observed with a portion of shredded beef. The portion of shredded beef was uneaten. Resident 31 was asked if he was done eating lunch. Resident 31 stated yes. When asked why he ate so little, Resident 31 stated he did not like beef. When asked if there were any other foods he disliked, Resident 31 stated he did not like pork. The lunch meal ticket dated 8/6/19, observed on Resident 31's lunch tray was consistent with Resident 31's statement, as it showed Resident 31 disliked beef and pork; however, someone had crossed out beef and pork with a pen. The meal ticket also showed the lunch tray was to include cranberry juice; however, no cranberry juice was observed on the lunch tray. On 8/6/19 at 1239 hours, an observation, interview, and facility document review was conducted with CNA 4. CNA 4 stated she assisted Resident 31 with eating lunch. CNA 4 stated Resident 31 consumed approximately 25 % of his lunch. CNA 4 verified the meal tray included a portion of shredded beef and did not contain cranberry juice. CNA 4 verified the lunch meal ticket dated 8/6/19, showed Resident 31 disliked beef and pork and cranberry juice should have been served. CNA 4 verified beef and pork were crossed out with a pen on the lunch meal ticket. CNA 4 stated Dietary Aid 1 had crossed out Resident 31's dislikes (beef and pork) on the lunch meal ticket. CNA 4 stated Dietary Aid 1 told her Resident 31's family said it was ok for Resident 31 to eat beef and pork. On 8/6/19 at 1257 hours, an interview was conducted with Dietary Aid 1. Dietary Aid 1 verified she crossed out Resident 31's dislikes (beef and pork) on his lunch meal ticket. Dietary Aid 1 stated Resident 31 and Resident 31's family told her six months ago Resident 31 liked beef and pork. On 8/6/19 at 1300 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS was asked how she determined residents' food likes and dislikes in order to prepare resident meals. The DSS stated she interviewed residents at the facility and, based on these interviews, determined resident food likes and dislikes. The DSS stated she documented this information on the Activity Log Report. The DSS stated this information was then printed onto the resident meal tickets, and the meal tickets were used to prepare resident meals. Review of Resident 31's Activity Log Report dated 4/24/18, showed Resident 31 disliked beef and pork. Review of Resident 31's Activity Log Report dated 1/25/19, showed Resident 31 made a special lunch request to have cranberry juice for lunch. The DSS reviewed Resident 31's lunch meal ticket dated 8/6/19, and verified Resident 31's dislikes (beef and pork) were crossed out with a pen. The DSS stated Dietary Aid 1 did not inform her Resident 31 or Resident 31's family stated he liked beef and pork. The DSS stated had if she been informed she would have updated Resident 31's Activity Log Report. On 8/12/19 at 0935 hours, an interview was conducted with the DSS. The DSS stated the purpose of determining Resident 31's dislikes was to avoid serving Resident 31 foods he disliked, which could potentially lead to loss of appetite or weight loss. When the DSS was asked if Resident 31 had any weight loss, she did not know, she did not see the weight loss lists.

Based on observation, interview, and medical record review, the facility failed to communicate the therapeutic diet orders to the kitchen staff for one nonsampled resident (Resident 767). This deficient practice resulted in Resident 767 receiving a diet that was not prescribed by her physician. Findings: On 8/7/19 at 1135 hours, during a concurrent tray line observation and interviews in the kitchen, [NAME] 1 and [NAME] 2 were observed preparing lunch trays with DM 2 and Dietary Aid 1. The diets being served were for dysphagia (for residents with difficulty swallowing), mechanical soft, puree, and heart healthy. DM 2 and Dietary Aid 1 were checking the tray cards to ensure the residents' prescribed diets were followed. There were no calls to the cooks from DM 2 or Dietary Aid 1 for a heart healthy diet during tray line. At the end of lunch service, an interview was conducted with DM 2. DM 2 was asked if there were any therapeutic diets ordered for that day. DM 2 looked at the dietary orders and stated there was one heart healthy diet ordered. When asked what the heart healthy diet was for that day, DM 2 looked on the meal tracker and stated it was an American version of the heart healthy diet. DM 2 was asked what the diet was supposed to include. DM 2 read the menu and stated it should have been pizza with ricotta cheese and vegetables. [NAME] 1 was asked if he made the pizza with ricotta cheese and vegetables. [NAME] 1 stated no. DM 2 was asked what Resident 767 actually received. The DSS, DM 2, and Dietary Aide 1 went to the dining room and checked Resident 767's tray card. DM 2 verified the tray card showed Resident 767 was to receive a heart healthy diet, but Resident 767 received pepperoni pizza. DM 2 verified the cook did not prepare the items per the therapeutic menu. Review of Resident 767's physician's orders showed an order dated 8/1/19, for a heart healthy diet, regular texture.

