Based on interview and record review, the facility failed to report to the Department an injury of unknown source (an injury which was not observed, cannot be explained by the resident, and is suspicious because of the extent or location) for one of three sampled residents (Resident 1) when Resident 1 had a bruise on the right side of her neck and left clavicle (a bone that connects the breastbone to the shoulder blade) identified on 11/14/24 and 11/15/24 respectively, and the facility did not report this to the Department until 11/21/24. This failure resulted in a delay in the Department investigation into Resident 1' s bruises and had the potential for an occurrence of abuse to go undetected. Findings: A review of Resident 1' s admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a decline in memory or other thinking skills severe enough to reduce a person ' s ability to perform everyday activities). During a review of Resident 1' s Minimum Data Set (MDS-an assessment and care planning tool), dated 10/17/24, the cognitive patterns section of the MDS indicated Resident 1 had short-term and long-term memory problems. The MDS also indicated Resident 1 was severely impaired with daily decision making. During a review of Resident 1 ' s Skin Integrity Care Plan (a document that summarizes a person ' s health needs, care, and treatment, and helps ensure their needs are met), dated 4/11/24, indicated on 11/14/24 a discoloration to the right neck was discovered, and a discoloration to the left clavicle was discovered on 11/15/24. During a review of Resident 1' s ED Physician Notes (ED- hospital emergency department), dated 11/16/24, indicated, Patient has unexplained bruising on her neck and the ER [emergency room] nurse filled out an APS [adult protective services] report. During a review of a report received by the Department from the facility dated 11/21/24, the report indicated Resident 1 had bruising to both sides of the neck. The bruise on the right side of the neck was found by staff on 11/14/24, and the left clavicle on 11/15/24. Review of Resident 1 ' s clinical record, PROGRESS NOTE dated 11/21/24, written by Resident 1 ' s physician indicated, Pt [patient] has dementia + unable to give any history. During an interview on 11/22/24, at 9:45 a.m. with the Administrator (ADM), the ADM stated he reported Resident 1 ' s bruises to the Department on 11/21/24 after Resident 1 ' s family members requested an investigation into the possibility of abuse. The ADM explained the cause of the bruises to Resident 1 ' s neck was identified during the facility ' s 5-day follow-up investigation and did not warrant a report of potential abuse. During an interview on 12/9/24, at 1:45 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was taken to the emergency department of an acute hospital for evaluation of the unexplained bruising of Resident 1 ' s neck. The DON further indicated the facility had investigated and ruled out abuse, so there was no need to report the injury of unknown source to the Department. During a review of the facility ' s policy and procedure titled, Abuse Prevention Policy and Procedure, revised date 3/29/17, indicated, .It is the responsibility of staff, consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source .All injuries to unknown source will be reported to appropriate agencies .All suspected or alleged abuse/neglect will be investigated and reported to the local ombudsman or the local law enforcement agency by telephone or written document immediately or within 24 hours, and by written report sent within two working days .Facility shall report all incidents of alleged abuse/neglect or suspected abuse/neglect .to DHS [Department of Health Services] within 24 hours .

Based on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for two of 34 sampled residents (Resident 114 and 70) when: 1. Licensed Nurse 3 (LN 3) did not wear gloves during the administration of Resident 114's Paroxetine (medication used to treat depression) per physician's order; and 2. The dose for Resident 70's Zolpidem (medication used to treat insomnia [trouble falling asleep]) was not given but was signed as administered. These failures had the potential to result in contamination of the medication and exposure of Resident 114 and the LN to side effects, and confusion and inaccuracies in Resident 70's medication administration. Findings: 1. During a review of Resident 114's admission records, the records indicated Resident 114 was admitted in June 2024 with diagnoses which included depression. Resident 114's Minimum Data Set (MDS, an assessment tool) indicated Resident 114 had intact cognition. During a review of Resident 114's physician order dated 6/24/24, the order indicated, Paroxetine .40 MG (milligrams, a unit of measure) Give 1 tablet by mouth one time a day for depression m/b (manifested by) verbalization of declining health .Use single gloves if handling intact tablet; double gloves and gown if crushing. During the medication