**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to two of 15 final sampled residents (Residents 24 and 31). - The physician's order for the resident to be up in the chair during meals was not carried out for Resident 24. - The physician's order was not obtained and the care plan was not developed for the use of the wander guard for Resident 31. These failures had the potential for these residents to not receive the necessary care and services to meet their care needs. Findings: 1. Review of the facility's P&P titled Physician Orders revised on 11/2019 showed the physician's orders shall be obtained prior to the initiation of any medication or treatment. All the orders must be specific and complete with all the necessary details to carry out the prescribed order without any questions. Medical record review for Resident 24 was initiated on 3/25/25. Resident 24 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 24's H&P examination dated 3/325, showed Resident 24's memory was impaired. Review of Resident 24's Physician's Orders for March 2025 showed an order dated 3/7/25, for the resident to be up in the chair for all the meals. On 3/26/25 at 0801 hours, an observation and concurrent interview was conducted with CNA 3 in Resident 24's room. Resident 24 was observed eating breakfast in bed and pointing at her wheelchair located in front of the foot of her bed. When CNA 3 asked Resident 24 if she wanted to transfer to the wheelchair, Resident 24 nodded her head yes. CNA 3 stated she would assist the resident to be up in the wheelchair. On 3/27/25 at 0756 hours, an observation and concurrent interview was conducted with CNA 4 in Resident 24's room. CNA 4 verified Resident 24 was eating breakfast in bed. CNA 4 stated Resident 24 should be up in the wheelchair for her meals. On 3/27/25 at 0804 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified Resident 24 had the order to be up in the chair for all meals including breakfast, lunch, and dinner. LVN 2 stated the resident should be up in the wheelchair as ordered by the physician and to help prevent aspiration. On 3/27/25 at 0840 hours, a concurrent interview and medical record review was conducted with the DOR. The DOR verified Resident 24's order and stated the ST documentation from 3/7/25, showed for the resident to be upright in the chair for all meals as the resident's head of bed could not be elevated to 90 degrees. On 3/28/25 at 0755 hours, an observation and concurrent interview was conducted with Resident 24 in her room. Resident 24 was observed eating breakfast in bed. When Resident 24 was asked if she wanted to be up in wheelchair while eating, Resident 24 nodded her head yes. On 3/28/25 at 0804 hours, an observation and concurrent interview was conducted with LVN 2 in Resident 24's room. LVN 2 verified the observation of Resident 24 eating breakfast in bed. LVN 2 stated Resident 24 should be up in the wheelchair to eat her meals, including breakfast. On 3/28/25 at 1336 hours, an interview with the Administrator and DON was conducted. The DON and Administrator acknowledged above findings. 2. Review of the facility's P&P titled Wander System Monitoring Program revised 12/2023 showed it is the policy of this facility that all new residents will be evaluated, a part of the initial assessment process, for being at risk for wandering. Any residents identified as a wandering risk will be reassessed quarterly and with change in behavior. All residents identified to be at risk for wandering will have a wandering-monitoring bracelet placed. Anytime a wander system alarm sounds all staff are to respond and verify all residents at risk for wandering are accounted for. - one wander-monitoring bracelet will be placed on either resident's wrist or approved alternate location, (i.e. ankle or nonmetal back of resident's wheelchair) - each monitoring wristband will be checked every shift for placement and function and replaced as per manufacturer's recommendation Medical record review for Resident 31 was initiated on 3/25/25. Resident 31 was admitted on [DATE], and readmitted on [DATE]. Review of Residents 31's MDS assessment dated [DATE], showed Resident 31's BIMS score of 8 (meaning cognitive impaired). On 3/27/25 at 0835 hours, an observation and concurrent interview was conducted with CNA 1. Resident 31 was observed lying in bed with the wander guard on her right ankle. CNA 1 stated Resident 31 had had her wander guard since her admission to the facility for elopement prevention. However, further review of Resident 31's medical record failed to show the physician's order was obtained and the care plan was developed for use of the wander-monitoring bracelet. On 3/27/25 at 0906 hours, an interview and concurrent record review was conducted with the DSD. Review of Resident 4's medical record failed to show documentation the facility had an order, informed consent, and care plan for the use of the wander guard. The DSD verified there was no current physician's order and care plan for the use of the wander guard. On 3/27/25 at 1042 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Nutrition revised 5/2019 showed it is the policy of the facility to ensure that all the residents maintain an acceptable parameters of the nutritional status, such as body weight and protein labels, unless the residents clinical condition demonstrates that this is not possible. Further review of the P&P showed any of the resident's weight that varies from the previous reporting period by 5% or 5 lbs. in 30 days, 7.5% in 90 days, and 10% in 180 days will be evaluated by the IDT to determine the cause of weight loss/gain and intervention required. Under the section clinical evaluation showed the following: - The nurse will notify the physician, family, and/or resident of weight loss or gain with interventions. - Any resident meeting the criteria for weight loss and any resident at risks will be weighed weekly with the weight entered into POC/PCC. Weekly weight will be reviewed by the Registered Dietitian/designee. - The IDT will update and revise the care plan as appropriate. Medical record review for Resident 32 was initiated on 3/25/25. Resident 32 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE], showed Resident 32 was cognitively intact. Review of Resident 32's Weights and Vitals Summary from 2/7/25 to 2/28/25, showed the following weight and comparison. - dated 2/7/25, 192 lbs; - dated 2/10/25, 181 lbs; - dated 2/18/25, 179 lbs; - dated 2/28/25, 176 lbs; a loss of 16 lbs /8.33% in 21 days compared to 2/7/25; - dated 3/6/25, 176 lbs; - dated 3/12/25, 179 lbs; and - dated 3/19/25, 180 lbs. a. Review of the Resident 32's Nutrition Evaluation and RDN Review dated 2/12/24, showed the following: - Resident 32's weight was 181 lbs. - Weight loss of 11 lbs (5.7%) in three days. - BMI 28.3 in healthy range - Ideal weight range 133-148-163 lbs. - Desirable body weight 176-186 lbs. - Recommendation per registered dietician showed weekly weights. - Under the section for Nutritional Plan of Care showed to change GT feeding Jevity 1.5 (enteral formula) at 75 ml per hour for 20 hours (to provide 1500 ml/2250 calories/95.7 gm protein/1140 ml free water) in 24 hours; every four hours, to flush the tubing with 150 ml water (to provide 600 ml); and flush the GT with 20-30 ml of water pre and post medication administration. Review of Resident 32's Nutrition Interdisciplinary Team Update dated 2/17/25, showed Resident 32 had significant weight loss of 11 lbs in three days likely related to recent change to the enteral nutrition per Resident 32's family member and Resident 32 was not able to recall his usual body weight. The RD assessed the resident and received a new tube feeding order to better likely to meet estimated needs. The document further showed Jevity 1.5 formula at 75 ml per hour for 20 hours (to provide 1500 ml/ 2250 calories/95.7 gm protein/1140 ml free water) in 24 hours; every four hours, to flush the tubing with 150 ml water (to provide 600 ml); and flush the GT with 20-30 ml of water pre and post medication administration. Further review of Resident 32's medical records failed to show if the RD and IDT had evaluated and analyzed Resident 32's nutritional status when Resident 32 had the weight loss of 16 lbs./8.33 % in 21 days on 2/28/25. On 3/27/25 at 1334 hours, an interview and concurrent medical record review for Resident 32 was conducted with the RD. The RD verified the above findings and stated he was responsible to monitor the resident's weight in the facility. The RD verified Resident 32 had a significant weight loss of 16 lbs/8.33 % in 21 days on 2/28/25. The RD stated he was not able to find documentation to show the RD evaluation and IDT meeting for the nutritional status were done for the Resident 32 when he had the significant weight loss on 2/28/25. b. Review of the Resident 32's medical record did not show if the physician and the resident/resident's representative were notified when Resident 32 had the weight loss of 16 lbs./8.33 % in 21 days on 2/28/25. Review of the Resident 32's Care Plan revised 2/24/25, showed a care plan problem addressing Resident 32 being at risk for malnutrition. The intervention included to monitor and report to the MD as needed for any signs and symptoms of decreased appetite, nausea, vomiting, unexpected weight loss and to monitor, record, report to the MD as needed for signs and symptoms of malnutrition, emaciation, muscle wasting, and significant weight loss. On 3/27/25 at 0954 hours, an interview and concurrent medical record review for Resident 32 was conducted with LVN 3. LVN 3 stated the RD monitored the residents' weekly weights and notified the licensed nurses when there were significant weight changes, then the licensed nurse initiated the change in condition and notified the physician and the resident and/or their representative. LVN 3 verified Resident 32 had the weight loss of 16 lbs./8.33 % in 21 days on 2/28/25. LVN 3 stated she was not able to find documented evidence if the physician and Resident 32 or the resident's representative were notified of the above weight loss for Resident 32. c. Review of the Resident 32's Care Plan revised 2/24/25, showed a care plan problem addressing Resident 32 being at risk for malnutrition. The Care Plan further showed on 2/10/25, Resident 32 had 11 lbs weight loss in three days. Interventions included Jevity 1.5 formula at 75 ml per hour for 20 hours to provide 1500 ml/ 2250 calories/95.7 gm protein/1140 ml free water. Further review of Resident 32's Care Plan did not address Resident 32's weight loss of 16 lbs./8.33 % in 21 days on 2/28/25. On 3/27/25 at 1613 hours, an interview and concurrent medical record review for Resident 32 was conducted with the DON. The DON verified and acknowledged the above findings. The DON stated she and the RD were responsible to monitor the residents' weight in the facility. The DON stated when the resident had the significant weight changes, the RD should evaluate the resident, an IDT meeting should be conducted, the physician and resident should be notified, and the care plan should address the significant weight loss. The DON verified Resident 32 had a significant weight loss of 16 lbs/8.33 % in 21 days on 2/28/25. The DON verified there was no documented evidence if the RD evaluated Resident 32 for the above significant weight loss and the IDT meeting was conducted. The DON further verified she was not able to find documentation to show the physician and Resident 32 and/or the resident's representative were notified of the above significant weight loss of Resident 32 on 2/28/25. In addition, the DON verified the Care Plan for Resident 32 did not address the above weight loss on 2/28/25. 3. Review of the facility's P&P titled Charting and Documentation dated 4/2008 showed all observations, medications administered, services performed, etc., must be documented in the resident's clinical record. Review of the facility's P&P titled Nursing Administration dated 5/2019 showed to provide care and services including: defining and implementing the interventions for maintaining or improving the nutritional status that are consistent with the resident needs, goals, and recognized the standards of practice or explaining adequately in the medical record why the facility could not or should not do so and monitoring and evaluating the resident's response or lack of response to the interventions; and revising or discontinuing the approaches as appropriate, or justifying the continuation of the current approaches. Each resident is to be weighed upon admission, weekly weights for four weeks and monthly thereafter. The weight will be entered directly into POC/PCC. Review of the facility's P&P titled Care Plans - Comprehensive dated 5/2019 showed each of the resident's comprehensive care plan is designed to: a. Incorporate the identified problem areas; b. Incorporate the risks factors associated with the identified problems; c. Build on resident's strengths; d. Reflect the resident's expressed wishes regarding treatment and goals; e. Reflect the treatment and goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for the problem areas and conditions. Medical record review for Resident 41 was initiated on 3/25/25. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's Care Plan Report initiated on 2/14/25, showed a care plan problem addressing Resident 41's nutritional problem or potential nutritional problem related to acute chronic systolic CHF, cellulitis of the right lower/limb, cellulitis of left lower limb, Type 2 diabetes mellitus complications, weakness, and CKD Stage 3. The interventions included an 1800 ml/day fluid restriction and to monitor and report to the MD as needed for any signs and symptoms of decreased appetite, nausea, vomiting, unexpected weight loss, stomach pain , etc. Review of Resident 41's Weight and Vitals Summary showed Resident 41's recorded weight was 193 lbs which was documented based from the acute care hospital admission on [DATE], and 181 lbs on 2/18/25. Review of Resident 41's Amount Eaten record showed the Resident 41 refused his meal on the following mealtimes and dates: - breakfast on 3/15/25, - lunch on 3/15, 3/21, 3/22, and 3/24/25, and - dinner on 2/26-2/27/25, and 3/6, 3/11-3/13, and 3/20/25. Review of Resident 41's Amount Eaten record from 2/26/25 to 3/26/25, showed a missing documentation on the following mealtimes and dates: - breakfast on 3/16 and 3/21/25; - lunch on 3/6-3/7, and 3/12/25; and - dinner on 2/28/25, and 3/7, 3/9, 3/16, 3/21, and 3/24/25. Review of Resident 41's Fluid Intake from 2/26/25/25 to 3/27/25, showed the missing documentation on the following shifts and dates: - morning shift on 3/7, 3/10, 3/12, and 3/21/25; - evening shift on 2/28/25, and 3/7, 3/9-3/10, 3/16, 3/21, and 3/24/25, and - night shift on 3/13-3/14, Review of Resident 41's care plan showed no documented evidence of Resident 41's care plan problem regarding the refusal of the meals. On 3/27/25 at 0842 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified all of the above missing documentation and acknowledged no care plan was initiated on Resident 41's refusal of the meals. 03/27/25 at 1002 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified Resident 41's care plan problem to address the refusal of meals was not initiated. On 3/28/25 at 1520 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 41's recorded weight from admission date 2/14/25, was based from the acute care hospital record. The DON acknowledged the facility staff should have recorded Resident 41's weight at the time of admission. The DON verified all of the above findings. Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for three of three final sampled resident (Residents 4, 31, and 32) reviewed for weight loss. * The facility failed to ensure the RD's recommendations on 3/14/25, were followed up with the physician and addressed in the Nutrition IDT when Resident 4 had a severe weight loss of 15 lbs in seven days. This failure had the potential for Resident 4 not to receive the necessary intervention to prevent further weight loss. * The facility failed to ensure the RD and IDT analyzed and implemented the necessary interventions to address Resident 32's unplanned severe weight loss of 16 lbs which was equivalent to 8.33% in 21 days. In addition, the physician and resident and/or their representative were not notified of Resident 32's unplanned significant weight loss of 16 lbs, 8.33% between 2/7/25 and 2/28/25. Resident 32's resident-centered plan of care was not revised to address Resident 32's severe weight losses 8.33% between 2/7/25 and 2/28/25. * The facility failed to ensure a care plan problem was developed for Resident 41's refusal of meals, the accuracy of the documentation on Resident 41's weight upon admission, and amount of food intake and fluid intakes were completed for Resident 41. These failures posed the risk for the residents' weight loss to not be managed timely. Findings: Review of the facility's P&P titled Nutrition revised dated 5/2019 showed it is the policy of this facility to ensure that all the residents maintain acceptable parameters of nutritional status, such as the body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. The P&P also showed the following: - any resident's weight that varies from the previous reporting period by 5% or 5 lbs in 30 days, 7.5% in 90 days and 10 % in 180 days will be evaluated by the IDT to determine the cause of weight loss/gain and the intervention required. - the nurse will notify the physician, family and/or resident of the weight loss/gain with interventions. 1. Medical record review for Resident 4 was initiated on 3/25/25. Resident 4 was admitted to the facility on [DATE]. Review of Residents 4's MDS assessment dated [DATE], showed Resident 4's BIMS score was 9 (moderate cognitive impairment). Review of Resident 4's Weight Summary showed the following dates and weights: - on 2/9/25, 117 lbs; - on 2/10/25, 113 lbs; a weight loss of 4 lbs from 2/9/25; - on 2/28/25, 113 lbs; - on 3/6/25, 98 lbs, a weight loss of 15 lbs from 2/28/25; and - on 3/23/25, 102 lbs, a weight loss of 14.2 lbs from 2/9/25. Review of Resident 4's Order Summary report showed a physician's order dated 2/9/25, for a regular diet, regular texture with thin liquid. Review of Resident 4's Nutrition Evaluation note dated 2/10/25, showed Resident 4's goals was to maintain the weight of 112-122 lbs. On 3/28/25 at 0929 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked what the facility's plan was to address Resident 4's weight loss. Review of Resident 4's Nutrition IDT note dated 3/14/25, showed a recommendation to fortify Resident 4's diet. The RD failed to show documentation if the recommendations of the RD on 3/14/25, was communicated to the resident's physician. On 3/28/25 at 1501 hours, an interview and concurrent medical record review was conducted with the DON. Review of Resident 4's medical record failed to show documentation the facility had communicated and followed up with the resident's physician regarding Resident 4's weight loss. The DON verified the 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 GT placement check was performed prior to starting the resident's enteral feeding for one of one final sample resident reviewed for tube feeding (Resident 32). This failure had the potential for the residents to develop complications related to the GT care and management, including tube dislodgement. Findings: Review of the facility's P&P titled Enteral Feedings-Safety Precautions revised 12/2011 showed the section for Preventing Aspiration showing to check enteral tube placement prior to each feeding and administration of medication. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump dated 12/2011 showed the section for Steps in the Procedure showing to verify placement of the tube as follows: - Observe for a change in the external tube length marked at the time of the initial insertion X-ray. - Observe for signs of respiratory distress (if applicable). - Auscultate: attach 60 ml syringe containing approximately 10 ml air. Auscultate the abdomen (approximately three inches below the sternum) while injecting the air from the syringe into the tubing. Listen for whooshing sound to check the placement of the tube in the stomach. - Check pH of aspirate, if feeding has been interrupted for a few hours, aspirate a small amount from the stomach, observe the aspirate and then measure the pH (using pH strips). A pH of five or less suggests that the tube is placed in the stomach. However, pH of six or greater is not definitive of placement outside of the stomach. Further review of the P&P showed if any of the above suggests improper tube positioning, do not administer the feeding or medication; and to notify the charge nurse or physician. Medical record review for Resident 32 was initiated on 3/25/25. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's Order Summary Report showed the following physician's orders: - dated 2/7/25, to check the tube placement/patency before and after giving medications and before starting the tube feeding. - dated 3/25/25, for continuous Glucerna 1.5 (enteral feeding) at 75 ml/hr for 20 hours (to turn off at 0900 hours, and to start at 1300 hours). On 3/25/25 at 1517 hours, Resident 32 was observed lying in bed with enteral feeding connected; however, the enteral feeding was observed to be turned off. On 3/25/25 at 1523 hours, RN 2 was observed coming into Resident 32's bedside. RN 2 then proceeded to start Resident 32's enteral feeding. RN 2 was then observed priming and connecting the enteral feeding tube to the resident's GT and starting the enteral feeding. RN 2 was not observed checking for the GT placement. On 3/25/25 at 1539 hours, an interview was conducted with RN 2. RN 2 verified the above findings and stated he was notified regarding the problem with the feeding tube for Resident 32. RN 2 stated the resident's enteral feeding was initially started by a LVN; however, he should have verified the proper placement and patency of the feeding tube for Resident 32 before he started the enteral feeding for Resident 32. RN 2 further stated prior to starting an enteral feeding, he should verify the GT placement by injecting approximately 10 ml of air bolus into the tubing while using a stethoscope to auscultate and verify the placement. On 3/27/25 at 1613 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 necessary respiratory care and services were provided for two of two sampled residents (final sample resident, Residents 356 and nonsampled resident, Resident 705) reviewed for respiratory care. * The facility failed to ensure the oxygen was administered as ordered by the physician to Resident 356. * The facility failed to ensure the nasal cannula tubing was dated and a storage bag was provided for Resident 705. These failures had the potential for these residents to not receive the appropriate respiratory care or developed respiratory infection which may negatively affect the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the purpose of the procedure is to provide guidelines for safe oxygen administration. Further review of the P&P showed to verify that there is a physician order for the procedure and to review the physician's order or facility protocol for oxygen administration. Medical record review for Resident 356 was initiated on 3/25/25. Resident 356 was admitted to the facility on [DATE]. Review of Resident 356's Order Summary Report showed a physician's order dated 3/19/25, to administer the oxygen at two liters per minutes via nasal cannula continuously to keep the oxygen saturation level above 90%. Review of Resident 356's Care Plan dated 3/19/25, showed a care plan problem addressing the ADL self-care performance deficit. The interventions showed Resident 356 required staff assistance for bed mobility and transfers. Review of Resident 356's H&P examination dated 3/20/25, showed Resident 356 had no capacity to understand and make decisions. On 3/25/25 at 1232 hours, Resident 356 was observed lying in the bed. The oxygen was observed to be on at 3.5 liters per minutes and was not connected to the nasal cannula tubing. The nasal cannula tubing was observed on the bed, not on Resident 356 and was not connected to the oxygen machine. On 3/25/25 at 1234 hours, LVN 6 was called into the room of Resident 356. LVN 6 verified the above observation and stated Resident 356 required a continuous oxygen administration. LVN 6 further stated the nasal cannula should be on Resident 356's nose and connected to the oxygen machine. LVN 6 was observed checking Resident 356's oxygen saturation level using a pulse oximeter which showed 86% (normal range 95 -100 %). LVN 6 was then observed placing the nasal cannula on Resident 356 's nose and connected the tubing to the oxygen machine and started the oxygen at 2 liters per minute. LVN 6 again checked for the resident's oxygen saturation level which showed 93% with 2 liters per minute of the oxygen. On 3/27/25 at 1613 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. 