Based on observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the infection control practices for one of 23 final sampled residents (Resident 23). * The facility failed to ensure RN 1 performed hand hygiene in between changing gloves during the treatment of a wound, and changed gloves and performed hand hygiene during the treatment of a GT site for Resident 23. This failure posed the risk for transmission of disease causing microorganism. Findings: Review of the facility's P&P titled Hand Hygiene revised 11/15/18 showed under Process, perform hand hygiene before patient care, before an aseptic (free from contamination) procedure, after any contact with blood or other body fluids, even if gloves are worn, after patient care, and after contact with patient's environment. Hands are washed with soap and water when visibly soiled. When hands are not visibly dirty, alcohol-based sanitizers are the preferred method for hand hygiene. On 8/7/19 at 1048 hours, a treatment observation of Resident 23's wounds was conducted with RN 1. a. RN 1 donned gloves, cleansed the wound with wound cleanser, patted the area dry, removed the dirty gloves, donned clean gloves, and applied Santyl (medication to help heal wounds) ointment on the wound. RN 1 did not perform hand hygiene in between changing gloves during treatment of the wound. b. Observation of Resident 23's GT was then conducted with RN 1. RN 1 donned gloves, cleansed the GT site with normal saline, patted the area dry, and applied a clean dressing. RN 1 did not change gloves, and did not perform hand hygiene before applying the clean dressing to the GT site. An interview was conducted with RN 1 on 8/7/19 at 1136 hours. RN 1 stated she thought she had used alcohol gel after she removed the dirty gloves and before putting on clean gloves during the wound treatment observation. RN 1 stated she thought she had changed her gloves before applying the clean dressing to the GT site.

Based on observation and interview, the facility failed to ensure the medication refrigerators and a specimen refrigerator were free of ice buildup. This had the potential for the refrigerators not being maintained in safe operating condition. Findings: The facility was equipped with three medication refrigerators. 1. On 8/6/19 at 1115 hours, a concurrent observation and interview was conducted with RN 3. RN 3 verified the Station 2 medication refrigerator had approximately one half inch of ice buildup on the bottom surface of the freezer compartment. The ice buildup was observed extending to the drip tray, which stuck to the ice buildup. 2. On 8/6/19 at 1130 hours, a concurrent observation and interview was conducted with RN 2. RN 2 verified the Station 3 medication refrigerator had approximately one and one half inch of ice buildup on the bottom surface of the freezer compartment, extending to the drip tray. An ice pack used for the residents was observed embedded in the ice buildup. 3. On 8/6/19 at 1145 hours, a concurrent observation and interview was conducted with RN 2. RN 2 verified the freezer compartment of the specimen refrigerator was covered with ice buildup, measuring approximately 4 x 4 inches.

Based on observation, interview, and facility P&P review, the facility failed to ensure the pureed food prepared for lunch matched the facility recipe for 45 of 114 residents. This failure had the potential to change the nutritive value of the food which was determined by the recipe. On 8/7/19 at 0917 hours, [NAME] 1 was observed preparing pork and eggplant puree for lunch. [NAME] 1 stated he was preparing the puree for 45 residents. [NAME] 1 scooped the pureed pork from the blender and filled a deep pan 3/4 of the way full with pureed pork. [NAME] 1 then filled the same pan to an inch from the top with pureed eggplant. The recipe called for ¼ cup pureed pork and ¾ cup pureed eggplant per serving for each resident. No measurements were used. When asked if the pork and eggplant were being served in the correct amounts as the recipe directed, the cook stated he thought so. [NAME] 1 proceeded to put the pan in the serving compartment in the steam table. DM 2 was present and was asked if [NAME] 1 prepared the food according to the recipe. DM 2 stated No. On 8/7/19 at 1134 hours, an interview was conducted with [NAME] 1. [NAME] 1 was asked if the puree on the steam table was the same as prepared earlier that day. [NAME] 1 verified it was the same puree. The pureed pork and eggplant was observed to be served for lunch.

Based on observation and interview, the facility failed to ensure the expired foods were discarded from the walk-in refrigerator and the dented cans were labeled and returned back to the supplier. This failure had the potential to cause foodborne illness in the highly susceptible resident population. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility and dated 8/6/19, showed 93 of the 114 residents residing in the facility received food prepared in the dietary department. On 8/6/19 at 0925 hours, a tour of the kitchen was conducted with the DSS. The walk-in refrigerator was observed to contain the following: - A clear plastic bin containing cabbage was dated 7/22/19 to 7/29/19. The DSS stated the vegetables were delivered on 8/5/19, and produced an invoice to verify the date of delivery. The DSS stated the dates on the bin were incorrect. - A package of parsley with a use by date of 7/29/19, was inside a clear plastic bin with vegetables labeled as delivered on 8/5/19; - A package of cucumbers with a use by date of 7/29/19; - A package of red peppers with a use by date of 8/5/19; and - Iceberg lettuce was observed in a clear plastic bin with an expiration date of 8/5/19. The DSS verified the produce should have been thrown away. On 8/6/19 at 0932 hours, a tour of the dry storage area was conducted with the DSS. The dry storage area contained the following: - A dented can of Chili Con Carne, - A dented can of quail eggs, - A dented can of , tomato sauce, and - A dented can of Casa Solana Frijoles (beans). The DSS was asked what the policy was regarding dented cans. The DSS stated they label them and throw them away. On 8/6/19 at 0944 hours, the DSS removed the dented cans from the dry storage area.