pass observation on 10/16/24 at 8:22 a.m. with LN 3 in Resident 114's room, LN 3 was observed preparing five medications which included Paroxetine. LN 3 mixed the pills in apple sauce without gloves and administered the medications to Resident 114. During a concurrent interview and record review on 10/16/24 at 10:14 a.m. with LN 3, LN 3 stated, I don't think we need to wear gloves for Paroxetine. LN 3 reviewed the physician order and confirmed Paroxetine order indicated to use gloves during administration and verified gloves were not used during the administration. LN 3 stated, Expectation is to follow what's ordered. During an interview on 10/17/24 at 4:12 p.m. with the Director of Nursing (DON), the DON stated, Expectation is to always follow the doctor's order, expectation is to wear gloves because that's the order. During a review of the facility's policy and procedure (P&P) titled, Nursing Responsibilities, undated, the P&P indicated, Nursing services shall provide individualized care to meet the needs of each resident following current standards and regulations .Licensed nurses shall be responsible for administering medications and treatment as follows: .Medications and treatments shall be administered as prescribed . During a review of an online document titled NIOSH [National Institute of Occupational Safety and Health] List of Hazardous Drugs in Healthcare Settings, 2020, dated 2020, the document indicated, .NIOSH defines a hazardous drug as a drug that is: a. Is accompanied by prescribing information in the package insert that specifies special handling information .to protect workers handling the drug; or b. Is identified as a carcinogenic hazard, developmental hazard, reproductive hazard, genotoxic hazard, or other health hazard .The drugs in Table 2 meet the NIOSH definition of a hazardous drug .These drugs exhibit one or more of the type of toxicity described in the NIOSH definition of hazardous drug .paroxetine .Only met the NIOSH criteria as a developmental and/or reproductive hazard. (www.cdc.gov/niosh/docket/review/docket233c/pdfs/DRAFT-NIOSH-Hazardous-Drugs-List-2020.pdf). During a review of the facility's P&P titled IIA2: Medication Administration-General Guidelines, revised 1/1/23, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .4) All personnel handling hazardous drugs must be trained and competent in facility hazardous drug communication program. Personnel are assessed per facility policy and procedures and will understand proper handling, administration .of hazardous drugs .B. Administration .2) Medications are administered in accordance with written orders of the prescriber. 2. During a review of Resident 70's admission records, the records indicated Resident 70 was admitted in June 2023 with diagnoses which included insomnia. Resident 70's MDS indicated resident had intact cognition. During a review of Resident 70's physician order dated 10/16/24, the order indicated, Zolpidem Tartrate Oral Tablet 5 MG .Give 2 tablet by mouth at bedtime for insomnia for 14 days . During a review of Resident 70's Medication Administration Record (MAR) for October 2024, the MAR indicated Resident 70's Zolpidem was administered on 10/3/24 at 8 p.m. During a review of Resident 70's Controlled Drug Record (CDR), dated 9/22/24, the CDR did not indicate Zolpidem was given to Resident 70 on 10/3/24. During a review of Resident 70's Medication Administration Note dated 10/3/24, the note indicated, Waiting for pharmacy delivery. During a concurrent interview and record review on 10/18/24 at 9:22 a.m. with the DON, the DON verified Resident 70's Zolpidem was signed as administered on the MAR and stated, I don't find October 3rd on CDR. The DON further stated, [Staff] signed it in the MAR but notes indicated waiting for pharmacy .I don't know when it was delivered, whether it was delivered or not, I don't know .the MAR indicated it was given .I don't know what she was thinking .[staff] should check it, it was coded as administered .sometimes it's the process with the new nurses .the problem is if the medication was actually administered, where did you get the medication .Unfortunately, it was a wrong code . During a review of the facility's P&P titled Nursing Responsibilities, undated, the P&P indicated, 18. Licensed nurses shall be responsible for administering medications and treatment as follows: .The date, time, drug and dose of the drug or treatment administered shall be recorded on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) by the person administering the drug or treatment. During a review of the facility's P&P titled IIA2: Medication Administration-General Guidelines, revised 1/1/23, the P&P indicated, D. Documentation .1) The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of the medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: .(2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician . (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing - State of California Department of Consumer Affairs).