2. Review of the facility's P&P titled Oxygen Use of revised 5/2021 showed the oxygen cannula or mask will be changed at least every seven days, as well as the disposable humidifier. The tubing, masks, humidifiers and other disposables used for oxygen administration will be dated in an identifiable fashion. Medical record review for Resident 705 was initiated on 3/25/25. Resident 705 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 705's H&P examination dated 3/21/25, showed Resident 705 had a diagnosis of acute respiratory failure with hypoxia. Review of Resident 705's Order Summary Report dated 3/21/25, showed a physician's order dated 3/22/25, for oxygen at a rate of 2 liters per minute via nasal cannula to keep the oxygen saturation levels above 90%. On 3/25/25 at 1252 hours, during the initial tour of the facility, an observation was conducted for Resident 705. Resident 705 was observed lying in bed with oxygen at a rate of 2 liters per minute via nasal cannula The nasal cannula was observed undated and without a storage bag to keep the nasal cannula tubing when the tubing was not in use. On 3/25/25 at 1300 hours, an observation and concurrent interview was conducted with LVN 1 regarding Resident 705. LVN 1 was asked if Resident 705's nasal cannula was dated when it was changed and had a storage bag. LVN 1 stated there was a missing date on the nasal cannula when it was changed and the storage bag was not placed in the room for Resident 705. LVN 1 stated Resident 705 should have had a dated nasal cannula and a dated storage bag next to the oxygen machine. On 3/28/25 at 1117 hours, the DON and Administrator was made aware and acknowledged the 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 medication error rate was below 5%. The facility's medication error rate was 7.41%. * LVN 1 did not administer Resident 34's metformin HCL (medication to lower the blood sugar) with meal or food as ordered. * LVN 1 administered Advil (pain reliver) 200 mg two tablets for Resident 44's pain level of 8 which was not a prescribed pain level for this pain medication. These failures had the potential to negatively impact the residents' health outcomes. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medication shall be administered in a safe and timely manner, and as prescribed. The medications must be administered in accordance with the orders, including any required time frame. 1. On 3/26/25 at 0827 hours, a medication administration observation for Resident 34 was conducted with LVN 1. Resident 34 had no breakfast tray on the overbed table. LVN 1 prepared the following medications for Resident 34: - one tablet of allopurinol (prevent or lower high uric acid levels in the blood) 100 mg - one tablet of eliquis (blood thinner) 5 mg - one tablet of digoxin (used to treat heart failure and irregular heartbeat) 250 mcg - two tablet of gabapentin (anticonvulsant) 100 mg - one tablet of furosemide (diuretic) 20 mg - one tablet of metformin 500 mg with meals - one tablet of metoprolol (beta blocker) 50 mg hold if systolic blood pressure below 100 mmHg or pulse below 60 beats per minute. Medical record review for Resident 34 was initiated on 3/25/25. Resident 34 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Residents 34's MDS dated [DATE], showed Resident 34's BIMS score of 13 (meaning cognitively intact). Review of Resident 34's Order Summary Report showed the following active physician's order: - dated 1/10/25, to administer metformin Hcl 500 mg one tablet by mouth two times a day for diabetes mellitus and to take with meals On 3/26/25 at 1223 hours, an interview was conducted with LVN 1. LVN 1 verified the metformin medication was not given with meals nor food. 2. On 3/26/25/ at 0842 hours, a medication administration observation for Resident 44 was conducted with LVN 1. Resident 44 complained of pain and the pain level was at 8 (using the 0-10 pain scale with 0 = no pain and 10 = worst pain). LVN 1 prepared and administered the following medications: - two tablet of vitamin D3 (supplement) 25 mcg/1000 IU - two tablet of sodium chloride (supplement) tablet 1 gm - one syringe of enoxaparin (anticoagulant) 40 mg/4 ml - two tablet of ibuprofen (pain reliver, generic name for Advil) 200 mg Medical record review for Resident 44 was initiated on 3/25/25. Resident 44 was admitted to the facility on [DATE]. Review of Residents 44's MDS dated [DATE], showed Resident 44's BIMS score of 15 (meaning cognitively intact). However, review of Resident 44's Order Summary Report showed a physician's order dated 3/11/25, for Advil tablet 200 mg two tablets by mouth every six hours as needed for mild/moderate pain (pain level of 4-6), not for the pain level of 8. On 3/26/25 at 1032 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the Advil medication was given to Resident 44 with the pain level of 8.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications. * The facility failed to ensure Medication Cart A was maintained in a clean and sanitary manner. * The facility failed to ensure Medication Cart B was maintained in a clean and sanitary manner and the expired medication in the medication cart was disposed. * The facility failed to dispose of the expired medications in the Medication Storage Room. * The facility failed to store the oral and external medications separately in the Medication Storage Room. These failures had the potential to negatively impact the residents' well-being, for the medications to lose the stability and effectiveness, and medication errors. Findings: Review of the facility's P&P titled Drug Storage and Labeling (undated) showed the drugs and biologicals will be stored in a safe, secure and orderly fashion, and will be accessible only to the licensed nursing or pharmacy personnel. Oral medications will be stored separately from the ointments, creams, lotions, liquids and for external use. The eye medications will be kept separate from the ear medications. 1. On 3/26/25 at 0951 hours, an inspection of Medication Cart A and concurrent interview was conducted with LVN 4. The following was observed: - the first drawer compartment was not clean and had dried up light brown residue, and - the upper rim compartment where the tongue depressors were stored had a dark brown residue. LVN 4 verified the above findings. 2. On 3/26/25 at 1028 hours, an inspection of Medication Cart B and concurrent interview was conducted with LVN 3. The following was observed: - a bottle of Pro-stat concentrated liquid protein (protein supplement) had a sticky medication residue on the top part of the bottle, - the bottom drawer compartment was not clean and had a dried up yellow brown residue, and - a bottle of Glucosamine Chondroitin Complex (joint supplement) had an expiration date of 2/2025. LVN 3 verified the above findings. LVN 3 acknowledged the bottle of Glucosamine Chondroitin Complex should have been disposed. 3. On 3/26/25 at 1128 hours, an inspection of the Medication Storage Room and concurrent interview was conducted with RN 1. The Medication Storage Room was observed with four expired bottles of docusate sodium (stool softener). The two bottles had an expiration date of 6/2024 and the other two bottles had an expiration date of 1/2025. RN 1 verified the four expired bottles of docusate sodium should have been disposed properly. On 3/28/25 at 1050 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings. 4. On 3/26/25 at 1142 hours, an inspection of the Medication Storage Room and concurrent interview was conducted with RN 1. The following medications were observed stored side by side in the second shelf of Medication Storage Room cabinet: - one box of bisacodyl suppository (medication to relieve constipation), - one box of Salonpas (pain relieving patch), and - four bottles of Geri-tussin-DM (medication to relieve cough). RN 1 acknowledged the rectal suppository, pain relieving patch, and bottles of oral medications were stored together. On 3/26/25 at 1332 hours, an interview was conducted with the DON. The DON acknowledged the above findings, and stated the medications to be taken by mouth and suppository should not be stored together.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the egg rolls and cream of rice during the puree preparation. * Residents 7, 706, 707, 756, and 758 (nonsampled residents) were not served a regular textured diet as ordered by the physician. * Resident 706 (nonsampled resident) was not served the appropriate serving portion as ordered by the physician * [NAME] 1 failed to use the correct scoop size to serve rice for Resident 33 (final sample resident). These failures had the potential of not meeting the residents' nutritional needs which could lead to nutritional related health complications. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the kitchen. Review of the facility's P&P titled Menu Planning dated 2023 showed the menus are planned to meet nutritional needs of resident in accordance with established national guidelines, physician's orders, and to the extent medically possible, in accordance with the most recent recommended dietary allowance of the Food and Nutrition Board of National Research Council National academy of sciences. - Procedures: The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. Review of the facility's Week 3 cycle menu showed two #8 scoops for Beef and Broccoli stir fry; #8 scoop for steamed rice; and one egg roll each for a regular diet. Review of the facility's Week 3 cycle menu showed two #8 scoop for Beef and Broccoli stir fry; #16 scoop for steamed rice; and one egg roll each for Small Portion Diet. Review of the facility's Week 3 cycle menu showed #6 scoop for Beef and Broccoli stir fry; #16 scoop for egg roll; and four oz cream of rice for Puree Diet. Review of the facility's pureed recipe for Steamed Rice, Cycle 1, 2025 Winter for Purees: Stovetop Method: Add oil and salt to water, bring to a boil, stir in the rice, reduce heat to low; cover and simmer 20 minutes or until rice is tender, and most of the water has been absorbed, remove from heat and let stand (covered) for five minutes; transfer to the service line and serve with a #8 scoop; and prepare the rice according to regular recipe. Review of the facility's pureed recipe for Egg Roll (Vegetable) 1-1/2, Cycle 1, 2025 Winter for Dysphagia/Puree: Place portions needed into a food processor, process to a fine texture, prepare a slurry with hot liquid and thickener, mix well with a wire whip, add 1/2 (half) of the slurry to the egg rolls, and process for one minute. 1. On 3/26/25 at 1025 hours, an observation and concurrent interview was conducted with [NAME] 1 during the puree preparation process. [NAME] 1 was observed placing 10 egg rolls in the Robot Coupe and added ¾ (three forth) cup of slurry mixture and processed the egg rolls and the slurry together for a pureed texture. On 3/26/25 at 1042 hours, an observation of the Cream of [NAME] preparation was conducted with [NAME] 1. [NAME] 1 poured two cups of water in a deep metal pan over the stove top and without measuring poured the mixture of Cream of [NAME] into the pan while stirring with a spoon. On 3/26/25 at 1050 hours an interview and concurrent recipe review of Egg Rolls and Cream of [NAME] was conducted with [NAME] 1. [NAME] 1 was asked about the proper preparation of the egg rolls. [NAME] 1 verified the egg rolls should have been placed in the food processor and blended before adding the slurry mixture; however, they were processed together. [NAME] 1 was also asked about the preparation of the Cream of Rice. [NAME] 1 verified he did not follow the recipe and poured the cream of rice directly from the box into the pan instead of measuring. [NAME] 1 stated he was confused when preparing the meal. 2. On 3/26/25 at 1245 hours, an observation and concurrent interview was conducted in the kitchen with Cooks 1, 2, and the Dietary Resource. [NAME] 1 was observed preparing all lunch trays for the residents and stated he did not have enough regular textured Beef and Broccoli stir fry to serve the remaining five residents (Residents 7, 706, 707, 756, and 758) as ordered by the physician. When [NAME] 1 was asked how he would proceed with the serving of the meals for the five residents identified, he stated all he had left was chopped textured Beef and Broccoli for Residents 7, 706, 707, 756, and 758. [NAME] 1 was asked if the chopped texture diet followed the physician's orders, and he verified it did not. Dietary Resource also verified there was not enough food prepared to make sure Residents 7, 706, 707, 756, and 758 received the proper diet texture as ordered by the physician. a. Medical recorded review for Resident 7 was initiated on 3/26/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Order Summary Report dated 3/27/25, showed a physician's order dated 2/12/25, for no added salt diet, regular texture, thin liquids consistency. b. Medical record review for Resident 706 was initiated on 3/26/25. Resident 706 was admitted to the facility on [DATE]. Review of Resident 706's Order Summary Report dated 3/27/25, showed a physician's order dated 3/12/25, for Regular diet, regular texture, thin liquids consistency. c. Medical record review for Resident 707 was initiated on 3/26/25. Resident 707 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of 707's Order Summary Report dated 3/27/25, showed a physician's order dated 3/24/25, for Regular diet, soft and bite sized- level 6 texture, thin liquids consistency. d. Medical record review for Resident 756 was initiated on 3/26/25. Resident 756 was admitted to the facility on [DATE]. Review of 756's Order Summary Report dated 3/27/25, showed a physician's order dated 3/13/25, for Regular diet, regular texture, thin liquids consistency. e. Medical record review for Resident 758 was initiated on 3/26/25. Resident 758 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of 758's Order Summary Report dated 3/27/25, showed a physician's order dated 3/21/25, for constant carbohydrate diet, regular- level 7 texture, thin liquids consistency. 3. On 3/26/25 at 1251 hours, an observation and concurrent interview was conducted with [NAME] 1 and the RD regarding Resident 706. Resident 706 was observed receiving 1.25 scoops of Beef and Broccoli, stir fry. [NAME] 1 was asked why Resident 706 was receiving 1.25 scoops of Beef and Broccoli while the other residents received two full scoops for the regular diet ordered. [NAME] 1 verified he had ran out of food and did not have the correct portion size for Resident 706. When [NAME] 1 and the RD were asked how they would ensure to have enough food for the residents, the RD and [NAME] 1 stated they referred to the census of the facility. Medical record review for Resident 706 was initiated on 3/26/25. Resident 706 was admitted to the facility on [DATE]. Review of Resident 706's Order Summary Report dated 3/27/25, showed a physician's order dated 3/12/25, for regular diet, regular texture, thin liquids consistency. 4. On 3/26/25 at 1257 hours, an observation and concurrent interview was conducted with Cooks 1 and 2 in the kitchen. [NAME] 1 was observed using a #8 scoop for Resident 33's rice. Cooks 1 and 2 were asked if the right scoop size was used to serve rice for Resident 33 who had a meal ticket showing a small portion in blue writing. [NAME] 1 verified he did not use scoop size #16 to serve Resident 33's rice. [NAME] 2 verified it was the responsibility of both cooks to verify the meal cards upon serving the residents in the facility. Medical record review of Resident 33 was initiated on 3/25/25. Resident 33 was admitted on [DATE]. Review of Resident 33's Order Summary Report dated 3/27/25 showed a physician's order dated 3/14/25, for easy to chew- Level 7 texture, thin liquids consistency, small portion. On 3/28/25 at 1117 hours, the DON and Administrator were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical Record review for Resident 33 was initiated on 3/26/25. Resident 33 was admitted to the facility on [DATE]. Review of Resident 33's Order Summary Report showed a physician's order dated 3/23/25, for vancomycin HCl Intravenous Solution (antibiotics) 750 mg intravenously every day shift for 10 days for wound infection. Review of Resident 33's IV MAR for March 2025 did not show documented evidence Resident 33's peripheral IV site was monitored for the complicated reactions during the IV infusion and for the signs and symptoms of infiltration. On 3/26/25 at 1214 hours, an observation and concurrent interview was conducted with Resident 33. Resident 33 was observed to have a peripheral IV site on her right forearm covered with a light brown dressing. Resident 33 was asked since when the resident had the peripheral IV site and what it was for, Resident 33 stated she could not recall when it was inserted, and it was intended for an infection. On 3/26/25 at 1233 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified there was no documented evidence Resident 33's peripheral IV site was monitored for the complicated reactions during the IV infusion and for the signs and symptoms of infiltration. On 3/28/25 at 1330 hours, an interview was conducted with the DON. The DON was made aware and verified the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for two of 15 final sampled residents (Residents 4 and 33). * Resident 4's POLST failed to show documentation as to whether Resident 4 had formulated the advanced directive. * The facility failed to ensure Resident 33's peripheral IV catheter care was documented. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete. Findings: 1. Review of the facility's P&P titled Advance Directive revised 11/2019 showed once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to the members of the care plan team. The facility will also notify the attending physician of the advance directives so that, if necessary, the appropriate orders can be documented in the resident's medical record and plan of care. Medical record review for Resident 4 was initiated on 3/25/25. Resident 4 was admitted to the facility on [DATE]. Review of Residents 4's MDS assessment dated [DATE], showed Resident 4's BIMS score was 9 (moderately cognitive impaired). On 3/26/25 at 1326 hours, a review of Resident 4's POLST dated 1/8/25, was conducted. Section D of the POLST for Information and Signatures showed Resident 4 had no advance directive. However, the POLST failed to show documentation as to whether it was discussed with Resident 4 or the legally recognized decision maker. The form further showed the physician had signed the POLST on 1/9/25. On 3/27/25 at 0952 hours, an interview and concurrent medical record review was conducted with the SSD. A follow-up review of Resident 4's POLST dated 1/8/25, showed Section D for Information and Signatures showing Resident 4 had an advance directive dated 9/17 which was discussed with the Legally Recognized Decisionmaker and the box for No Advanced Directive indicated error. The form showed the physician had signed the POLST on 1/9/25. The SSD verified she just updated Resident 4's POLST. The SSD verified there was no documentation to show the SSD had updated Resident 4's POLST and communicated to the resident's physician prior to making the POLST modification. On 3/27/25 at 1206 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the hospice and facility staff worked collaboratively together in the plan of care for one of one hospice resident (final sampled resident, Resident 1) as per the hospice contract agreement. This failure had the potential of Residents 1 to not receive hospice care as per the hospice contract agreement and P&P. Findings: Review of the facility's P&P titled Hospice Program revised 12/2011 showed when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions. Review of Hospice A's Services Agreement: Exhibit B (undated) showed for Nursing Services, a registered nurse will be assigned to coordinate and supervise care and services for residents and families. Registered nurses responsibilities include the participation in interdisciplinary team, utilization review, discharge planning, and meetings. Medical record review for Resident 1 was initiated on 3/25/25. Resident 1 was admitted to the facility on [DATE], and readmitted back to the facility on 2/7/25. Review of Resident 1's Physician's Orders for March 2025 showed an order dated 3/4/25, to admit the resident to the facility under Hospice A. Review of Resident 1's Significant Change MDS assessment dated [DATE], showed Resident 1 with the BIMS score of 9 which meant the resident was cognitively moderately impaired. Review of Resident 1's Change of Condition Review IDT dated 3/7/25, showed no documented evidence a hospice representative was included in the IDT meeting. On 3/282/5 at 0953 hours, a concurrent interview and medical record review was conducted with the IP. The IP verified Resident 1 was under Hospice A services. Review of Resident 1's medical record showed no documented evidence the hospice care team had participated in the IDT meeting conducted on 3/7/25. The IP stated the hospice care team was also providing care to the hospice resident, therefore, the hospice staff should also be included in the IDT meeting to ensure for the continuation of care between the facility's nursing staff and hospice staff. On 3/28/25 at 1336 hours, an interview with the Administrator and DON was conducted. The DON and Administrator acknowledged above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 24 was initiated on 3/25/25. Resident 24 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 24's Physician's Orders for March 2025 showed an order dated 2/28/25, for continuous oxygen at one liter per minute via nasal cannula/mask to keep the oxygen saturation level above 90% every shift. Review of Resident 24's H&P examination dated 3/3/25, showed Resident 24 had impaired memory. On 3/25/25 at 1614 hours, during an observation, LVN 7 was observed in Resident 24's room wearing gloves and assisting Resident 24's roommate with her oxygen. LVN 7 was observed placing the nasal cannula on Resident 24's roommate and turning on the oxygen concentrator. LVN 7 was then observed going to Resident 24 to provide assistance to the resident with her oxygen and touched Resident 24's nasal cannula. LVN 7 was not observed performing hand hygiene between residents contact and did not change the gloves when working between Resident 24 and her roommate. On 3/25/25 at 1618 hours, an interview with LVN 7 was conducted outside of Resident 24's room. LVN 7 verified the above findings. LVN 7 stated she should have changed her gloves and perform hand hygiene between residents contact to ensure infection control and to prevent the spread of bacteria. On 3/28/25 at 1336 hours, an interview with the Administrator and DON was conducted. The DON and Administrator acknowledged above findings. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed as evidenced by: * The OTA failed to perform hand hygiene before and after assisting Resident 4 to the bathroom. * LVN 1 failed to perform hand hygiene before and after taking the resident's blood pressure, during the medication preparation and administration, and in between the medication administration for Residents 3 and 34. * LVN 7 failed to perform hand hygiene after removing her gloves and in between contacts with Resident 24's roommate and Resident 24. These failures posed the risk for the transmission of the communicable diseases to other residents in the facility. Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene dated 12/2012 showed the facility considers hand hygiene the primary means to prevent the spread of infection. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: - before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) - upon and after coming in contact with resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident). Review of the facility's P&P titled Administering Medication dated 12/2012 showed the staff follow establish facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medication, as applicable. 1. On 3/25/24 at 1135 hours, during the initial tour of the facility, an observation was conducted with the OTA with Resident 4. The OTA was observed taking Resident 4 to the bathroom with her gloved hands, and left Resident 4 in the bathroom. The OTA removed her gloves, did not wash her hands, took a clean towel on the hallway, and donned a new pair of gloves without hand washing. On 3/25/25 at 1155 hours, an interview was conducted with the OTA. The OTA acknowledged the findings and stated she should have washed her hands after removing her gloves. 2. On 3/26/25 at 0815 hours, a medication administration observation for Resident 3 was conducted with LVN 1. LVN 1 took Resident 3's blood pressure and prepared and administered Resident 3's medications. However, LVN 1 did not perform hand hygiene before and after taking Resident 3's blood pressure and during the medication preparation and administration. On 3/26/25 at 0827 hours, a medication administration observation for Resident 34 was conducted with LVN 1. LVN 1 took Resident 34's blood pressure and prepared and administered Resident 34's medications. However, LVN 1 did not perform hand hygiene before and after taking Resident 34's blood pressure and during the medication preparation and administration. Furthermore, LVN 1 was not observed performing hand hygiene in between the medication administration for Residents 3 and 34. On 3/26/25 at 1032 hours an interview was conducted with LVN 1. LVN 1 verified the above findings and stated she needed to wash her hands before and after taking the blood pressure and the medication administrations. On 3/28/25 at 1050 hours, an interview was conducted with the Administrator and DON. The 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 maintain the kitchen's essential equipment in a clean and safe operating condition when: * The ice machine was not cleaned as per the manufacturer's guidelines for cleaning and sanitizing. * The low temperature dishwasher handles were missing covers and had brown discoloration. * The low temperature dishwasher machine was not operating as per the manufacturer's instructions. * The residents' dining room refrigerator temperature log was not monitored as per the facility's policy. There failures had the potential for the essential equipment to not function in the way it was intended, and exposed the residents to unsafe practices, which could lead to food borne illnesses for the residents. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the kitchen. Review of the facility's P&P titled Sanitation dated 2023 showed the following: Policy: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. - All the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 1. On 3/25/25 at 1132 hours, during the initial tour of the kitchen with the RD and [NAME] 1, an inspection of the ice machine was conducted. The ice machine contained white flaky residue/build-up on the outside panel of the ice bin. The RD and [NAME] 1 verified the findings. On 3/27/25 at 1316 hours, a follow-up inspection of the ice machine and concurrent interview with the Maintenance Director was conducted. The top front cover of the ice machine was removed. The ice machine was observed with white and brown buildup on the base in between the left panel of the ice machine and the left side of ice maker door. The Maintenance Director was asked when the ice machine cleaning was last completed. The Maintenance Director stated the ice machine was cleaned and descaled once a month and the last cleaning was completed on 3/5/25. When the Maintenance Director was asked if he was aware of the white and brown buildup as identified during the ice machine inspection, the Maintenance Director stated his focus was on the inside of the ice maker door. When the Maintenance Director was asked if he was aware of the white flaky residue/build-up on the outside panel of the ice machine, he stated he was not aware of it. 2. On 3/26/25 at 1104 hours, an observation of the low temperature dishwasher and concurrent interview was conducted with the Dietary Resource. The low temperature dishwasher handles on the right and left of the machine showed brown discolored handles and were missing covers on each side of the handles. The Dietary Resource verified the findings. 3. Review of the reference range posted outside the low temperature dishwasher panel showed the reference range for chlorine level was 50-100 PPM. On 3/26/25 at 1105 hours, a concurrent observation, interview, and record review was conducted with Dietary Staff 1 regarding the low temperature dishwasher, with the presence of the Dietary Resource. Dietary Staff 1 was asked about the reference range for the chlorine levels for the dishwasher. Dietary Staff 1 stated the proper chlorine levels for the dishwashing machine were 50 to 100 PPM. Dietary Staff 1 was asked to conduct Ecolab Chlorine Paper Test which showed results of 200 PPM and displayed a near black color on the test strip. The Ecolab Chlorine Paper Test was conducted three more times. All the results showed the chlorine levels greater than 200 PPM and displayed a near black color on the test strip. Dietary Staff 1 was asked what the near black color on the test strip meant and he stated too much chemical chlorine was being dispensed when the dishwasher was running. The Dietary Resource stated the facility would use the two-sink compartment to wash the dishes. Review of the form titled Dishmachine Temperature and Sanitizing Agent Log dated March 2025 showed the result of the PPM levels for the breakfast, lunch, and dinner from 3/1 through 3/26/25 was 100 PPM. Dietary Staff 1 was asked for the possible reasons as to why the levels of the PPM were higher today compared to the documented results on March 2025 log. Dietary Staff 1 stated the Ecolab technician came on 3/26/25, and must have adjusted the setting which might have affected the chlorine levels. Dietary Staff 1 was asked what needed to be done when the chlorine levels were out of the acceptable range. Dietary Staff 1 stated he needed to contact the Ecolab technician to come back to fix the machine. 4. Review of the facility's P&P titled Cold Storage Temperature Monitoring and Record Keeping dated 2023 showed the following: - Food & Nutrition Services staff shall review and record temperatures of all the refrigerators and freezers to ensure they are at the correct temperature for food storage and handling. - Food & Nutrition Services staff will record and initial the temperatures on the Healthcare Menu Direct, LLC.'s Clod storage Temperature log at the beginning of the AM and PM shifts. On 3/27/25 at 0835 hours, an interview and concurrent facility document review was conducted with [NAME] 1 and the RD. [NAME] 1 was asked when the temperatures for the resident dining room refrigerator were recorded. [NAME] 1 stated the temperatures were recorded in the morning. Review of the form titled Resident Dining Room Refrigerator Temperature Log for March 2025 failed to show a recorded temperature for the dining refrigerator for 3/27/25. The RD and [NAME] 1 verified the findings. Review of the form titled Resident Dining Room Refrigerator Temperature Log dated February and March 2025 failed to show a recorded temperature for the PM shift. The RD and [NAME] 1 were asked where the PM shift temperatures were being recorded. The RD verified the staff have not been recording the temperatures on the temperature log for the evening shift. On 3/28/25 at 1117 hours, the DON and Administrator 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 food safety and sanitation guidelines were followed when: * The facility failed to ensure the food items were properly stored and maintained. * The facility failed to ensure the food items were dated and labeled. * The facility failed to ensure the kitchen equipment was maintained in a sanitary condition and/or cleaned properly. These failures had the potential to result in foodborne illnesses for 57 of 59 residents receiving the dietary services in the facility's kitchen. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the facility's kitchen. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Labeling and Dating of Foods dated 2023 showed the following: Policy: All food items in the storage room, refrigerator, and freezer need to be labeled and dated. Procedure: -Food delivered to the facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date for the product. -Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines within the this section- specifically the Dry Goods Storage Guidelines. 1. On 3/25/25 at 1115 hours, during the initial tour of the kitchen, a concurrent observation and interview with [NAME] 1 and the RD were conducted. The following was observed: - Five pumpkin pies with a label date of 2/23/25, and without the expiration dates; - One box of the tater tots removed from the freezer by [NAME] 1, placed directly on the floor, and put back into the freezer; - One buttermilk ranch bottle used, without the opened date and expiration date; - One bread knife with a melted handle; - One missing tile on the drain next to the ice maker machine - Grey web-like formation on the vent above the stove - Two bags of the wheat toast with best by dates of 3/19 and 3/22/25; and - Two bags of the bagels with an opened date of 3/14/25, and without an expiration date Cook 1 verified the above findings and stated the damaged items needed to be discarded and the expired bread needed to be discarded. The RD stated the food items should have been dated to ensure the kitchen staff were aware of how long the food items had been opened. The RD also verified the box of tater tots removed from the freezer and placed directly on the floor and returned to the freezer could contaminate the remaining items in the freezer and spread infection. [NAME] 1 stated he did not know the tile on the drain near the ice machine was missing. [NAME] 1 further stated the vent above the stove was cleaned on 3/19/25; however, he did not see the web-like formation. The RD and [NAME] 1 verified all the findings. 2. Review of the facility's P&P title Dishwashing dated 2023 showed all dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean ad in good working order. - Gross food particles shall be removed by carefully scraping and pre-rinsing in running water. On 3/25/25 at 1132 hours, a concurrent observation and interview was conducted with [NAME] 1 and the RD. The following was observed: - Three 7-inch pans with blue handles with brown sticky residue and dark brown stains; - One large deep rectangular pan with brown and black discoloration on the exterior surface; - Two large draining pans with brown and white flaky residue around the rim of each pan; - One can opener with brown residue covering the spinning wheel of the device; and - [NAME] sticky residue stains on the floor, in between the coffee machine table and juice machine table. Cook 1 and the RD verified the findings and stated the kitchen equipment needed to be cleaned properly. 3. On 3/26/25 at 1104 hours, a concurrent observation and interview was conducted with the Dietary Resource. Below the dish drying table, a melted grey, white, and brown substance covering the right side of the pole was observed. The Dietary Resource verified the pole underneath the dish drying table had rust and brown discoloration. The Dietary Resource also stated the pole needed to be re-welded. On 3/28/25 at 1117 hours, the DON and Administrator were informed and acknowledged the above findings.

**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 treat one of three sampled residents (Resident 2) with dignity when the staff removed her indwelling urinary Foley catheter. * The facility failed to get permission from Resident 2 for multiple staff to be present during the Foley catheter removal. This failure had the potential to negatively affect Resident 2's well-being. Findings: Review of the facility's P&P titled Resident Rights revised 10/2009 showed the Federal and state laws guarantee certain basic rights to all residents of this facility which includes to choose a physician and treatment, and participate in decisions and care planning. Our facility will make every effort to exercise his/her rights to assure the resident is always treated with respect, kindness, and dignity. Review of the facility's P&P Titled Quality of Life-Dignity revised 10/2009 showed the staff members shall promote, maintain, and protect the residents' privacy, including bodily privacy during assistance with personal care and during treatment procedures. Medical record review for Resident 2 was initiated on 11/19/24. Resident 2 was admitted to the facility on [DATE]. On 11/19/24 at 1032 hours, an interview was conducted with Resident 2. Resident 2 stated on 11/16/24, two male and one female staff came into her room to remove her indwelling urinary foley catheter. Resident 2 stated she felt it did not take three people to remove the indwelling urinary Foley catheter, and the staff were treating her like a body and not as a person. On 11/19/24 at 1401 hours, a follow-up interview was conducted with Resident 2. Resident 2 stated when the staff came to remove her indwelling urinary Foley catheter, the staff did not ask her permission, and it was more like an announcement. Resident 2 further stated the staff did not ask her permission for the other staff to be present when removing her indwelling urinary Foley catheter. Resident 2 stated she felt upset, embarrassed, violated, and caused her to cry afterwards. On 11/19/24 at 1508 hours, an interview was conducted with LVN 2. LVN 2 stated she went in Resident 2's room to help LVN 4 and CNA 4 remove the indwelling urinary Foley catheter. LVN 2 stated Resident 2 requested for LVN 2 to remove it since the morning nurse was a male staff. When asked who was present during the procedure, LVN 2 stated the three of us. When asked if Resident 2 was crying, LVN 2 stated Resident 2 was crying afterwards and stated she was shocked because the two gentlemen came in. When asked if Resident 2 should have been asked for the permission to have male staff present in the room when performing the procedure, LVN 2 stated, yeah I should have. On 11/21/24 at 1225, an interview was conducted with CNA 4. CNA 4 stated, we told Resident 2 there was an order from the physician for the indwelling urinary foley catheter to be removed. When asked who was present in the room during the procedure, CNA 4 stated two other charge nurses LVNs 2 and 4. When asked if Resident 2 was asked permission if all the three staff members can be present during the procedure, CNA 4 stated no, we just asked if it was okay to remove the indwelling urinary foley catheter. On 11/21/24 at 1557, an interview was conducted with LVN 4. LVN 4 stated he helped Resident 2 back in the bed for the procedure along with two other staff members. LVN 4 stated, Resident 2 asked why they were all there and stated it would not take three people to take the indwelling urinary catheter out. When asked if Resident 2 was asked for permission for all the three staff members to be present, LVN 4 stated I did not think so. On 11/22/24 at 1406 hours, an interview was conducted with the DSD. The DSD stated if the resident was uncomfortable with male staff being present in the room during the removal of the indwelling urinary foley catheter, they should have asked for permission first. The DSD stated it usually only takes one licensed nurse to remove an indwelling urinary foley catheter and one staff member should have left. On 11/22/24 at 1612 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings. F755 - D Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the medications were administered as ordered for one of three sampled residents (Resident 2). * The facility failed to ensure the medications scheduled for 0900 hours were administered to Resident 2 timely. This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medications must be administered within one hour of their prescribed time unless otherwise specified (for example before and after meal orders). Medical record review for Resident 2 was initiated on 11/19/24. Resident 2 was admitted to the facility on [DATE]. Resident 2 had a diagnosis of muscle spasms, hypertension, multiple sclerosis, and osteoarthritis. On 11/19/24 at 1005 hours, an interview was conducted with Resident 2. Resident 2 stated she had not received her knee patch and meloxicam (nonsteroidal anti-inflammatory medication) for her left knee pain. On 11/19/24 at 1014 hours, an observation was conducted with LVN 1, when LVN 1 answered Resident 2's call light. Resident 2 stated to LVN 1 that she had not received her morning medications yet. Resident 2 stated the physical therapy already came by, but I can't do anything yet until I get my medications. LVN 1 replied to Resident 2, I haven't given them yet, because I'm still passing out meds. We can put on your patch now. Review of Resident 2's MAR for November 2024 showed physician's order for the following medications scheduled to be administered at 0900 hours: - meloxicam oral tablet 15 mg-give one tablet by mouth one time a day for pain. - lidocaine external patch 4% apply to affected area topically one time a day for pain management. - lidocaine external patch 5% apply to left knee topically one time a day for pain management. - gabapentin oral capsule 300mg-give 300 mg by mouth three times a day for neuropathy (nerve pain). - calcium plus vitamin D3 oral tablet 600-10 mg-mcg-give one tablet one time a day for supplement. - hydrocortisone tablet 5 mg-give two tablets by mouth one time a day for inflammation. - amlodipine besylate tablet 10 mg-give one tablet by mouth one time a day for hypertension (high blood pressure). - ascorbic acid oral tablet 250 mg-give one tablet by mouth one time a day for supplement. - losartan potassium oral tablet 100 mg give one tablet by one dime a day for hypertension. - baclofen tablet 20 mg give one tablet by mouth four times a day for muscle spasms. - tizanidine HCL tablet 4 mg give one tablet by mouth one time a day for muscle relaxant. - multiple vitamin tablet-give one tablet by mouth one time a day for supplementation. - oxybutynin chloride ER tablet extended release 24-hour 10 mg give one tablet two times a day for OAB (overactive bladder). Review of Resident 2's Medication Admin Audit Report for 11/19/24, showed the following medications were administered at 1030 hours: - lidocaine external patch 4% - lidocaine external patch 5% - gabapentin oral capsule 300mg-give 300 mg - calcium plus vitamin D3 oral tablet 600-10 mg-mcg - hydrocortisone tablet 5 mg - amlodipine besylate tablet 10 mg - baclofen tablet 20 mg - tizanidine HCL tablet 4 mg - multiple vitamin tablet - oxybutynin chloride ER tablet extended release 24-hour 10 mg Further Review of Resident 2's Medication Admin Audit Report showed the ascorbic acid was administered at 1029 hours and meloxicam and losartan potassium were administered at 1031 hours. On 11/16/24 at 1020 hours, an interview was conducted with LVN 1. LVN 1 verified Resident 2's medications were administered late, more than one hour of the prescribed time (at 0900 hours) to be administered. On 11/22/24 at 1612 hours, an interview was conducted with the DON. The DON was made ware 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 pharmaceutical services to ensure the medications were administered as ordered for one of three sampled residents (Resident 2). * The facility failed to ensure the medications scheduled for 0900 hours were administered to Resident 2timely. This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medications must be administered within one hour of their prescribed time unless otherwise specified (for example before and after meal orders). Medical record review for Resident 2 was initiated on 11/19/24. Resident 2 was admitted to the facility on [DATE]. Resident 2 had a diagnosis of muscle spasms, hypertension, multiple sclerosis, and osteoarthritis. On 11/19/24 at 1005 hours, an interview was conducted with Resident 2. Resident 2 stated she had not received her knee patch and meloxicam (nonsteroidal anti-inflammatory medication) for her left knee pain. On 11/19/24 at 1014 hours, an observation was conducted with LVN 1, when LVN 1 answered Resident 2's call light. Resident 2 stated to LVN 1 that she had not received her morning medications yet. Resident 2 stated the physical therapy already came by, but I can't do anything yet until I get my medications. LVN 1 replied to Resident 2, I haven't given them yet, because I'm still passing out meds. We can put on your patch now. Review of Resident 2's MAR for November 2024 showed physician's order for the following medications scheduled to be administered at 0900 hours: - meloxicam oral tablet 15 mg-give one tablet by mouth one time a day for pain. - lidocaine external patch 4% apply to affected area topically one time a day for pain management. - lidocaine external patch 5% apply to left knee topically one time a day for pain management. - gabapentin oral capsule 300mg-give 300 mg by mouth three times a day for neuropathy (nerve pain). - calcium plus vitamin D3 oral tablet 600-10 mg-mcg-give one tablet one time a day for supplement. - hydrocortisone tablet 5 mg-give two tablets by mouth one time a day for inflammation. - amlodipine besylate tablet 10 mg-give one tablet by mouth one time a day for hypertension (high blood pressure). - ascorbic acid oral tablet 250 mg-give one tablet by mouth one time a day for supplement. - losartan potassium oral tablet 100 mg give one tablet by one dime a day for hypertension. - baclofen tablet 20 mg give one tablet by mouth four times a day for muscle spasms. - tizanidine HCL tablet 4 mg give one tablet by mouth one time a day for muscle relaxant. - multiple vitamin tablet-give one tablet by mouth one time a day for supplementation. - oxybutynin chloride ER tablet extended release 24-hour 10 mg give one tablet two times a day for OAB (overactive bladder). Review of Resident 2's Medication Admin Audit Report for 11/19/24, showed the following medications were administered at 1030 hours: - lidocaine external patch 4% - lidocaine external patch 5% - gabapentin oral capsule 300mg-give 300 mg - calcium plus vitamin D3 oral tablet 600-10 mg-mcg - hydrocortisone tablet 5 mg - amlodipine besylate tablet 10 mg - baclofen tablet 20 mg - tizanidine HCL tablet 4 mg - multiple vitamin tablet - oxybutynin chloride ER tablet extended release 24-hour 10 mg Further review of Resident 2's Medication Admin Audit Report showed the ascorbic acid was administered at 1029 hours and meloxicam and losartan potassium were administered at 1031 hours. On 11/16/24 at 1020 hours, an interview was conducted with LVN 1. LVN 1 verified Resident 2's medications were administered late, more than one hour of the prescribed time (at 0900 hours) to be administered. On 11/22/24 at 1612 hours, an interview was conducted with the DON. The DON was made ware 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 one of 23 final sampled residents (Resident 443) was assessed to self-administer his medications. This failure had the potential for Resident 443 to administer medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications revised 12/2012 showed the residents have the right to self-administer medications if the staff and practitioner have determined that it is clinically appropriate and safe for the resident to do so. Determination of a resident's ability to self-administer medications shall be documented in the resident's medical record. On 10/2/23 at 0924 hours, an observation and concurrent interview was conducted with Resident 443 and CNA 1. Resident 443 was observed with two medicine cups containing pink cream on the bedside table. Resident 443 stated the cream was for the inflamed skin between his groins. Resident 443 stated the nurse left the cream at his bedside. CNA 1 was asked about the cream and stated the cream was for Resident 443's rash. Medical record review for Resident 443 was initiated on 10/2/23. Resident 443 was admitted to the facility on [DATE]. Review of Resident 443's Order Summary Report dated 10/3/23, showed a physician's order dated 9/26/23, for Resident 443 having the capacity to make health care decisions and the following physician's orders: - dated 9/27/23, to cleanse abdominal fold MASD (moisture-associated skin damage; inflammation or skin erosion caused by prolonged expose to a source of moisture) with normal saline (NS), pat dry, and apply Calmoseptine every shift; - dated 9/27/23, to cleanse perianal MASD with NS, pat dry, and apply Calmoseptine every shift; and - dated 9/27/23, to cleanse right and left groin MASD with NS, pat dry, apply Calmoseptine every shift. Further review of Resident 443's Order Summary Report failed to show a physician's order for self-administration of medication. Further review of Resident 443's medical record failed to show Resident 443 was assessed for self-administration of medication. On 10/2/23 at 1030 hours, an observation and concurrent interview for Resident 443 was conducted with the Treatment Nurse. The Treatment Nurse verified Resident 443 had two medicine cups containing Calmoseptine cream at the bedside. The Treatment Nurse stated the staff was responsible for applying the Calmoseptine cream for Resident 443. The treatment nurse further stated the cream should not be left at bedside. On 10/3/23 at 1423 hours, a follow-up interview and concurrent medical record review was conducted with the Treatment Nurse. The Treatment Nurse verified Resident 443 did not have a physician's order to self-administer medication. The Treatment Nurse also verified there were no assessments for self- administration of medication found in Resident 443's medical record. On 10/5/23 at 1330 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the medication should not have been left at bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 543's Order Summary Report dated 9/20/23, showed a physician's order dated 9/20/23, for duloxetine HCL oral capsule delayed release particles 30 mg in the morning for anxiety m/b verbalizations of feeling nevous. Review of Resident 543's Order Summary Report dated 9/20/23, showed a physician's order dated 9/20/23, for trazodone HCL oral tablet 50 mg one tablet by mouth Q HS as needed for depression m/b inability to sleep. Review of Resident 543's plan of care failed to show a specific care plan was initiated to address the use of duloxetine HCL and trazodone; and failed to show specific behavioral manifestations for the staff to monitor regarding the use of duloxetine HCL and trazodone. On 10/3/23 at 1432 hours, an interview and concurrent medical record review was conducted with the SSD and DON. The DON verified no patient centered care plans were developed to address Resident 543's use of Duloxetine and Trazadone. The DON further stated the care plan should be specific to Resident 543's plan of care. 2. Medical record review for Resident 37 was initiated on 10/2/23. Resident 37 was admitted to the facility on [DATE], with a diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following a cerebral infarction (a stroke) affecting the right dominant side. Review of Resident 37's MDS dated [DATE], showed Resident 37 had severely impaired cognition (a person has trouble remembering, learning new things, concentrating or making decisions that affect everyday life), total dependence on functional status (individual's ability to perform normal daily activities required to meet basic needs) and on a feeding tube. Review of Resident 37's fall risk assessment titled LN-Fall Risk Evaluation dated 6/27/23, showed Resident 37 was at high risk for falls. Review of Resident 37's plan of care showed a care plan problem initiated on 7/4/23, addressing Resident 37's risk for falls related to confusion, gait/balance problems, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The intervention included to implement floor mats. On 10/3/23 at 0920 hours, an observation and concurrent interview was conducted with CNA 1. Resident 37 was observed lying in bed with no bilateral floor mats. CNA 1 verified the findings. On 10/3/23 at 1220 hours, an observation, interview, and concurrent medical record review for Resident 37 was conducted with LVN 3. LVN 3 stated Resident 37 had a stroke with right sided weakness. LVN 3 verified Resident 37's care plan titled at risk for falls initiated on 7/4/23, showed an intervention to implement floor mats. LVN 3 verified Resident 37 did not have floor mats in place. On 10/5/23 at 1600 hours, the Administrator and DON were notified and acknowledged the above findings. Cross reference to F689, example #1. 3. Medical record review for Resident 29 was initiated on 10/2/23. Resident 29 was admitted to the facility on [DATE]. Review of Resident 29's H&P examination dated 8/14/23, showed Resident 29 had the capacity to understand and make decisions. Resident 29 had a diagnosis of obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep). Review of Resident 29's MAR for October 2023 showed a physician's order dated 10/3/23, to apply CPAP at setting of 15 cmH2O every night. Review of Resident 29 Comprehensive Plan of Care failed to address the use of Resident 29's CPAP machine. On 10/3/23 at 1506 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the resident's rehabilitation therapy services, medications, nursing services, and any treatment provided would be include in the resident's comprehensive care plan. RN 1 verified Resident 344's comprehensive plan of care did not address the use of Resident 344's CPAP machine. Cross reference to F695, example #3. 4. Review of the facility's P&P titled Catheter Care, Urinary revised 10/2010 showed under input and output, to observe thr resident's urine level for noticeable increases or decreases. If levels stay the same, or increase rapidly, report it to the physician or supervisor; and maintain accurate record of the resident's daily output. Medical record review for Resident 344 was initiated on 10/2/23. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's H&P examination dated 9/25/23, showed Resident 344 was alert and oriented x3 and was able to follow commands. Resident 344 had neurogenic bladder (a term for urinary conditions in people who lack bladder control due to brain, spinal cord or nerve problem) or urinary retention, which a new suprapubic catheter (a thin, flexible rubber or plastic tube use to drain urine from the urinary bladder when a person cannot void on their own) was in placed. Review of Resident 344's Order Summary Report for September 2023, showed the following physician's orders regarding Resident 344's suprapubic catheter: - dated 9/25/23, for suprapubic catheter due to urinary incontinence, - dated 9/25/23, to perform indwelling catheter care every shift, - dated 9/25/23, to change catheter drainage bag as needed if soiled or leaking, - dated 9/25/23, to follow up with the urologist due to new suprapubic catheter, and - dated 10/2/23, to cleanse suprapubic catheter site with NS, pat dry, apply split gauze, and tape into place daily shift and as needed for if soiled or dislodged. Review of Resident 344's Care Plan Problem titled Suprapubic Catheter due to Urinary Neurogenic Bladder with Urinary Retention revised 10/2/23, showed an intervention to monitor and record intake and output. Review of Resident 344's CNA Task, under Fluid Intake, for September and October 2023, showed the record of fluid intakes, for example: -on 9/25/23 at 0559 hours, 120 ml; at 1359 hours, 680 ml; and at 2146 hours, 120 ml. -on 9/26/23 at 0222 hours, 120 ml; at 1259 hours, 880 ml; and at 2108 hours, 580 ml. -on 10/3/23 at 0109 hours, 120 ml; at 1359 hours, 680 ml; and at 2158 hours, 480 ml. Review of Resident 344's CNA Task, under Fluid Output, for September and October 2023 showed the fluid output amount was recorded as No Data Found. Review of Resident 344's CNA Task, under Bladder Continence Output, for September and October 2023 showed checked marks for example: -on 9/25/23 at 0559 and 2146 hours, the continence not rated due to indwelling catheter had a check mark, and at 1359 hours, the continence not rated due to urinary ostomy had a check mark. -on 9/26/23 at 0222 hours, the continence not rated due to indwelling catheter had a check mark, and at 1359 and 2059 hours, the continence not rated due to urinary ostomy had a check mark. -on 10/3/23 at 0109 and 1359 hours, the continence not rated due to indwelling catheter had a check mark, and at 2159 hours, the continence not rated due to urinary ostomy had a check mark. On 10/4/23 at 0912 hours, an interview and medical record review was conducted with CNA 4. CNA 4 stated his responsibility regarding if a resident had a urinary drainage catheter was to empty the bag where the urine was collected. CNA 4 further stated he record the amount of urine collected in the resident's urinary bag electronically in the facility's POC (electronic based system where CNAs document performed tasks done for each resident) system under the resident's name and in the fluid output section. On 10/4/23 at 0920 hours, an interview was conducted with the Treatment Nurse. The Treatment Nurse stated the CNAs were responsible to record the resident's fluid output. However, the Treatment Nurse further stated if the resident had a physician's order to monitor for a fluid intake and output, she would record the resident's fluid intake and output. On 10/4/23 at 0944 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 344's Fluid Output section showed, No Data Found. The DON stated the CNAs did not have to record the exact amount of Resident 344's urine output collected in her urinary drainage bag. The DON stated if there was a check mark under the resident's Bladder Continence section in the CNA Task tab, it meant the resident was having an output. On 10/4/23 at 1014 hours, a follow-up interview was conducted with the DON. The DON was asked if Resident 344's urine out should be recorded. The DON stated normally, a person would have an output of 30 ml/hr and multiply to 24 hours and that would be the amount of urine that a person urinated. The DON further stated if a resident had a significant increase or decrease urine output, then she would be able to identify a concern. The DON was asked if she would be able to identify the accurate amount of Resident 344's urine output with the documented check marks under the CNA Task tab in the Bladder Continence section. The DON stated, I don't know. Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was developed and/or implemented for five of 23 final sampled residents (Residents 21, 29, 37, 344, and 543). * The facility failed to ensure the bilateral floor mats were implemented in accordance with Residents 21 and 37's care plan. * The facility failed to develop a comprehensive person-centered care plan to address the use of CPAP machine for Resident 29. * The facility failed to ensure to follow a plan of care intervention to monitor and document intake and output for Resident 344's use of suprapubic catheter. * The facility failed to initiate a care plan to address the use of duloxetine HCL (an antidepressant medication) and trazodone (an antidepressant medication and sleep aid) including specific behavioral manifestations to be monitored by staff for Resident 543 These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Care Plans-Comprehensive revised 10/2010 showed each resident's comprehensive care plan is designed to incorporate risk factors associated with identified problems; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. 1. Medical Record Review for Resident 21 was initiated on 10/2/23. Resident 21 was admitted to the facility on [DATE]. Review of Resident 21's Fall Risk Evaluation dated 9/3/23 at 1139 hours, showed Resident 21 was at high risk for falls. Review of Resident 21's care plan problem titled Actual Fall initiated 8/27/23, due to poor balance, poor communication/comprehension, and unsteady gait, showed an intervention for floor mats. On 10/3/23 at 1100 hours, an observation and concurrent interview was conducted on Resident 21. Resident 21 was observed lying in bed. Resident 21 stated she had fallen in the past at home and in the facility. Resident 21's bed was observed with two floor mats positioned underneath her bed. On 10/3/23 at 1135 hours, an observation and concurrent interview was conducted with PTA 1. Resident 21 was observed lying in bed. Resident 21's bed was observed with two floor mats positioned underneath her bed. PTA 1 verified the floor mats should be positioned adjacent to each side of Resident 21's bed rather than positioned underneath Resident 21' s bed. PTA 1 stated Resident 21 was at risk for falls due to generalized weakness. Cross reference to F656, example #2.

**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 to ensure one of 23 final sampled residents (Resident 543) attained and maintained highest practicable physical well being. * The facility failed to ensure Resident 543's blood pressure and pulse rate were assessed and documented as ordered. * The facility failed to address Resident 543's complaints of constipation, notify physician of the change in condition, provide bowel regimen for constipation, and follow the care plan for pain medication and constipation monitoring. These failures had the potential to adversely affect the physical health and create the risk of not providing appropriate and consistent care to the resident. Findings: a. Review of the facility's P&P titled Administering Medications revised 12/2012 showed medications shall be administered in a safe and timely manner and as prescribed. Medical record review for Resident 543 was initiated on 10/3/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23, for hydralazine HCL (medication to treat high blood pressure) oral tablet 25 mg one tablet by mouth two times a day for HTN, hold if SBP <110 mmHg or P <60 beats per minute. Review of Resident 543's MAR for September and October 2023 showed a physician's order dated 9/20/23, for hydralizine HCL oral tablet 25 mg one tablet by mouth two times a day for HTN, hold if SBP <110 mmHg or P <60 beats per minute. However, the MAR showed no documented Resident 543's blood pressure and pulse rate were monitored and recorded as follows: - no blood pressure monitoring at 0900 hours on 9/28 and 9/29/23; and at 1700 hours on 9/21 and 9/29/23. - no pulse rate monitoring at 0900 hours, on 9/21, 9/22, 9/25, 9/28, 9/29, and 10/1/23; and 1700 hours on 9/21 and 9/29/23. Further review of the MAR showed on 9/21/23 at 0900 hours, Resident 543's blood pressure was 108/62 mmHg; however, the medication was administered to Resident 543 when the blood pressure was below the parameter of SBP < 110 mmHg. On 10/3/23 at 1432 hours, an interview and concurrent record review was conducted with the DON. The DON acknowledged the findings and stated the blood pressure and pulse rate should have been recorded for Resident 543. b. On 10/2/23 at 1208 hours, an interview was conducted with Resident 543. Resident 543 stated her bowel movements had been hard to get out. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23, for Norco (controlled medication to treat pain) oral tablet 5-325 mg one tablet by mouth every six hours as needed for severe pain (a pain level 7-10). Review of Resident 543's MAR dated 9/1-9/30/23, showed Resident 543 received Norco on the following dates and times: - 9/21/23 at 0200 and 0930 hours - 9/22/23 at 0222 and 0945 hours - 9/23/23 at 1353 and 2033 hours - 9/24/23 at 1149 and 2046 hours - 9/25/23 at 0350, 1241, and 2124 hours - 9/26/23 at 0530, 1302, and 2127 hours - 9/27/23 at 0836 and 1715 hours - 9/28/23 at 0219, 1029, and 2111 hours - 9/29/23 at 0951 and 2355 hours - 9/30/23 at 0748, 1425, and 2147 hours Review of Resident 543's plan of care showed a care plan problem for acute/chronic pain dated 9/21/23. The care plan interventions showed to monitor/document for side effects of pain medication and to observe for constipation. Review of Resident 534's bowel movements documentation showed Resident 543 did not have a bowel movement from 9/25/23-9/30/23. On 10/05/23 at 1134 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 543 complained of constipation on 9/25/23. CNA 2 stated an LVN was notified and Resident 543 also reported to the LVN about constipation. On 10/05/23 at 1330 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated if a resident did not have a bowel movement for three or more days, the PCC would trigger and provide a notification. LVN 3 stated did not receive a notification. LVN 3 verified Resident 543 did not have documentation of bowel movements from 9/25/23-9/30/23; no physicians' orders for bowel management; and no interventions were given for Resident 543's complaints of constipation. LVN 3 further stated the nursing intervention would be to call the physician for a PRN order to address Resident 543's constipation. On 10/05/23 at 1604 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged Resident 543 did not have a bowel movement for five days. DON stated the standard of care was to notify the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of facility's P&P titled Change of Condition Reporting revised 5/2019, showed the licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two hours or until condition has stabled. Medical record review for Resident 10 was initiated on 10/2/23. Resident 10 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Anxiety Disorder, Immune Thrombocytopenic Purpura (blood disorder characterized by abnormal decrease in the number of platelets in the blood) and Hypertension (high blood pressure) among others. Review of Resident 10's History and Physical examination dated 8/19/23, showed Resident 10 had no capacity to make decisions. Review of Resident 10's MDS dated [DATE], showed Resident 10's BIMS (brief interview of mental status) was documented as never really understood, and Resident 10 needed extensive two person assist for mobility, transfer, and toileting. Review of Resident 10's fall risk assessment titled LN- Fall Risk Evaluation dated 8/17/23, showed Resident 10 was at high risk for falls. On 10/2/23 at 1009 hours, a concurrent observation and interview was conducted with Resident 10 and Resident 10's family member. Resident 10 was observed awake and lying on his bed. Resident 10's family member was at bedside. Resident 10's family member stated Resident 10 did not speak English. A floor mattress was observed on the floor at the right side of the bed. Resident 10's family member stated she was informed by the facility that Resident 10 was found kneeling on the floor, but she did not think he fell. Resident 10's family member was unable to remember when did the incident happened. Review of Resident 10's Change of Condition Note dated 9/14/23 at 2212 hours, showed Resident 10 fell on 9/14/23 at 2020 hours. Resident 10 fell from the bed (in lowest position) to floor mattress, had no injuries from fall and was stable. Resident 10's level of consciousness was within baseline. Resident 10's primary care physician and family member were notified. No new orders. Review of Resident 10's Progress Notes dated 9/14-9/17/23, failed to show documented evidence of continued monitoring to assess for negative impact from the fall incident. On 10/4/23 at 1401 hours, an interview with CNA 4 was conducted. CNA 4 stated a fall was considered a change of condition that he needed to report to the licensed nurse. On 10/5/23 at 1112 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated a resident's fall incident was considered as change of condition. LVN 2 stated if there was a fall incident, the COC was initiated by the licensed nurses, and every shift monitoring and assessment done by the licensed nurse for the COC for 72 hours. LVN 2 also stated for a fall incident, the nurses had to assess and document neuro check every shift for 72 hours. LVN 2 stated the DON had the neuro check form that they used. LVN 2 verified there were missing assessment or monitoring every shift for 72 hours. On 10/5/23 at 1604 hours, an interview with the DON was conducted. The DON stated the nurses had to assess and document neuro check and document assessment every shift for 72 hours for COC in progress note. The DON was made aware that there were missing nursing assessment for Resident 10's COC regarding fall. The DON acknowledged the above finding. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 23 final sampled residents (Residents 10, 21, and 37) remained free from accident hazards. *The facility failed to implement bilateral floor mats as per the physician's order and as care planned for Resident 37. *The facility failed to ensure the bilateral floor mats were implemented as per the care plan for Resident 21. *The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 10. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Review of the facility's P&P titled Falls and Fall Risk, Managing revised 12/2007, showed staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling, and to try to minimize complications from falling. Medical record review for Resident 37 was initiated on 10/2/23. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's MDS dated [DATE], showed Resident 37 had severely impaired cognition (a person has trouble remembering, learning new things, concentrating or making decisions that affect everyday life), total dependence on functional status (individual's ability to perform normal daily activities required to meet basic needs) and on a feeding tube. Review of Resident 37's fall risk assessment titled LN- Fall Risk Evaluation dated 6/27/23, showed Resident 37 was at high risk for falls. Review of Resident 37's plan of care showed a care plan problem, initiated on 7/4/23 addressing Resident 37's risk for falls related to confusion, gait/balance problems, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The interventions included to implement floor mats for Resident 37. Review of Resident 37's Order Summary Report showed a physician's order dated 7/21/23, for bilateral floor mats. On 10/3/23 at 0920 hours, a concurrent observation was conducted with CNA 1. Resident 37 was observed lying in bed with no bilateral floor mats at bedside. CNA 1 verified these findings. On 10/3/23 at 1220 hours, an interview and concurrent observation and medical record review for Resident 37 was conducted with LVN 3. LVN 3 stated Resident 37 had a stroke with right sided weakness. LVN 3 verified the facility did not implement bilateral floor mats as per the physician's order and Resident 37's plan of care. Cross reference to F656 example 2. 2. Medical Record Review for Resident 21 was initiated on 10/2/23. Resident 21 was admitted to the facility on [DATE]. Review of Resident 21's Change of Condition Note dated 9/3/23 1131 hours, showed during a therapy session, Resident 21 attempted to stand up and she fell back, having sustained an assisted fall. Review of Resident 21's Fall Risk Evaluation dated 9/3/23 1139 hours, showed Resident 21 was at high risk for falls. Review of Resident 21's care plan problem titled Actual Fall dated 8/27/23, due to poor balance, poor communication/comprehension, and unsteady gait, showed an intervention for floor mats initiated on 8/27/23. On 10/3/23 at 1100 hours, an observation and concurrent interview was conducted on Resident 21. Resident 21 was observed lying in bed. Resident 21 stated she had fallen in the past at home and in the facility. Resident 21's bed was observed with two floor mats positioned underneath her bed. On 10/3/23 at 1135 hours, an observation and concurrent interview was conducted with PTA 1. Resident 21 was observed lying in bed. Resident 21's bed was observed with two floor mats positioned underneath her bed. PTA 1 verified the floor mats should be positioned adjacent to each side of Resident 21's bed rather than positioned underneath Resident 21' s bed. PTA 1 stated Resident 21 was at risk for falls due to generalized weakness. Cross reference to F656, example #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the purpose of this procedure is to provide guidelines for safe oxygen administration and verify that there is a physician's order for this procedure. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23, to administer continuous oxygen at 2 L/min via nasal cannula/mask to keep oxygen saturation above 90% every shift. On 10/3/23 at 1114 hours, Resident 543 was observed on oxygen via nasal cannula. Upon checking oxygen concentrator, Resident 543 received oxygen at 1.5 L/min. On 10/3/23 at 1120 hours, an interview and concurrent observation was conducted with the OTA. The OTA stated Resident 543 was on 2 L/min. However, when the OTA was asked to verify the readings on the oxygen concentrator, the OTA verified Resident 543 was receiving 1.5 L/min. On 10/3/23 at 1121 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 543 was receiving 1.5 L/min. LVN 3 verified the physician's orders showed to administer continuous oxygen at 2 L/min 6. Review of the facility's P&P titled Disposition of Respiratory Equipment Disposables revised 8/2019 showed supplies will be clearly dated when initially set up or changed. On 10/2/23 at 1023 hours, during the initial tour of the facility, Resident 10's nebulizer mask was observed on top of his bedside drawer. Resident 10's daughter was at bedside stated Resident 10 received breathing treatments few times each day. The nebulizer mask was inside a plastic bag with no name, label, and the tubing was dated 8/23/23. Medical record review for Resident 10 was initiated on 10/2/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's MAR dated 9/1-9/30/23, showed the following: - a physician's order dated 8/16/23, for Albuterol Sulfate (medication to help with breathing) Nebulization Solution (2.5 mg/3 ml) 0.083% 3 ml inhale orally via nebulizer every 4 hours for shortness of breath administer 1 vial via face mask nebulizer every 4 hours around the clock; - a physician's order dated 8/28/23, for budesonide inhalation suspension (medication to help with breathing) 0.5 mg/2 ml one vial inhale orally two times a day for COPD, administer one vial via face nebulizer for COPD; and - a physician's order dated 8/28/23, for Brovana (medication to help with breathing) Inhalation Nebulization Solution 15 mcg/2 ml 1 vial inhale orally via nebulizer two times a day for COPD administer 1 vial via face mask nebulizer every 12 hours around the clock. On 10/2/23 at 1030 hours, an interview was conducted with LVN 2. LVN 2 stated that the facility's process was to change the mask and tubing every week on Sunday night by a nurse. LVN 2 stated it should be labeled with the resident's name and date. LVN 2 verified Resident 10's nebulizer mask and tubing were last changed on 8/23/23. LVN 2 stated if the mask and tubing were not changed, the resident might develop infection and could lead to hospitalization. On 10/5/23 at 1354 hours, an interview was conducted with the IP. The IP verified the respiratory care items, including the nebulizer mask and tubing should be changed every Sunday night by a licensed nurse to prevent infection. The IP stated the nebulizer mask and tubing should be stored in a plastic bag with the resident's name and date when it was last changed. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for five of 23 final sampled residents (Residents 10, 24, 29, 344, and 543) and one nonsampled resident (Resident 43). * The facility failed to administer oxygen therapy treatment as ordered by the physician for Resident 344. * The facility failed to ensure Resident 43's nebulizer mask was stored properly. * The facility failed to ensure Resident 29's CPAP mask was stored properly. * Resident 24 received continuous oxygen at 3 L/min via nasal cannula without a physician's order. * The facility to administer oxygen therapy as ordered by the physician for Resident 543. * The facility failed to ensure that nebulizer mask and tubing were changed and labeled as per the facility's policy for Resident 10. These failures had the potential risk for residents' respiratory equipment to become contaminated and negatively affect the residents' medical condition. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify that there is a physician's order for the procedure and to review the physician's order or facility protocol for oxygen administration. Review of the facility's P&P titled Disposition of Respiratory Equipment Disposables revised 8/2019 showed each facility will stock disposable supplies adequate to provide safe respiratory care to respiratory patients. Supplies will be clearly dated when initially set up or changed. 1. On 10/2/23 at 1037 hours, Resident 344 was observed not wearing her oxygen nasal cannula attached to an oxygen machine that was off. Medical record review for Resident 344 was initiated on 10/2/23. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's H&P examination dated 9/25/23, showed Resident 344 was alert and oriented x3 and was able to follow commands. Review of Resident 344's Order Summary Report for September 2023 showed a physician's order dated 9/25/23, to administer continuous oxygen at 2L/min via nasal cannula to keep oxygen saturation level above 90%. On 10/2/23 at 1044 hours, an observation, interview, and concurrent medical record review was conducted with the DON. The DON verified the above finding. The DON stated the oxygen machine should be on and the oxygen nasal cannula should be worn in Resident 344's nose. 2. During the initial tour of the facility on 10/2/23, Resident 43's nebulizer mask was observed on top of her bedside drawer. Resident 43 stated she received treatment a few times each day. Medical record review for Resident 43 was initiated on 10/2/23. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Order Summary Report for September 2023 showed a physician's order dated 9/30/23, to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml 3 ml inhale orally every four hours as needed for SOB or wheezing via nebulizer. Review of Resident 43's MAR for September 2023 showed Resident 43 received the Ipratropium-Albuterol Solution treatment via nebulizer on 9/1/23 at 1355 hours. On 10/2/23 at 0937 hours, an observation and concurrent interview was conducted with the IP. The IP verified the above finding. The IP stated the nebulizer mask should be stored in a labeled and dated plastic bag when not in use to prevent infection. 3. During the initial tour of the facility on 10/2/23 at 0828 hours, Resident 29's CPAP mask was observed on top of his bedside drawer. Resident 29 stated he used his CPAP during the night while sleeping. Medical record review for Resident 29 was initiated on 10/2/23. Resident 29 was admitted to the facility on [DATE]. Review of Resident 29's H&P examination dated 8/14/23, showed Resident 29 had the capacity to understand and make decisions. Review of Resident 29's MAR for October 2023 showed a physician's order dated 10/3/23, to apply CPAP at setting of 15 cmH2O every night. On 10/2/23 at 0934 hours, an observation and concurrent interview was conducted with the IP. The IP verified the above finding. The IP stated the CPAP mask should be stored in a labeled and dated plastic bag when not in use. Cross reference to F656, example #3. 4. Medical record review was initiated on 10/2/23. Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 24's H&P examination dated 6/30/23, showed Resident 24 did not have the capacity to understand and make decisions. Review of Resident 24's Order Summary Report dated 10/3/23, did not show a physician's order to administer oxygen at 3 L/min via nasal cannula continuously. Review of Resident 24's plan of care showed a care plan focus dated 7/25/23, addressing altered respiratory status/difficulty breathing. The interventions/tasks included to provide oxygen as ordered. During the initial tour of the facility on 10/2/23 at 0934 hours, Resident 24 was observed with oxygen at 3 L/min via nasal cannula. On 10/2/23 at 1317 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 reviewed the physician's orders which did not show an order for oxygen administration. LVN 4 verified the findings. On 10/2/23 at 1321 hours, a concurrent interview and medical record review was conducted with the DON. The DON reviewed and verified the physician's orders did not show an order for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the availability of the prescribed supplements for one nonsampled resident (Resident A). * Resident A had a physician's order for garlic supplement and glucosamine supplement. The licensed nurse was unable to administer the garlic and glucosamine supplements as ordered due to the unavailability of the supplements. This failure posed the risk for inhibiting the therapeutic effects of the supplements and had the potential to negatively affect the resident's health. Findings: Medical record review for Resident A was initiated on 10/2/23. Resident A was admitted to the facility on [DATE]. Review of Resident A's Order Summary Report showed a physician's order dated 9/26/23, to administer garlic tablet 1 mg orally once a day for supplement. Review of Resident A's Order Summary Report showed a physician's order dated 9/26/23, to administer a glucosamine capsule 500 mg orally twice a day for supplement. On 10/5/23 at 0809 hours, a medication administration observation for Resident A was conducted with LVN 3. LVN 3 prepared and administered Resident A's medications and supplements. LVN 3 verified Resident A had a physician's order dated 9/26/23, to administer garlic tablet 1 mg orally once a day for supplement (at 0900 hours), and a physician's order dated 9/26/23, to administer a glucosamine capsule 500 mg orally twice a day (at 0900 hours and 1700 hours) for supplement. LVN 3 stated she was unable to administer Resident A's garlic tablet 1 mg and glucosamine capsule 500 mg due to the unavailability of the supplements. Review of Resident A's MAR dated 10/2023 showed documentation Resident A had not received his garlic 1 mg tablet orally on 10/3, 10/4, or 10/5/23 at 0900 hours, as ordered by the physician. On 10/5/23 at 1425 hours, a follow-up interview was conducted with LVN 3. LVN 3 was asked if the facility had obtained Resident A's garlic 1 mg tablet and glucosamine 500 mg capsule (which was ordered to be administered at 0900 hours this morning). LVN 3 stated Resident A had not yet received his ordered garlic 1 mg tablet and glucosamine 500 mg capsule as the pharmacy had not delivered Resident A's garlic and glucosamine supplements.

**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 ensure the Pharmacy Consultant's recommendations from drug regimen review in August 2023 were acted upon for one of 23 final sampled residents (Resident 9). This failure placed the resident at risk for receiving unnecessary medications, increasing their risk for side effects. Findings: Review of the facility's P&P titled Medication Therapy revised date 4/2007 showed the Consultant Pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. The Physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: when a medication is being given in excessive doses, for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rationale; when the results of ongoing assessment, or the presence of clinically significant adverse consequences monitoring, suggest that a medication should be reduced or discontinued entirely; and when a medication is being prescribed to treat, or in anticipation of, an adverse consequence of another prescribed drug. Medical record review for Resident 9 was initiated on 10/2/23. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's H&P examination dated 12/24/22, showed Resident 9 had the capacity to understand and make decisions. Review of Resident 9's Order Summary Report dated 10/3/23, showed a physician's order dated 8/24/23, for fluoxetine HCL (antidepressant) capsule 20 mg one capsule by mouth one time a day for verbalization of feeling depressed; and a physician's order dated 12/20/22, for amitriptyline HCL (antidepressant and nerve pain medication) tablet 50 mg one tablet by mouth at bedtime for neuropathy (weakness, numbness, and pain from nerve damage). Review of the Note to Attending Physician/Prescriber dated 8/6/23, showed a recommendation from the Pharmacy Consultant to consider reevaluating the continued use or a dose reduction of fluoxetine and amitriptyline. Review of the Behavior Management Follow-up dated 9/25/23, did not show documentation regarding the fluoxetine and amitriptyline medications, identified/target behaviors, and progress/updates/side effects. On 10/5/23 at 1454 hours, an interview and concurrent medical record review was conducted with the SSD and DON. The SSD stated she met with the Psychiatrist and DON once a month, and the Psychiatrist reviewed the medications and assessed the need for a dosage increase and/or decrease. When asked the DON about medication regimen review (MRR) process, she stated the Pharmacist came every month and reviewed the medications, and the pharmacy recommendations were sent via email and completed as soon as possible. When asked the DON about gradual dose reduction (GDR) process, she stated the facility met with the Psychiatric Nurse Practitioner every month to discuss medications, how often undesirable expression of distress occurred, review monthly summary, or tally of behaviors; and assessed if gradual dose reduction was appropriate. The DON verified the above findings and stated the GDR for fluoxetine and amitriptyline were not attempted and the above medications should have been included in the Behavior Management Follow-up form. The DON stated the pharmacy recommendation should have been followed up with the physician and she did not know why the above medications were not included in the Behavior Management Follow-up form.

**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 ensure two of 23 final sampled residents (Residents 10 and 543) were free from the unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure Resident 543's episodes of behaviors for the use of duloxetine (medication used to treat depression) and Trazadone (medication used to treat depression and aid with sleep) were consistent with the physician's orders. * The facility failed to provide the non-pharmacological interventions to Resident 10's anxiety to minimize the Xanax and lorazepam use; failed to provide the physician's documentation to extend Resident 10's Xanax and lorazepam medications (psychotropic medications) after 14 days of PRN use; and failed to ensure Resident 10's episodes of behavior for the use of Xanax (antianxiety medication) were accurately monitored and documented in the MAR. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Review of the facility's P&P titled Psychoactive Drug Management dated 12/98, showed it is the policy of this this facility that each resident's drug regimen is free from unnecessary drugs. Unnecessary drugs are drugs used in excessive dose, for excessive duration, without adequate monitoring, without adequate indication for use and/or in the presence of adverse consequences which indicate the dose should be reduced or the drug discontinued. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to facility on 9/20/23. Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23 to monitor episodes of anxiety AEB verbalization of feeling nervous (specify medication). * However, the order did not specify the name of medication for Resident 543. In addition, the Order Summary Report did not show Resident 543 had an order for medications to treat anxiety. Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23, to monitor episodes of depression AEB inability to sleep (trazodone). * However, the Order Summary Report failed to show the number of hours of sleep for Resident 543 was being monitored. Review of Resident 543's plan of care showed a care plan problem initiated on 9/21/23, for antidepressant medication. Interventions included to monitor/document/report to MD PRN for ongoing sign and symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and constant reassurance. Further review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/29/23, for duloxetine HCL oral capsule Delayed Release Particles 30 mg one capsule by mouth in the morning for depression m/b verbalization of feeling sad; and a physician's order dated 9/29/23, for trazodone HCL oral tablet 50 mg one tablet by mouth as needed for depression m/b inability to sleep Q HS for 14 days. Review of Resident 543's MAR for September and October 2023 showed the monitored behaviors were anxiety m/b verbalization of feeling nervous; and depression m/b inability to sleep. * However, the MAR did not show Resident 543 was monitored for hours of sleep. Review of Resident 543's Behavior Management Follow-Up dated 9/25/25, showed trazodone 50 mg one tablet PRN for depression m/b inability to sleep Q HS and duloxetine 30 mg one tablet PO Q AM for depression m/b verbalization of depressed mood. On 10/3/23 at 1432 hours, an interview and concurrent medical record review for Resident 543 was conducted with the SSD and the DON. The DON stated she was in charge of the drug regimen review for the residents. The DON acknowledged behavior monitoring for trazadone did not show monitoring hours of sleep to determine if Resident 543 was having difficulty sleeping. The DON acknowledged the sleep hours should be tallied and recorded into the resident's record. In addition, the DON verified there was no monitoring of depression m/b verbalization of feeling sad for the use of duloxetine as ordered by the physician for Resident 54. 2. Medical record review for Resident 10 was initiated on 10/3/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Telephone Order Sheets showed the following orders: -A physician's order dated 9/14/22, to administer Xanax (medication to treat anxiety) oral tablet 0.5 mg (Alprazolam) one tablet by mouth every 8 hours PRN for anxiety for 14 days manifested by verbalizations of feeling anxious; -A physician's order dated 9/14/22, to administer lorazepam (medication to treat anxiety) Intensol Oral Concentrate 2 mg/ml 0.25 ml by mouth every 6 hours PRN for anxiety and agitation manifested by restlessness for 14 days. a. Review of Resident 10's MAR for September 2023 showed a physician's order dated 8/17/23, for non-pharmacologic interventions- (AA)-Intervention Codes: 1=one on one; 2= activity; 3= adjust room temperature; 4= back rub; 5= change position; 6= give fluids; 7= give food; 8= re-direct; 9= refer to nurses notes; 10= remove resident from environment; 11= return to room; 12= toilet; and 13= other as needed related to anxiety. Review of Resident 10's MAR for September 2023 showed lorazepam medication was given on the following dates and times:: - 9/15/23 at 0455 hours - 9/16/23 at 0345 hours - 9/20/23 at 0010 and 0610 hours - 9/26/23 at 0414 hours However, Resident 10's MAR failed to show documentation non-pharmacological interventions were provided to Resident 10 prior to the administration of lorazepam medication. On 10/5/23 at 1112 hours, an interview and concurrent medical record review was conducted with LVN 2. When asked if the non-pharmacological interventions were provided to Resident 10 for anxiety and prior to the administration of lorazepam, LVN 2 stated there were no documentation of non-pharmacological interventions provided for Resident 10's anxiety. b. Review of Resident 10's Telephone Order Sheet dated 9/29/23, showed a physician's order for Xanax 0.5 mg one tablet PO PRN Q 8 hours for anxiety m/b verbalizations of feeling anxious; and continue lorazepam 0.25 ml (0.5 mg) PO/SL PRN Q 6 hours for anxiety/SOB. The physician's order for Xanax and lorazepam failed to include a stop date of 14 days. Review of Resident 10's medical record failed to show the physician's documentation to extend the PRN Xanax and lorazepam use beyond 14 days. The facility was unable to provide the physician's documentation. On 10/5/23 at 1450 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated there should be a physician's documentation to extend any psychotropic medication after 14 days of PRN use. LVN 1 verified the Xanax and lorazepam medications were reordered on 9/29/23, but there was no physician's documentation to extend Resident 10's Xanax and Lorazepam after 14 days of PRN use. c. Review of Resident 10's Telephone Order Sheet dated 9/29/23, showed a physician's order for Xanax 0.5 mg one tablet PO PRN Q 8 hours for anxiety m/b verbalizations of feeling anxious; and continue lorazepam 0.25 ml (0.5 mg) PO/SL PRN Q 6 hours for anxiety/SOB. Review of Resident 10's MAR for September and October 2023 showed the behavior monitored for anxiety was episodes of restlessness. On 10/5/23 at 1540 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 stated Resident 10's episodes of behavior for the use of Xanax should have been accurately documented in the MAR. LVN 5 verified there was no documented evidence of monitoring for verbalization of feeling anxious as ordered for the use of Xanax.

**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 medication error rate was below 5%. The facility's medication error rate was 7.41%. Two of two licensed nurses (LVNs 2 and 4) were found to have made errors during the medication administration observations. * Resident 10 had a physician's order to apply 2 grams of 1% Voltaren (pain relief gel); however, the LVN failed to utilize the dosing card to determine the dose of Voltaren administered to Resident 10. * Resident A had a physician's order for Pulmicort inhalation (corticosteroid medication) for hypoxia which was scheduled to be administered at 0900 hours; however, the LVN did not administer Resident A's Pulmicort until approximately 5 hours after the mediation was ordered to be administered. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medications must be administered in accordance with the orders, including any required time frames. The medications must be administered within one hour of their prescribed time, unless otherwise specified. 1. On 10/4/23 at 0816 hours, a medication administration observation for Resident 10 was conducted with LVN 2. LVN 2 prepared and administered Resident 10's medications which included 1% Voltaren external topical gel 2 grams for pain. LVN 2 was observed squeezing the 1% Voltaren gel from a medicine tube into a plastic medicine cup (without having utilized the dosing card). LVN 2 then administered the 1% Voltaren topical gel to Resident 10. Medical record review for Resident 10 was initiated on 10/2/23. Resident 10 was admitted to the facility on [DATE]. Review of the physician's order dated 9/28/23, showed to apply 2 grams of 1% Voltaren external gel topically to bilateral knees two times a day for pain. At the conclusion of the medication administration observation for Resident 10, LVN 2 was asked how she determined she administered the ordered dose (2 grams) of 1% Voltaren topical gel to Resident 10. LVN 2 stated the 1% Voltaren topical gel came with a dosing card used to ensure accurate dosing of the medication. LVN 2 stated she should have utilized the dosing card, which showed 2.25 inches of 1% Voltaren topical gel, when applied to the dosing card, equated to 2 grams of the medication. 2. On 10/5/23 at 0809 hours, a medication administration observation for Resident A was conducted with LVN 3. LVN 3 prepared and administered Resident A's medications. On 10/5/23 at 1010 hours, after having administered Resident A's scheduled medications, a medical record review was conducted with LVN 3. Review of Resident A's physician's order dated 9/26/23, showed an order for Pulmicort inhalation suspension 0.5 mg/2 ml one vial two times a day (at 0900 hours and 1700 hours) for hypoxia. LVN 3 verified she failed to administer Resident A's Pulmicort inhalation suspension 0.5 mg/2 ml as ordered by the physician. On 10/5/23 at 1425 hours, an interview was conducted with LVN 3. LVN 3 was asked if Resident A had received his morning dose (0900 hours) of Pulmicort suspension 0.5 mg/2 ml one vial inhalation. LVN 3 stated she had not administered Resident A's Pulmicort 0.5 mg/2 ml one vial via inhalation (scheduled for 0900 hours). LVN 3 then went to Resident A's room and administered Resident A's Pulmicort suspension 0.5 mg/2 ml one vial via inhalation at 1420 hours (which was scheduled to be administered at 0900 hours).

Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly two of four medication carts and failed to store resident biologicals and treatment supplies in a safe manner for one of one treatment cart. *The facility failed to ensure two medication carts (Medication Carts A & B) were kept locked when unattended by staff. * The facility failed to ensure medications were not left unattended on top of Medication Cart B. * The facility's treatment cart was observed with several unpackaged gauze pads lying on top of a pair of scissors and Calmoseptine ointment stored inside of a plastic cup. These failures posed the risk of unauthorized persons having access to the medications and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Storage of Medications revised 4/2007 showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the facility's P&P titled Administering Medication, revised 12/2012 showed medications shall be administered in a safe and timely manner, and as prescribed. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward all other sides closed. No medications are kept on top of the cart. The care must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Review of the facility's P&P titled Security of Medication Cart revised 4/07 showed medication carts must be securely locked at all times when out of the nurse's view. 1. On 10/3/23 at 1117 hours, LVN 3 was observed leaving Medication Cart B unattended and out of sight, parked across Resident 543's room facing the hallway. Plastic cups contained medications were observed on top of the cart. LVN 3 came out of Resident 543's room after a couple of minutes. LVN 3 verified Medication Cart B had medications left on top of the cart and the medications belonged to Resident 443. LVN 3 stated the medication cups contained medications including: Vancomycin (antibiotic), Losartan (medication to treat high blood pressure), Lasix (medication to treat fluid retention), Metformin (medication to treat high blood sugar), Potassium Chloride (medication to treat and prevent low potassium), Probiotic (medication to maintain good bacteria in the body), Docusate Sodium (stool softener), doxazosin (medication to treat high blood pressure and urinary retention), and cephalexin (antibiotic). LVN 3 verified the findings and stated she should not have left the medications unattended. 2. On 10/4/23 at 0930 hours, Medication Cart A was observed parked in the hallway in front of Room A. Medication Cart A was facing the hallway, unlocked, and unattended. On 10/4/23 at 0956 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Medication Cart A was unlocked and unattended . LVN 2 stated she forgot to lock Medication Cart A when she moved to another cart. LVN 2 further stated the medication cart should be locked at all times when not attended. 3. On 10/5/23 at 0844 hours, and inspection of the facility's treatment cart was conducted with the treatment nurse. The top drawer of the treatment cart was observed with several unpackaged gauze pads lying on top of a pair of scissors. Additionally, a plastic cup was observed with an ointment inside of the plastic cup, and located within the plastic cup was the end of an application stick. The top drawer of the treatment cart also contained vinyl exam gloves, tape, and plastic bags. The Treatment Nurse verified the findings. The Treatment Nurse stated the ointment in the plastic cup was Calmoseptine ointment (skin barrier ointment). The Treatment Nurse stated she prepared the Calmoseptine ointment yesterday and planned to apply the ointment to a resident; however, the resident was unavailable. The Treatment Nurse stated she should have thrown the Calmoseptine ointment (inside of the plastic cup) and the unpackaged gauze into the trash. The Treatment Nurse stated storing clean gauze unpackaged and Calmoseptine ointment in a plastic cup (within the residents' treatment cart) was not in accordance with the facility's infection control practices. The Treatment Nurse stated clean gauze was to be stored in a clean package and Calmoseptine ointment not in use was to remain in the original package (tube).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Diagnostic Test Results Notification revised 1/2022 showed results of laboratory, radiology, and diagnostic tests outside the clinical references ranges shall be reported to the resident's attending physician, PA, and NP. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 543's laboratory report dated 9/22/23, showed the following results outside of the clinical reference range: For CBC with differential test result: - Red blood cells 2.87 (L) (reference range: 4.80-11.00 K/uL) - Hemoglobin 9.2 (L) (reference range: 12.0-16.0 g/dL) - Hematocrit 29.2 (L) (reference range: 36.0-48.0 %) - MCV: 101.7 (H) (reference range: 80.0-100.0 fL) - MCH: 32.1 (H) (reference range: 37.0-31.0 pg) - MCHC: 31.5 (L) (reference range: 32.0-37.0 g/dL) - % Neutrophils 81.1 (H) (reference range: 36.0-75.0 %) - Absolute Lymphocytes 0.81 (L) (reference range: 1.50-4.00 K/uL) For BMP test result: - Sodium (Na) 134 (L) (reference range: 135-145 mmo/L) - Chloride (Cl) 96 (L) (reference range: 100-110 mmo/L) - Carbon Dioxide (CO2) 33 (H) (reference range: 24-32 mmo/L) - BUN (Blood Urea Nitrogen) 24 (H) (reference range: 7-17 mg/dL) Review of the laboratory results showed a handwritten note the NP was notified. However, there was no documentation of the name of reporting staff, the time when the NP was notified, or if there were any new orders for the abnormal lab results. On 10/03/23 at 1432 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no documentation in the Resident 543's medical record or progress notes showing the NP was notified, any new orders, or if any interventions were implemented. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the physician was notified regarding laboratory services were not performed as ordered and abnormal laboratory test results were reported for two of 23 final sampled residents (Residents 344 and 543). * The facility failed to ensure the physician was notified of laboratory test not performed as ordered for Resident 344. * The facility failed to ensure the physician was notified of the abnormal lab results and documented in Resident 543's medical record. These failures had the potential to adversely affect the residents' physical health. Findings: Review of the facility's P&P titled Diagnostic Test Results Notification revised 1/2022 showed it is the policy of the facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant, or Nurse Practitioner. Laboratory and radiology services will be arranged as ordered. Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges shall be reported to the resident's attending Physician, Physician Assistant or Nurse Practitioner. 1. Medical record review for Resident 344 was initiated on 10/2/23. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's H&P examination dated 9/25/23, showed Resident 344 was alert and oriented times three (oriented to time, place, and person) and able to follow commands. Review of Resident 344's Order Summary Report for September 2023 showed a physician's order dated 9/25/23, for Resident 344 to have laboratory testing completed for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), and UA with C and S (Urinalysis with Culture and Sensitivity) for 9/26/23. Review of Resident 344's MAR for September 2023 showed a physician's order dated 9/25/23, for Resident 344 to have laboratory testing completed for CBC, Comprehensive Metabolic Panel, and Urinalysis with Culture and Sensitivity for 9/26/23. Review of Resident 344's Skilled Nursing Facility Laboratory Test Request draw date 9/26/23, showed CBC with differential, CMP, Urinalysis, and Urinalysis with reflex to microscopic and culture if indicated were checked. Further review of the clinical record showed no documented evidence of the above laboratory testing results. Review of Resident 344's Nurses Progress Notes for September 2023 showed no documented evidence the laboratory testing were not drawn on 9/26/23, or the physician was notified of the laboratory testing not performed as ordered for Resident 344. On 10/4/23 at 1005 hours, an interview, concurrent medical record review, and facility document review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 verified there was no laboratory test results in Resident 344's electronic and paper medical record. LVN 1 verified there was no documentation to show laboratory test results were received or reported to the physician. LVN 1 showed the Skilled Nursing Facility Laboratory Request form that Resident 344 laboratory test samples were drawn. LVN 1 stated he would call the laboratory to request for the results of the laboratory test performed on 9/26/23. On 10/4/23 at 1014 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON verified there was no documented evidence to show Resident 344's laboratory results were received and reported to the physician in the electronic or paper medical record. The DON stated the laboratory result form might be in the overflow in the Medical Records room. The DON was asked if the laboratory results should be readily available in the resident's medical record and she stated, yes. On 10/4/23 at 1041 hours, the DON stated she could not find the laboratory test results for Resident 344. The DON stated LVN 1 called the laboratory and found out the laboratory testing for Resident 344 were not drawn on 9/26/23, due to Resident 344 was not available at the time when the samples should be collected. The DON stated the nurses should have a documentation showing Resident 344 was not available for the blood draw or urine sample collection. The DON further stated the physician reordered the laboratory testing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 23 final sampled residents (Resident 343) was provided a prescribed therapeutic diet. This failure posed the risk of Resident 343's nutrition needs not being met. Findings: Review of the facility's P&P titled Nutrition Care: Diet Orders for New Admission, Diet Changes, Nothing by Mouth (NPO), or Hold Meals (undated) showed all residents/patients will have a written diet order on admission which has been prescribed by the physician. Verbal telephone orders may be received and recorded by a registered dietitian and will be signed by the prescriber. On 10/2/23 at 1229 hours, during the dining observation, Resident 343 stated she had a thyroid surgery in the past. Resident 343 stated she did not eat most of her protein in her plate because it was harder for her to swallow, or the food got stuck in her throat. Resident 343's meal card ticket showed a regular soft diet and bite-sized texture with thin liquids. Medical record review for Resident 343 was initiated on 10/2/23. Resident 343 was admitted to the facility on [DATE]. Review of Resident 343's H&P examination dated 9/28/23, showed Resident 343 had the capacity to understand and make decisions. Review of Resident 343's Order Summary Report for September and October 2023 did not show a physician's order for Resident 343's diet. Review of Resident 343's MAR for September and October 2023 did not show a physician's order for Resident 343's diet. Review of Resident 343's Nursing Progress Notes for September 2023 did not show an admission note or documented evidence Resident 343 had a therapeutic diet order that was verified by the physician. Review of Resident 343's Speech Therapy Evaluation and Plan of Treatment dated 9/27/23, showed Resident 343 had history of thyroidectomy (a surgical removal of all or part of the thyroid gland). Resident 343 reported diet texture for approximately four to five years now after the surgery. Resident 343 was on a regular diet, soft, and bite size texture, thin liquids consistency, and aspiration precautions. Review of Resident 343's diet slip dated 9/27/23, showed a regular diet, mechanical soft texture, and thin liquids. On 10/2/23 at 1230 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified there was no physician's diet order in the resident's electronic or paper medical record. LVN 5 showed a yellow diet slip of Resident 343 which showed a regular diet, mechanical soft texture, and thin liquids in Resident 343's paper medical record. On 10/2/23 at 1236 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON stated there should be a physician's diet order in place for the residents. On 10/2/23 at 1250 hours, an interview was conducted with ST 1. ST 1 stated Resident 343 had an order for ST evaluation to determine, assess, and perform swallowing trials for the appropriate and least restrictive diet for the resident. ST 1 stated Resident 343's diet was her baseline due to Resident 343's history of thyroidectomy. ST 1 stated she determined the resident's diet by looking into resident's electronic medical record or in the green admission binder. On 10/2/23 at 1301 hours, an interview and medical record review was conducted with LVN 1. LVN 1 verified there was no admission report document for Resident 343 in the green admission binder. On 10/2/23 at 1501 hours, a follow-up interview and concurrent medical record review was conducted with the DON. The DON showed the ST's Evaluation and Plan of Treatment documentation dated 9/27/23, and stated Resident 343's diet was listed in the document and the physician signed the document. However, the DON also verified the diet order should still be in a written physician's order. The DON also verified there was no admission note or any documented evidence in the nursing progress note to show Resident 343's diet order was verified by the physician. On 10/3/23 at 0846 hours, an interview was conducted with the RD. The RD stated she got the resident's physician's diet order electronically or by the diet slip turned in the kitchen by the licensed nurses upon admission. The RD further stated she did not verify the residents' diet orders with the physician, and the licensed nurse was to verify the residents' diet orders with the physician.

**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 rehabilitation services for one of 23 final sampled residents (Resident 345). * The facility failed to ensure Resident 345 was provided RNA services for AROM exercises to bilateral upper and lower extremities as per the physician's orders. This failure had the potential for Resident 345 to decline in the ROM functions and mobility. Findings: Review of the facility's P&P titled Quality of Care: RNA, Restorative Nursing, and Documentation revised 2/2022 showed it is the policy of the facility that Restorative Nursing shall be provided to a resident upon recommendation by the rehabilitation department to meet the resident restorative nursing care need. Physician's orders are to be obtained when a resident is to participate in the facility's restorative nursing program for ambulation or range of motion (ROM). The staff providing the program shall document that the RNA program is provided by documenting on the Restorative Record of Care under RNA or PCC-POC point click care record, or nursing assistant's notes. When a treatment is refused or withheld, the reason shall be documented and that the charge nurse was notified. Weekly progress notes are to be written by the staff providing the program. The content is to include the following: therapy program provided, equipment or apparatus used, and resident's response and comparison from the previous weeks. During the initial tour of the facility on 10/2/23 at 0824 hours, an interview was conducted with Resident 345. Resident 345 had not started rehabilitation therapy, wished to do rehabilitation therapy exercises and had been in the facility for two weeks. On 10/3/23 at 1029 hours, and 10/5/23 at 0743 hours, a concurrent observation and interview with Resident 345 was conducted. Resident 345 was observed in bed with head of the bed elevated watching television. Resident 345 stated there were no staff assisting her to perform the exercises. Resident 345 was asked if she refused any services offered to her such as restorative nursing services for exercises of her range of motion, and Resident 345 stated she had not refused any offered exercises. Resident 345 stated she moved her extremities on her own. Resident 345 further stated she had not seen the DOR since she had been admitted to the facility. Medical record review for Resident 345 was initiated on 10/2/23. Resident 345 was admitted to the facility on [DATE]. Review of Resident 345's H&P examination dated 9/18/23, showed Resident 345 was oriented to place, person, time, and followed commands. Review of Resident 345's MDS dated [DATE], showed the following: - Section C, Resident 345 was cognitively intact. - Section G, Resident 345 required extensive assistance from two staff for bed mobility, and had one impairment to her lower extremities. - Section O, Resident 345 was under hospice care. Review of Resident 345's Joint Mobility assessment dated [DATE], showed Resident 345 had limited ROM of BLEs. Review of Resident 345's Order Summary Review for September 2023 showed the following physician's orders: - dated 9/25/23, RNA to begin on 9/26/23, 5x/week as tolerated for BUE AROM exercises to prevent contracture; - dated 9/25/23, RNA to begin 9/26/23, 5x/week as tolerated for BLE AROM exercises to prevent contracture; and - dated 10/3/23, the RNA services was discontinued. Review of Resident 345's CNA Tasks for September and October 2023 showed No Data Found under Nursing Rehab: Active ROM to BUE and AROM exercises to BLE to prevent further contracture. Review of Resident 345's Therapy Notes dated 10/3/23, showed per the resident and RNA, Resident 345 stated she did not want to get into the chair or any ROM exercises to the upper/lower extremities at this time. The risks and benefits were explained to Resident 345. Further medical record review for Resident 345 showed no documented evidence Resident 345 was provided, offered, or refused RNA services. On 10/5/23 at 0808 hours, an interview and concurrent medical record review was conducted with RNA 1. RNA 1 stated when the residents completed their physical or occupational therapy, the therapy department would recommend RNA services. RNA 1 stated she and the DSD each got a copy of the RNA orders. RNA 1 stated she documented electronically in the Point Click Care system (PCC) under the CNA task tab where it showed the recommended RNA services specific for the resident. RNA 1 stated when a resident refused the RNA services, she would notify the charge nurse and document the refusal. RNA 1 stated there should be a check under the Resident Refused in the CNA task tab under the RNA question. RNA 1 further stated she was involved in the weekly RNA meeting that included the DOR, DON, and DSD to discuss the residents' response to the RNA services. RNA 1 stated Resident 345 refused her RNA services for AROM to BUE and BLE when she offered in the morning and afternoon. RNA 1 confirmed there was no documentation when Resident 345 was offered or refused RNA services for AROM to BUE and BLE. RNA 1 further stated she only documented for RNA services electronically. On 10/5/23 at 0817 hours, an interview and concurrent medical record review was conducted with the Medical Records Director. The Medical Records Director verified there was No Data Found in the CNA task tab under RNA services. On 10/5/23 at 0825 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD stated she was part of the weekly RNA services meeting. The DSD stated she was the one responsible in the documentation of the report in the nurses progress notes for any updates of the resident's response to their RNA services. The DSD verified there was no documented evidence for Resident 345 regarding if RNA services were offered, performed, or refused. On 10/5/23 at 0852 hours, an interview was conducted with the DOR. The DOR stated the rehabilitation department performed a Joint Mobility Assessment prior to the recommendation of RNA services to determined if residents would benefit and to prevent further ROM decline. The DOR stated the facility offered RNA services if there was a need even if the resident was on hospice. The DOR was asked what Resident 345's cognition was, and the DOR stated she did not assess for Resident 345's cognition but Resident 345 was able to converse. The DOR stated Resident 345 did not want to do RNA services that was why the RNA services discontinued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 543 was initiated on [DATE]. Resident was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. a. Review of Resident 543's Physician's Order for Life-Sustaining Treatment (POLST) form dated [DATE], showed the following items were selected: - Section A: Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B) - Section B: Selective Treatment-goal of treating medical conditions while avoiding burdensome measures. In addition, Section D of the POLST form did not show a physician's signature. Review of the POLST form under the section for Directions for Health Care Provider showed the following: - To be valid a POLST form must be signed by a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law. - Any incomplete section of the POLST form implies full treatment for that section. On [DATE] at 1432 hours, an interview and concurrent medical record review was conducted with the SSD and DON. The DON stated the licensed nurses looked at the POLST; however, the physician needed to verify the information on the document. The DON also verified Resident 543's POLST was inaccurate when Section B was checked for Selective Treatment, instead of Full Treatment. When asked when the POLST needed to be signed by the physician when Resident 543 was admitted on [DATE], the DON stated the physician was required to sign within 72 hours of admission. b. Medical record review for Resident 543 was initiated on [DATE]. Resident 543 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 543's Order Summary Report dated [DATE], showed the physician's orders dated [DATE], for the following: - to cleanse the right buttock Stage 2 pressure ulcer with NS (normal saline), pat dry, apply calmoseptine, and cover with foam and dry dressing every day shift - to cleanse groin MASD with NS, pat dry, and apply calmoseptine every shift for 21 days - to cleanse bilateral buttocks MASD with NS, pat dry, and apply calmoseptine every shift for 21 days Review of Resident 543's TAR for [DATE] showed no documentation of wound care performed on the PM shifts on 9/23, 9/28, 9/29, and [DATE], for the following wound care: - to cleanse groin MASD with NS, pat dry apply calmoseptine every shift for 21 days - to cleanse the bilateral buttocks MASD with NS, pat dry apply calmoseptine every shift for 21 days [DATE] at 1405 hours, an interview and concurrent medical record review of Resident 543 was conducted with the Treatment Nurse. The Treatment Nurse verified the missing documentation for the dates identified. When asked if the treatment was performed on the above shifts where no documentation shown, the Treatment Nurse stated she would not know if it was not documented. 3. During an initial tour of the facility on [DATE] at 0856 hours, Resident 31 was observed sitting in her wheelchair. Resident 31 was observed with edema on her bilateral upper arms. Resident 31 stated she had it before admission to the facility. Resident 31 also stated she had swelling on her left leg. Medical record review for Resident 31 was initiated on [DATE]. Resident 10 was admitted to the facility on [DATE]. The H&P examination dated [DATE], showed Resident 10 had the capacity to make decisions. Review of Resident 31's Order Summary dated [DATE] at 1150 hours, showed an order to monitor BUE nonpitting edema for skin breakdown every shift for 21 days and monitor LLE +2 edema for skin breakdown every shift for 21 days. Review of Resident 31's eMAR for [DATE] showed missing documentation for BUE and LLE edema monitoring on the following days: - 9/11, 9/12, 9/13, 9/14, 9/18, 9/19, 9./20, 9/21, 9/26, 9/27, [DATE], for PM shift. - 9/19, 9/20, 9/21, and [DATE], for NOC shift On [DATE] at 1434 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified the order for edema monitoring for Resident 31. LVN 1 verified edema monitoring should be reflected in the eMAR as ordered. LVN 1 acknowledged and verified the above findings. 4. On [DATE] at 1145 hours, review of Resident 31's medical record was initiated. However, Resident 44's Order Summary dated [DATE] at 1157 hours, was found in Resident 31's medical record under the physician's order tab. On [DATE] at 1153 hours, a concurrent interview and Resident 31's medical record review was conducted with the Treatment Nurse. The Treatment Nurse verified the physician's order was for Resident 44 and it was her signature on Resident 44's physician order. The Treatment Nurse stated she must have mistakenly filed it in Resident 31's medical record. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 23 final sampled residents (Residents 10, 31, 344, and 543) were complete and accurate. * The facility failed to ensure the indwelling urinary catheter care was recorded for Resident 344. * Resident 10's physician's order for Pilocarpine 1% ophthalmic solution contained a conflicting administration frequency. * The facility failed to record the edema assessment for Resident 31. * Resident 31's medical record contained a physician's order for another resident (Resident 44). * The facility failed to ensure Resident 543's POLST form was accurate and signed by the physician. * The facility failed to ensure Resident 543's wound treatments were documented in the TAR. These failures had the potential to not providing necessary care and services to these residents as their medical information was inaccurate. Findings: Review of the facility's P&P titled Charting and Documentation revised 4/2008 showed all observations, medications administered, services performed, etc., must be documented in the resident's medical records. 1. Medical record review for Resident 344 was initiated on [DATE]. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's H&P examination dated [DATE], showed Resident 344 was alert and oriented times three and able to follow commands. Review of Resident 344's Order Summary Report for [DATE] showed a physician's order dated [DATE], to perform an indwelling urinary catheter (a catheter inserted through the urethra into the bladder to drain urine) care every shift. Review of Resident 344's TAR for [DATE] showed an indwelling urinary catheter care every shift was not recorded on 9/26-[DATE] for PM shift, and on 9/29-[DATE] for NOC shift. On [DATE] at 0930 hours, an interview and concurrent medical record review was conducted with the Treatment Nurse. The Treatment Nurse verified the above finding. The Treatment Nurse stated after she provided the indwelling urinary catheter care for Resident 344, she would document in the TAR to show the care was provided and completed. On [DATE] at 0944 hours, the DON verified and acknowledged the above finding. 2. Medical record review for Resident 10 was initiated on [DATE]. Resident 10 was admitted to the facility on [DATE]. On [DATE] at 0816 hours, an interview and concurrent medical record review was conducted with LVN 2. Review of Resident 10's Order Summary Report dated [DATE], showed a physician's order dated [DATE], for Pilocarpine 1% ophthalmic solution instill 1 drop in both eyes three times a day for glaucoma and to instill 1 drop into both eyes two times a day for glaucoma. LVN 2 verified the conflicting of administration frequency in the order and stated she would clarify the order with Resident 10's physician, specific to the frequency in which to administer the Pilocarpine 1% ophthalmic solution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Catheter Care, Urinary revised 10/2010 showed the purpose of the procedure is to prevent catheter-associated urinary tract infections. Further review of the facility's P&P showed to be sure the catheter tubing and drainage bag are kept off the floor Medical record review for Resident 393 was initiated on 10/04/23. Resident 393 was admitted to the facility on [DATE]. On 10/02/23 at 1208, 1215, and 1230 hours, Resident 393 was observed in bed with an indwelling urinary catheter attached to a urinary drainage bag with a clear meter drainage plastic container. The bed was observed at the lowest position and close to the floor. The urinary drainage bag with attached clear meter drainage container were observed lying directly on the floor. On 10/02/23 at 1233 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the bed was at the lowest position and the urinary drainage bag attached to the clear meter drainage container were lying directly on the floor. On 10/03/23 at 1037 hours, an interview was conducted with the IP. The IP stated the indwelling catheter bag should not be touching the floor and it could have a potential point of entry for the bacteria; and it should not be touching the floor even if there was a dignity bag covering it. Based on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and prevent the transmission of diseases and infections to all residents; and fail to implement safe and sanitary infection control practices for one of 23 final sampled residents (Resident 393). * The facility failed to ensure the personal items were not on the clean sorting table in the laundry. * The facility failed to ensure Resident 393's urinary drainage bag and urine meter drainage container (used to measure and drain urine when emptying) were not touching the floor. These failures posed the risk for transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled Laundry revised 2/2022 showed it is the policy of the facility that careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious disease to other staff members, residents, and visitors. The supervisor of laundry services will work closely with the infection control team to establish and maintain consistent high standards. On 10/4/23 at 1341 hours, an inspection of the laundry area and concurrent interview with the Maintenance Director was conducted. The following was observed on top of the clean sorting table: - a bottle water, - a coffee cup, - a cellphone, and - an identification badge. The Maintenance Director verified the above findings. The Maintenance Director stated there should not be any personal items on top of the clean sorting table area.

5. During dining observation of the facility on 10/2/23 at 1233 and 1301 hours, CNA 3 was observed not offering and providing hand hygiene to Residents 31 and 36 before and after meals. On 10/2/23 at 1301 hours, a concurrent observation and interviewed with Residents 31 and 36 was conducted. Resident 31 was observed sitting in the wheelchair. Resident 31 stated she needed assistance going to the restroom. Resident 31 stated she was not offered hand hygiene before and after her meal. Resident 36 was observed sitting on her bed with her head elevated at 90 degrees. Resident 31 stated she needed assistance getting out of the bed. Resident 36 stated she was not offered hand hygiene prior and after her meal. On 10/2/23 at 1310 hours, an interview was conducted with CNA 3. CNA 3 stated she needed to offer hand wipes, hand washing, or wash cloth to the residents before and after they ate. CNA 3 stated that she forgot to offer hand hygiene to Residents 31 and 36 before they ate. CNA 3 stated she offered a wash cloth to Residents 31 and 36 after they ate. On 10/2/23 at 1317 hours, an interview was conducted to Residents 31 and 36. Both residents denied they were offered a wash cloth by CNA 3 after they ate. On 10/5/23 at 1354 hours, an interview was conducted with the IP. The IP stated the facility's protocol was for the staff to offer and provide hand hygiene to the residents before and after meals. The IP stated the facility did not use a specific handwipes and the staff could just offer a wash cloth for the hand hygiene. The IP stated if hand hygiene was not provided to the residents, there could be a potential introduction of germs or bacteria to their mouth if their hands were dirty and an infection could develop and lead to hospitalization. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the blenders used for puree preparation were air dried prior to storing. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to offer and provide hand hygiene to the residents before and after meals. These failures had the potential to cause foodborne illnesses for the residents in the facility. Findings: Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility on 10/3/23, showed 54 of 57 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. During the initial kitchen tour on 10/2/23 at 0842 hours, a concurrent observation and interview was conducted with the DSS. The heavy-duty blender, robot coupe blender, and standard blender were observed stored on the counter shelves and still wet and with visible water inside. The DSS verified the above findings and stated it should have been air dried because moisture caused bacteria. 2. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. During the initial kitchen tour on 10/2/23 at 0845 hours, a concurrent observation and interview was conducted with the DSS. A yellow, red, brown, green, and white cutting boards were observed with deep groves, heavily marred, discolored, and fuzzy. The DSS acknowledged the above findings and stated it should have been changed when it started to get bad. 3. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. During the initial kitchen tour on 10/2/23 at 0840 hours, a concurrent observation and interview was conducted with the DSS. Three white spatulas with red handles and one white plastic spatula were cracked, chipped, discolored, appeared to be partially melted and worn off. The DSS verified the findings and stated the spatulas were used for puree preparation, it was not safe to use because small pieces from the spatulas could chipped and mixed with the food. 4. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. During the initial kitchen tour on 10/2/23 at 0847 hours, a concurrent observation and interview was conducted with Dietary Aide 1. Black dirt residue was observed on the kitchen hood. Dietary Aide 1 verified the findings and stated the kitchen staff were supposed to clean the hood weekly, and the hood was to be cleaned every six months by an outside company.

**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 ensure documentation of transfer information in the medical record for one of two closed medical records sampled residents (Resident 60). * The facility failed to document Resident 60's transfer information in the medical record. This failure had the potential of miscommunication of information and not providing necessary care and services for this resident. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation revised December 2012, under the policy interpretation and implementation section, showed the information pertaining to the transfer or discharge of a resident will be documented in the resident's medical records. The P&P also showed the following documentation from the Care Planning Team concerning all transfers or discharge: - the reason for the transfer or discharge - the date and time of the tansfer or discharge - the mode of transportation - a summary of the resident's overall medical, physical, and mental condition On 7/20/22 at 1055 hours, closed medical record review was initiated for Resident 60. Resident 60 was admitted to the facility on [DATE], and transferred to the acute care hospital on 5/19/22. Review of Resident 60's closed medical record showed no documented evidence of the following: - When and why the resident was transferred; - The notification to the physician of the resident's condition and hospital transfer. - The physician's order to transfer the resident - How the resident was transferred. - Offering of bedhold. On 7/21/22 at 1547 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 was unable to locate the documentation and verified the above findings were not found in Resident 60's medical record. On 7/22/22 at 1116 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON was unable to locate the documentation and verified the above findings. On 7/22/22 at 1612 hours, an interview with the DON was conducted. The DON stated she reviewed Resident 60' medical record and did not find Resident 60's transfer documentation in the progress notes. The DON also stated if the ADON was not able to locate the physician's order to transfer Resident 60 to the acute care hospital, then there was no physician's order to transfer Resident 60 to the acute care hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to develop and implement a comprehensive care plans to address the individual care needs for two of 12 final sampled residents (Residents 13 and 561). * The facility failed to implement Resident 561's plan of care to provide bilateral floormats (padded mat placed on each side of the bed) for safety. * The facility failed to develop a comprehensive care plan to address Resident 13's bilateral lower extremity edema. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: 1. Medical record review for Resident 561 was conducted on 7/19/22. Resident 561 was admitted to the facility on [DATE]. Review of Resident 561's Order Summary Report showed a physician's order dated 7/19/22, to provide the bilateral floormats for safety. Review of Resident 561's Fall Risk assessment dated [DATE], showed Resident 561 was a high risk for falls. Review of Resident 561's Baseline Care Plan date 7/15/22, showed to have the bilateral floormats as safety devices. Review of Resident 561's comprehensive care plan was initiated on 7/15/22, showed a care plan problem addressing Resident 561's high risk for falls related to incontinence and impaired mobility. The interventions included the resident needs a safe environment with: bilateral floormats in placed. On 7/20/22 at 1133 hours, an interview and concurrent medical record review was conducted with LVN 2. The Comprehensive Care Plan for Resident 561 was reviewed. LVN 2 stated Resident 561 had a care plan addressing the risk for falls. When asked, LVN 2 stated the bilateral floormats were included in the care plan interventions. LVN 2 verified Resident 561's bilateral floormats were not implemented. Cross reference to F689. 2. Medical record review for Resident 13 was initiated 7/19/22. Resident 13 was admitted to the facility on [DATE]. On 7/20/22 at 1113 hours, an interview and concurrent medical record review was conducted with the treatment nurse, LVN 6. Review of Resident 13's medical record showed Resident 13 was admitted to the facility on [DATE]. LVN 6 conducted Resident 13's admission skin assessment on 9/3/20, and Resident 13 was not assessed with bilateral lower extremity edema. LVN 6 stated on 4/7/2022, she noted an order for Resident 13, to apply ted hose for recurring edema. Further review of Resident 13's medical record failed to show documentation an assessment was conducted specific to Resident 13's edema. LVN 6 verified the findings and stated a change of condition assessment should have been conducted and documented in Resident 13's medical record at the time Resident 13's edema was identified. On 7/20/22 at 1028 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 reviewed Resident 13's current comprehensive care plans and verified the facility failed to develop a comprehensive care plan to address Resident 13's bilateral lower extremity edema. LVN 6 stated a care plan should be in place specific to Resident 13's bilateral lower extremity edema. Cross reference to F684.

**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 conduct an assessment for the resident's change of condition for one of 12 final sampled residents (Resident 13). * Resident 13 presented with bilateral ankle edema; however, a change of condition assessment was not conducted and the weekly assessments were not performed thereafter as per the facility's P&P and practice. This failure had the potential for a delay in treatments and interventions which posed the risk of negative health outcomes to the resident. Findings: Review of the facility's P&P titled Acute Condition Changes Clinical Protocol revised 12/2012 showed before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician, for example, history of present illness. The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. The staff will monitor and document the resident's progress and responses to treatment, and the physician will adjust treatment accordingly. Medical record review for Resident 13 was initiated 7/19/22. Resident 13 was admitted to the facility on [DATE]. On 7/19/22 at 1147 hours, an observation and concurrent interview was conducted with Resident 13. Resident 13 was observed sitting in his wheelchair and had bilateral ankle edema. Resident 13 stated his ankles had been swollen for approximately six months. Resident 13 stated he had an order for bilateral lower extremity ted hose; however, the staff failed to apply the ted hose this morning. Review of Resident 13's Skin Observation Tool dated 9/3/20, showed documentation for Resident 13's admission skin assessment. The skin assessment did not show Resident 13 had bilateral lower extremity edema. Review of Resident 13's Order Summary Report showed an order dated 4/7/22, to don the ted hose in the morning and remove in the evening for edema as needed. On 7/20/22 at 1113 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated she conducted Resident 13's admission skin assessment on 9/3/20, and verified Resident 13 was not assessed with bilateral lower extremity edema. Further review of Resident 13's medical record failed to show documentation an assessment was conducted specific to Resident 13's edema. LVN 6 verified the findings and stated a change of condition assessment should have been conducted and documented in Resident 13's medical record when the edema was identified, and the weekly assessments should have been performed thereafter. LVN 6 stated the assessment of Resident 13's edema would include the site of the edema, grading the severity of the edema, skin integrity, pedal pulses, and the presence of pain. LVN 6 stated the assessments would allow a determination to be made as to whether Resident 13's edema was improving or worsening; and if Resident 13's edema worsened, Resident 13's physician would need to be notified. Cross reference to F656, example #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide devices to prevent accidents for one of 12 final sampled residents (Resident 561) as ordered by the physician. * The facility failed to provide the bilateral floormats for Resident 561 as ordered by the physician. This posed the risk for injury should Resident 561 had a fall. Findings: Medical record review for Resident 561 was conducted on 7/19/22. Resident 561 was admitted to the facility on [DATE]. Review of Resident 561's Order Summary Report showed a physician's order dated 7/15/22, to provide the bilateral floormats for safety. Review of Resident 561's Fall Risk assessment dated [DATE], showed Resident 561 was a high risk for falls. Review of Resident 561's Baseline Care Plan dated 7/15/22, showed to provide the bilateral floormats as safety devices. On 7/19/22 at 1122 hours, an observation of Resident 561's room was conducted. The bilateral floormats were not observed to be placed on the floor by the resident's bed as ordered. On 7/20/22 at 1133 hours, a concurrent observation, interview, and medical record review was conducted with LVN 2. LVN 2 reviewed Resident 561's Order Summary Report and verified the physician's order for the bilateral floormats for safety. During Resident 561's room observation with LVN 2, the bilateral floormats were not observed by the resident's bed. LVN 2 verified the bilateral floormats were not provided to Resident 561 as ordered by the physician. *Cross reference to F656, example #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.a. On 7/19/22 at 0857 hours, an observation was conducted in Resident 561's room. Resident 561 had an oxygen concentrator at bedside. Resident 561 stated he used oxygen once and did not use oxygen daily. Medical record review for Resident 561's was conducted on 7/19/22. Resident 561 was admitted to the facility on [DATE]. Review of Resident 561's SBAR Communication Form and progress note dated 7/17/22, showed Resident 561 had a change of condition for shortness of breath and low oxygen saturation level and was provided oxygen therapy via nasal cannula. Review of Resident 561's oxygenation summary showed the following: - On 7/17/22 at 0152 hours, oxygen saturation level of 86% (room air) - On 7/17/22 at 0216 hours, oxygen saturation level of 94% (oxygen via nasal cannula) Review of Resident 561's Order Summary Report showed no physician's order for oxygen therapy. On 7/19/22 at 1733 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above findings. RN 2 stated Resident 561 was given oxygen therapy without a physician's order. b. On 7/19/22 at 0857 hours, an observation of Resident 561`s room was conducted. Resident 561 had a concentrator at bedside with the nasal cannula dated 7/17/22, hanging on the concentrator and the tubing was touching the floor. On 7/19/22 at 1702 hours, an observation of Resident 561's room was conducted. Resident 561's nasal cannula was observed hanging on the concentrator and the tubing was touching the floor. On 7/19/22 at 1705 hours, an observation and concurrent interview was conducted with LVN 3. Resident 561's nasal cannula was observed hanging on the concentrator and the tubing was touching the floor. LVN 3 was asked how Resident 561's nasal cannula should be stored when not in use. LVN 3 stated Resident 561's nasal cannula was supposed to be off the floor and inside the plastic bag. On 7/20/22 at 1133 hours, an observation and concurrent interview was conducted with LVN 2. Resident 561's nasal cannula dated 7/17/22, was observed inside a plastic bag dated 7/19/22. LVN 2 was informed Resident 561's nasal cannula dated 7/17/22, was observed hanging on the concentrator and the tubing was touching the floor witnessed by LVN 3 on 7/19/22. LVN 2 stated Resident 561's nasal cannula dated 7/17/22, should be changed if it touched the floor because it posed a risk of infection. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide respiratory care in accordance with the facility's P&P, and failed to ensure the infection control measures for the safe storage of oxygen administration equipment were followed for two of 12 final sampled residents (Residents 261 and 561). * Resident 261 received continuous oxygen therapy without a physician's order. * Resident 261's nasal cannula was improperly stored, having been found lying on top of an oxygen concentrator. * Resident 561 received oxygen therapy without a physician's order. * Resident 561's nasal cannula was improperly stored, having been found hanging on the oxygen concentrator and the tubing was touching the floor. These failures had the potential for negative health outcomes for a highly vulnerable resident population related to infection control practices and the administration of oxygen therapy without a physician's order. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify there is a physician's order for oxygen administration. 1.a. Medical record review for Resident 261 was initiated on 7/19/22. Resident 261 was admitted to the facility on [DATE]. Review of Resident 261's Hospitalist Discharge summary dated [DATE], showed Resident 261 was admitted from the acute care hospital, having received treatment for pneumonia. Review of Resident 261's medical record showed after being admitted to the facility, Resident 261 received oxygen therapy. Review of Resident 261's oxygen saturation level summary showed the following: * 7/18/22 at 2241 hours, oxygen saturation level of 97% (oxygen via nasal cannula). * 7/19/22 at 0010 hours, oxygen saturation level of 97% (oxygen via nasal cannula). * 7/19/22 at 0235 hours, oxygen saturation level of 97% (oxygen via nasal cannula). Further review of Resident 261's medical record failed to show a physician's order for the administration of oxygen. On 7/19/22 at 1734 hours, an interview was conducted with Resident 261. Resident 261 stated she utilized oxygen throughout the night (on 7/18/22) via a nasal cannula. On 7/19/22 at 0908 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 261 was admitted to the facility in the evening of 7/18/22, from the acute care hospital. Resident 261 was diagnosed with pneumonia in the acute care hospital. RN 1 stated when Resident 261 arrived at the facility, the EMTs were providing Resident 261 with continuous oxygen. RN 1 stated the facility continued providing Resident 261 with continuous oxygen at 2 liters per minute via oxygen concentrator and nasal cannula. RN 1 stated a physician's order was required for the administration of oxygen. RN 1 reviewed Resident 261's medical record and verified Resident 261 did not have an order for the administration of oxygen. b. On 7/19/22 at 0858 hours, an observation and concurrent interview was conducted with CNA 5. Resident 261's nasal cannula was observed lying on top of the oxygen concentrator. CNA 5 stated Resident 261 utilized oxygen therapy at night as needed. CNA 5 was asked the facility's practice specific to how Resident 261's nasal cannula should be stored when not in use. CNA 5 stated Resident 261's nasal cannula should have been stored in a clean plastic bag when not in use, as an infection control measure, being the oxygen concentrator was potentially dirty. CNA 5 then proceeded to place the nasal cannula in a clean plastic bag; however, CNA 5 failed to provide Resident 261 with a new nasal cannula. On 7/19/22 at 0908 hours, an interview was conducted with RN 1. RN 1 was asked the facility's infection control practice specific to the storage of Resident 261's nasal cannula when not in use by Resident 261. RN 1 stated Resident 261's nasal cannula should be stored in a clean plastic bag when not in use. RN 1 was informed Resident 261's nasal cannula was observed lying on the oxygen concentrator, and CNA 5 then placed the nasal cannula into a plastic bag. RN 1 stated she would ensure Resident 261 received a new nasal cannula.

**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 pharmaceutical services to meet the resident's needs for two of 12 final sampled residents (Residents 19 and 39). * The facility failed to ensure Residents 19 and 39's medications were administered as ordered by the physician. This failure had the potential to negatively affect the residents' health conditions. Findings: Review of the facility's P&P titled Administering Medications revised December 2012, under the section for Policy Statement, showed the medications shall be administered in a safe and timely manner and as prescribed. 1. Review of Resident 19's medical record was initiated on 7/21/22. Resident 19 was admitted to the facility on [DATE]. Review of the MAR for July 2022 showed an order dated 5/27/22, to administer metoprolol tartrate (medication to treat high blood pressure) 25 mg one tablet by mouth two times a day and hold if the systolic blood pressure (the pressure caused by the heart contracting and pushing out blood) was less than 110 mmHg or the pulse rate (number of times the heart beats within a certain time, usually a minute) was less than 60 bpm. Further review of the MAR showed the following: - On 7/1/22, Resident 19 received metoprolol tartrate at 1700 hours, with the blood pressure (measure of the force that the heart uses to pump blood around the body) reading of 102/64 mmHg. - On 7/4/22, Resident 19 received metoprolol tartrate at 0900 and 1700 hours, with the blood pressure reading of 106/72 mmHg. 2. Review of Resident 39's medical record was initiated on 7/21/22. Resident 39 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MAR for July 2022 showed an order dated 6/22/22, to administer amlodipine besylate (medication to treat high blood pressure) 5 mg one tablet by mouth one time a day and hold if the systolic blood pressure was less than 110 mmHg or the pulse rate was less than 60 bpm. Further review of the MAR showed the following: - On 7/3/22, Resident 39 received amlodipine besylate at 1200 hours, with the blood pressure reading of 104/75 mmHg. - On 7/4/22, Resident 39 received amlodipine besylate at 1200 hours with the blood pressure reading of 102/60 mmHg. - On 7/7/22, Resident 39 received amlodipine besylate at 1200 hours with a blood pressure reading of 108/70 mmHg. On 7/22/22 at 0933 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 acknowledged and verified the above findings for Residents 19 and 39, and further stated the medications should not be given.

**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 ensure two of 12 final sampled residents (Residents 24 and 610) and one of five sampled residents for unnecessary medications (Resident 30) were free from unnecessary psychotropic medications. * Resident 24 had the order for Abilify (medication for bipolar disorder). The facility failed to ensure the inform consent was obtained from Resident 24 prior to the use of this medication. * Resident 30 had an order for quetiapine fumarate (antipsychotic medication). The facility failed to ensure the informed consent was obtained from Resident 30 prior to the use of this medication. * Resident 610 had an order for clonazepam (medication to treat anxiety). The facility failed to ensure the inform consent was obtained from Resident 610 prior to the use of this medication. These failures created the risk of these residents not being informed of the risk and benefit of the psychotropic medications administered to them. Findings: Review of the facility's P&P titled Informed Consent-Psychotherapeutic Medication and Restraint Devices revised 11/28/16, showed the resident has the right to give informed consent and receive information related to the need for and the risks related to the use of chemical restraints. The healthcare practitioner ordering psychotherapeutic medication (physician ordering chemical restraint) is responsible for obtaining informed consent, providing risks, benefits, and other related information from the resident and/or resident's representative for use of such medication. Also, providing documentation that informed consent was obtained, including diagnosis and clinical indications for the medications. The facility's P&P also showed the staff shall verify the resident's record contains documentation that the resident has given informed consent to the proposed treatment or procedure before initiating the administration of chemical restraints and psychotherapeutic drugs. 1. Medical record review for Resident 24 was initiated on 7/20/22. Resident 24 was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident 24's licensed nurse admission summary progress notes dated 7/17/22 at 2030 hours, showed Resident 24 was alert and oriented times three to four. Review of Resident 24's admission Record dated 7/20/22, showed Resident 24 was self-responsible. Review of Resident 24's Order Summary Report for July 2022 showed an order dated 7/18/22, to administer Abilify 5 mg one tablet by mouth in the evening for psychosis manifested by bipolar disorder as evidenced by inconsolable episodes of calling out. Review of Resident 24's MAR for July 2022 showed Resident 24 was administered Abilify 5 mg by mouth in the evening as ordered by the physician. However, further review of medical record failed to show documentation of informed consent obtained from Resident 24 for the use of Abilify. On 7/20/22 at 1503 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. When RN 1 was asked to locate the documentation for informed consent for Abilify, RN1 stated there was no documentation. RN1 called the DMR via phone and asked if she had the informed consent for the Abilify. The DMR responded no she did not have it. On 7/20/22 at 1510 hours, an interview was conducted with the DMR. The DMR verified the above findings. When the DMR was asked if she had the documents of Resident 24's informed consent for Abilify, she stated she did not have it. On 7/20/22 at 1519 hours, an interview was conducted with Resident 24. Resident 24 verified the above findings. When Resident 24 was asked if any of the staff spoke to her regarding the medication and administration of Abilify, she stated she did not recall any of the staff discussing Abilify to her. 3. Medical record review for Resident 610 was initiated on 7/21/22. Resident 610 was admitted to the facility on [DATE]. Review of Resident 610's History and Physical Examination dated 7/20/22, showed Resident 610 had the capacity to understand and make decisions. Review of Resident 610's Order Summary Report showed an order dated 7/15/22, to administer clonazepam 0.5 mg one tablet by mouth two times a day for anxiety manifested by verbalization of feeling anxious. Review of Resident 610's July 2022 MAR showed Resident 610 was administered clonazepam on 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, and 7/21/22, as ordered by the physician. However, further review of Resident 610's medical record failed to show documentation of informed consent obtained from Resident 610 for the use of clonazepam. On 7/21/22 at 1444 hours, an interview with Resident 610 was conducted. When Resident 610 was asked if the physician explained risk and benefits, Resident 610 was unable to recall which medications. On 7/21/22 at 1557 hours, an interview and concurrent medical record review conducted with LVN 1. LVN 1 verified Resident 610 had been receiving clonazepam twice daily and LVN 1 was unable to locate the informed consent for clonazepam in the medical record. LVN 1 stated clonazepam needed the informed consent prior to administering to the resident. 2. Medical record review for Resident 30 was initiated on 7/21/22. Resident 30 was admitted on [DATE], with diagnoses including dementia with behavioral disturbances. Review of Resident 30's admission Record dated 7/21/22, showed Resident 30 was self-responsible. Review of Resident 30's Order Summary Report for July 2022 showed an order dated 5/30/22, to administer quetiapine fumarate 25 mg one tablet by mouth three times a day for psychosis manifested by inconsolable episodes of yelling out. However, further review of the medical record failed to show documentation of informed consent obtained from Resident 30 for the use of quetiapine fumarate. Review of Resident 30's MAR for July 2022 showed Resident 30 was administered quetiapine fumarate 25 mg by mouth three times a day as ordered by the physician. On 7/21/22 at 1526 hours, a concurrent interview and medical record review was conducted with LVN 5. When asked to show the informed consent for quetiapine fumarate medication, LVN 5 was unable to show the informed consent was obtained. LVN 5 verified the findings. On 7/21/22 at 1601 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure the diet menu was followed for three of 15 nonsampled residents (Residents 14, 20, and 28). This failure posed the risk for the residents to not receive the diet as prescribed. Findings: Review of the facility's P&P titled Menus dated 2018 showed menus are planned to meet the nutritional needs of the resident in accordance with the physician's diet order. Review of the facility's document titled Therapeutic Spreadsheets Cycle 3 Week 3 Wednesday undated showed the CCHO diet receives three ounces of oven fried chicken, #8 scoop (1/2 cup) of mashed potatoes/gravy, #8 scoop of carrots, 1 roll with margarine, ½ square [NAME] hash cake, and 8 ounces of milk for the Wednesday lunch meal. During an observation of the lunch meal tray line and concurrent interview with DA 1 on 7/20/22 at 1141 hours, Residents 14, 20, and 28's lunch meal trays were checked by DA 1 and loaded onto the lunch meal cart with the following identified: - Resident 20's lunch meal ticket showed Resident 20 was on the CCHO diet with regular texture. Resident 20's lunch meal contained a whole square of [NAME] hash cake. An interview was conducted with DA 1. DA 1 was asked to review the therapeutic spreadsheet and explain what ½ square [NAME] hash cake meant for the CCHO diet. DA 1 stated she did not know what ½ square meant. The DNS confirmed the CCHO diet should receive ½ portion (square) of the [NAME] hash cake. - Resident 28's lunch meal ticket showed Resident 28 was on the CCHO diet with regular texture and a preference for sugar free ice cream. Resident 28's lunch meal did not contain sugar free ice cream. The DNS confirmed the sugar free ice cream was missing from the tray and it was added. - Resident 14's lunch meal ticket showed Resident 14 was on the CCHO NAS diet with regular texture. Resident 14's lunch meal did not include a ½ square of [NAME] hash cake. When point it out, DA 1 then added a ½ square piece of [NAME] hash cake to the resident's lunch meal. On /20/22 at 1210 hours an interview was conducted with the DNS. The DNS stated DA 1 was nervous but should know how to follow the diet spreadsheet.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary conditions in the kitchen when: * The water temperature at the kitchen hand washing sink did not reach a minimum of 100 degrees F. * DA 2 did not wash her hands for a minimum of 20 seconds prior to touching clean dishes. * The residents' food items brought from outside were not labeled and dated. These failures posed the potential risk to expose the high risk residents who received food from the kitchen to food borne illnesses. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 7/19/22, showed 44 of 45 residents residing in the facility received food prepared in the kitchen. 1. According to the 2017 USDA Food Code Section 5-202.12 Handwashing Sink, Installation, warm water is more effective than cold water in removing the fatty soils encountered in kitchens. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from the hands. ASTM Standards for testing the efficacy of handwashing formulations specify a water temperature of 40°C (Celsius) ± 2°C (100 to 108°F). Review of the facility's P&P titled Handwashing dated 2018 showed in part, 3. Follow the following steps to effectively wash hands: a. turn on water slowly to a warm, comfortable temperature; 100-110 degrees F. During the initial tour of the kitchen on 7/19/22 at 0748 hours, the water temperature at the kitchen hand washing sink was measured and took more than one minute to reach 92 degrees F. On 7/19/22 at 0925 hours, an interview and concurrent observation of the kitchen handwashing sink was conducted with the DES. The DES stated the water temperature for the kitchen hand washing sink should be 105-120 degrees F. The DES confirmed the water at the kitchen hand washing sink was 83.3 degrees F. The DES stated he had adjusted the mixing valve (a valve to mix hot and cold water) because the kitchen employees complained the water was too hot. On 7/20/22 at 0816 hours, an observation of the kitchen handwashing sink was conducted. Cooks 1, 2, and DA 2 washed their hands in the kitchen handwashing sink. The water temperature at the kitchen handwashing sink was 81.7 degrees F. On 7/20/22 at 0825 hours, an interview was conducted with the DNS. The DNS confirmed the water temperature at the kitchen handwashing sink was less than 100 degrees F. The DNS stated it was difficult to obtain the correct water temperature due to the fact that the faucet had a sensor to turn the water on and the water needed to run for a while to get hot. 2. Review of the facility's P&P titled Handwashing dated 2018 showed in part, the following: 2. When to wash hands B. After handing .soiled dishes . 3. Follow the following steps to effectively wash hands b. Wet hands, wrists and forearms. Apply soap. Wash and scrub for 20 seconds or more. On 7/20/22 at 0819 hours, an observation of the dishwashing was conducted. DA 2 touched the dirty dishes with ungloved hands, then was observed to wash her hands for less than five seconds. DA 2 then touched the clean dishes. DA 2 was observed on a second occasion to touch the dirty dishes, then wash her hands for less than three seconds, and proceeded to touch the clean dishes. On 7/20/22 at 0825 hours, an interview was conducted with DA 2 and the DNS. The DNS was asked how long the hands should be washed. The DNS showed DA 2 a handwashing poster which stated to wash hands for at least 20 seconds. 3. Review of the facility's P&P titled Food From Outside Sources dated 2018 showed in part, 3. All food brought in should .placed in a tightly sealed container with the resident's name and date. On 7/19/22 at 1051 hours an observation of the refrigerator located in the activity room, which was used to store resident food from the outside and concurrent interview was conducted with CNA 1. CNA 1 stated the resident's food brought to the facility from the outside should have the resident's name and date when the food was brought in. The refrigerator contained one non-alcoholic beer without a name or date, one plate of food covered with plastic wrap with a name and no date, and a lunch bag with a name and no date. CNA 1 confirmed the findings. On 7/19/22 at 1055 hours, an interview was conducted with RN 1. RN 1 confirmed the items in the refrigerator should be labeled and dated.

Based on interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of July 2021 through June 2022. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility included the residents identified as not having infections (not having met McGeer's Criteria) in the facility's total monthly resident infection rate from July 2021 through June 2022. These failures posed the risk for not identifying infections and controlling the transmission of communicable disease to other residents throughout the facility. Findings. Review of the facility's P&P titled Surveillance for Infections/Infectious Diseases, undated, showed the purpose of the surveillance of infections included: Identify and monitor potential disease problems so treatment can be initiated or continued as needed. Identify baseline information about the type, frequency etc., of infections occurring within the facility, in order to plan and evaluate measures of control. All personal shall be instructed to assist in the disease identification process. This process includes observations of all residents, visitors, and other facility personnel for symptoms of potential disease problems. A monthly report of the infections occurring within the facility shall also be maintained. These reports shall be completed by the Infection Control Coordinator and submitted to the Infection Control Committee routinely for evaluation and recommendations. Review of the facility's P&P titled Infection Control Program Revised McGeer's Criteria for LTC dated 7/8/16, showed the Infection Control Coordinator is assigned the task of overseeing the infection control program. For any suspected infection(s), the facility will determine if it is a TRUE infection(s) based on the revised McGeer's Criteria. McGeer's Criteria is a surveillance tool used to determine a true infection that may need an antibiotic regimen to treat the resident. Licensed nurses will identify all signs and symptoms of a suspect infection. The Infection Control Coordinator will review the collected data and individual assessment sheets every week, to determine whether the resident's condition is due to a Community-Associated Infection (CAI), Healthcare-Associated Infection (HAI) or does not meet the criteria (McGeer's Criteria) category. If the criteria for infection according to the revised McGeer's criteria is not met, it will not be factored into the infection rate. 1.a. On 7/21/22 at 1318 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked to review and explain the facility's infection control surveillance program. The IP stated she was responsible for conducting surveillance of resident infections within the facility. The IP stated the facility utilized McGeer's Criteria to determine whether a resident had an infection. The IP stated a HAI occurred when a resident met McGeer's Criteria and was prescribed an antimicrobial medication (48 hours after admission to the facility). The IP stated a CAI occurred when a resident was admitted to the facility with an infection and prescribed antimicrobials, or met McGeer's criteria and is prescribed antimicrobials (within 48 hours of admission to the facility). The IP stated she documented the facility's resident infection data on the facility's monthly infection surveillance form (data included site of infection, infectious organism, and signs and symptoms associated with infection). The IP stated the identification and surveillance of resident infections in the facility were to identify and correct breaches in infection control practices that contribute to the spread of infections and to prevent the further spread of infections in the facility. Additionally, the IP stated the resident infection surveillance data was collected and interpreted to monitor increases and decreases in the facility's infection rates. Review of the facility's monthly infection control surveillance forms from July 2021 through June 2022 showed the following resident infection surveillance data: - 7/2021, HAI - 1 and CAI - 18 - 8/2021, HAI - 1 and CAI - 27 - 9/2021, HAI - 0 and CAI - 17 - 10/2021, HAI - 2 and CAI - 5 - 11/2021, HAI - 0 and CAI - 22 - 12/2021, HAI - 0 and CAI - 12 - 1/2022, HAI - 5 and CAI - 19 - 2/2022, HAI - 0 and CAI - 10 - 3/2022, HAI - 2 and CAI - 21 - 4/2022, HAI - 2 and CAI - 17 - 5/2022, HAI - 1 and CAI - 21 - 6/2022, HAI - 2 and CAI - 19 Review of the facility's monthly infection control surveillance forms from July 2021 through June 2022 showed documentation that all residents determined to have an HAI or CAI were also prescribed antimicrobial medications. Further review of the facility's monthly infection control surveillance forms from July 2021 through June 2022 showed the facility failed to conduct surveillance for all resident infections, specific to the residents who met McGeer's Criteria and were not prescribed antimicrobial medications. The IP verified the findings and stated the facility was not conducting surveillance of all resident infections (specific to the residents who met Mc'Geers Criteria and were not prescribed antimicrobials). The IP was asked how many residents in the facility had infections (met McGeer's Criteria) and were not prescribed antimicrobial medications (from July 2021 through June 2022). The IP stated she was unable to make that determination. b. Review of the facility's Monthly Infection Surveillance Report for the months of July 2021 through June 2022 showed data specific to the facility's calculated total monthly resident infection rates. The facility's total monthly resident infection rates from July 2021 through July 2022 were calculated by adding the HAI Rate, CAI Rate, and Did Not Meet McGeers' Criteria Rate together. The facility incorrectly included the residents identified as not having infections (not having met McGeer's Critieria) when calculating the facility's total monthly resident infection rates. For example, the Monthly Infection Surveillance Report dated October 2021 showed the HAI rate of 1.5%, CAI rate of 3.8%; and Did Not Meet McGeer's Criteria rate of 6.1%. The facility's calculated total monthly resident Infection rate was 11.4%. The Monthly Infection Surveillance Report dated March 2022 showed the HAI rate of 1.1%, CAI rate of 12.6%, and Did Not Meet McGeer's Criteria rate of 2.4%. The facility's calculated total monthly resident Infection rate was 16.1%. In accordance with the facility's P&P titled Infection Control Program Revised McGeer Criteria for LTC revised 7/8/16, if the criteria for infection according to the revised Mc Geer's criteria is not met, it will not be factored into the infection rate. The IP verified the findings.

Based on observation, interview, and facility document review, the facility failed to ensure the essential equipment was maintained in a safe operating condition when: * The ice machine was not clean. * The ice machine's manufacturer sanitizing instructions were not followed. * The freezer component of the refrigerator used to store the resident food from the outside had excessive ice build-up. These failures had the potential for equipment to not function in the way they were intended. Findings: 1. According to the 2017 USDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment, Food-Contact Surfaces and Utensils shall be clean to the sight and touch. Review of the facility's P&P titled Cleaning Ice Machine dated 2018 showed the ice machine will be cleaned and sanitized once a month or per manufacturer recommendations. Review of the facility's document titled Ice Machine Preventative Maintenance Program dated January 2007 showed the ice machine was last cleaned on 5/28/22. On 7/19/22 at 920 hours, an observation of the facility's ice machine located in the kitchen and concurrent interview was conducted with the DES. The DES stated the facility's ice machine located in the kitchen was the only ice machine for the facility. Upon inspection of the interior components of the ice machine, a red residue was observed on the sump [a tray under the evaporator (the area ice was produced)] and on the evaporator lower curtain (a flap that directs ice into the storage bin), which was removed with a white paper towel. A white residue resembling hard water deposits was observed on the inside of cover of the ice machine. The DES confirmed the ice machine was not clean and stated he would turn it off and clean it. The DES stated he last cleaned the ice machine on May 28, 2022. The DES stated he was too busy to clean the ice machine in June. 2. Review of the facility's P&P titled Cleaning Ice Machine dated 2018 showed the ice machine will be cleaned and sanitized once a month or per the manufacturer's recommendations. Review of the ice machine owner's manual cleaning and sanitizing procedures showed in part, proper cleaning of an ice machine requires two parts: descaling and sanitizing. Descaling dissolves the mineral deposits on the evaporator and other surfaces. It removes scale, calcium, lime scale and other mineral build-up. Sanitizing should be performed after each descaling . Sanitizing disinfects the machine and removes microbial growth including mold and slime . 9. Measure the appropriate amount of descaler according to the machine size and sump volume from chart below. Carefully pour the descaler into the sump using the lower curtain to prevent splash. Replace upper evaporator cover. 10. The machine will remain in the wash cycle for 15 minutes . 18. Sanitizing the ice machine is recommended after descaling. Repeat the process with sanitizer at correct ratio. On 7/19/22 at 920 hours, an interview was conducted with the DES regarding the cleaning procedure of the ice machine. The DES stated he ran the descaler through the machine for a few minutes then used a brush to clean what areas he could reach. To sanitize the ice machine, the DES stated he used a rag soaked with the sanitizer from the kitchen to wipe down the areas he could reach. On 7/19/22 at 1602 hours, an interview was conducted with the DES and DNS. The DES was asked to clarify how he sanitized the ice machine. The DES stated he used the sanitizer from the kitchen to wipe down the areas he could reach. When asked if he ran the sanitizing solution through the wash cycle of the ice machine as specified in the manufacturer instructions, the DES confirmed he was not running the sanitizer through the machine, he only wiped the ice machine components with the sanitizing solution. 3. According to the 2017 USDA Food Code Section 4-501.11, equipment shall be maintained in a state of repair and condition that meets the requirements. On 7/19/22 at 1051 hours, an observation of the refrigerator located in the activity room used to store the resident food brought from the outside and concurrent interview was conducted with CNA 1. The freezer of the refrigerator was observed with an excessive ice build-up. CNA 1 stated she did not know who cleaned the refrigerator. On 7/19/22 at 1055 hours, an observation of the refrigerator located in the activity room used to store the resident food brought from the outside and concurrent interview was conducted with RN 1. RN 1 confirmed the refrigerator freezer had an excessive amount of ice build-up. RN 1 stated the maintenance was responsible to clean the refrigerator. On 7/19/22 at 1446 hours, an interview was conducted with the DES and DNS. The DES stated he was responsible to clean the refrigerator used to store the resident food from the outside. The DES stated he cleaned it every Wednesday and defrosted the freezer each time. The DES also stated he discarded any outdated food items. Upon inspection of the refrigerator used to store resident food from the outside, the freezer compartment no longer had any ice build-up. The DNS confirmed the refrigerator used to store resident food from the outside was replaced earlier that day.