Based on interview and record review, the facility failed to ensure the physician was notified in a timely manner of a medication refusal for one of 34 sampled residents (Resident 12). This failure had the potential to cause negative outcomes to Resident 12's physical and mental well being. Findings: A review of the admission Record indicated Resident 12 was admitted with diagnoses including pulmonary embolism (a blood clot gets stuck in a blood vessel in the lung blocking blood flow) and atrial fibrillation (irregular heart rhythm that may lead to blood clots if left untreated). A review of Resident 12's Order Summary Report indicated a physician order dated 9/26/24, Xarelto (blood thinner, treats or prevents blood clots) Oral Tablet 20 MG (milligram, unit of measurement) .Give 1 tablet by mouth one time a day for A. Fibrillation. Hold for heavy vaginal bleeding. On hold from 10/02/2024 .to 10/09/2024 . A review of Resident 12's care plan initiated 2/10/24 indicated, I am at risk for bleeding r/t: [related to] Xarelto use A review of Resident 12's Medication Administration Note indicated: -On 10/10 and 10/12/24, the note indicated Resident 12 chose not to take Xarelto since she's afraid she might bleed again; -On 10/11/24, the note indicated Resident 12 chose not to take Xarelto; and, -On 10/13 and 10/14/24, the note indicated Resident 12 chose not to take Xarelto. Resident 12 stated she might bleed again and she wants to talk to the [ordering physician] before taking the medication. In an interview on 10/15/24 at 1:40 p.m., Resident 12 stated she was just started on a blood thinner today and she was concerned about possible bleeding. In a concurrent interview and record review with the Director of Nursing (DON) on 10/16/24 starting at 4:43 p.m., the DON confirmed Resident 12's Xarelto was on hold for 7 days and should be resumed on 10/10/24. The DON further confirmed Resident 12 refused Xarelto for 5 days from 10/10 to 10/14/24. The DON stated this was an unusual case since Resident 12 had bleeding and her expectation was for licensed nurses to notify the ordering physician the first day Resident 12 refused to take the medication. The DON further stated the ordering physician was informed of the refusals on 10/15/24, 5 days later, and the DON added she could not find documentation that the primary care physician was notified of Resident 12's refusal to take Xarelto. A review of the facility's policy and procedure revised 01/01/2023, and titled, Medication Administration-General Guidelines indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .Refusals of Medication .Medications may be refused due to unwanted or unpleasant side effects .Facility staff should document on the MAR [Medication Administration Record] and/or medical record and notify the prescriber if medication is routinely refused .If medication doses are .refused .the physician is notified. Nursing documents the notification and physician response.

2. A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility in March 2024 with multiple diagnoses including dementia and diabetes (disorder characterized by difficulty in blood sugar control). A review of Resident 37's Minimum Data Set (MDS-a federally mandated resident assessment tool), Cognitive Patterns, dated 7/3/24, indicated Resident 37 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status) score of 6 out of 15 that indicated Resident 37 had severe cognitive impairment. A review of Resident 37's MDS, Functional Abilities and Goals, dated 7/3/24, indicated Resident 37 required moderate assistance for bed mobility. A review of Resident 37's Braden Scale for Predicting Pressure Sore Risk Original [tool used to predict the risk of pressue ulcers], dated 7/4/24, indicated Resident 37 was at moderate risk for developing pressure sores and had problem with friction and shear due to frequently sliding down in bed leading to almost constant friction. A review of Resident 37's Care Plan, initiated 9/1/24, indicated Focus .I have a higher potential for and actual impairment to skin integrity .r/t [related to] fragile skin, coumadin [blood thinner medication] use .Interventions I need (pressure relieving/reducing mattress, pillows, padding, etc) to protect the skin while in bed .Use caution when repositioning or transferring me to avoid friction . During an observation on 10/15/24 at 8:47 a.m., observed Resident 37 in bed asleep with foot cradle in place. Observed towels and linens on top of foot cradle frame weighing down the blanket causing blankets to be laying directly on Resident 37's lower legs and feet. During a concurrent observation and interview on 10/15/24 at 9:15 a.m. with Licensed Nurse (LN) 3, observed towels and linens on top of Resident 37's foot cradle, weighing down the blankets causing the blankets to be laying directly on her lower legs and feet. LN 3 acknowledged that the towels and linens should not have been placed on the top of the foot cradle. LN 3 stated, It defeats the purpose. During an interview on 10/15/24 at 9:45 a.m.with Certified Nursing Assistant (CNA) 3, reviewed that towels and linens were on top of Resident 37's foot cradle weighing the blankets down on her lower legs and feet. CNA 3 stated, I shouldn't have done that. I brought in blankets and towels for her bath and got called away to another resident and had to leave. I was in a hurry. It defeated the purpose of the foot cradle. During an interview on 10/17/24 at 11:42 a.m. with the DON, the DON stated the foot cradle is a nursing intervention and does not need a physician's order. The DON stated the foot cradle is used to make sure pressure is not on the lower extremities and is used if there is a wound or to make sure a wound does not develop. Reviewed observation of Resident 37 with towels and linens on top of foot cradle weighing down the blankets onto the lower extremities. The DON acknowledged, It should not have happened. A review of the facility's policy and procedure (P&P) titled Skin Care and Wound Management, revised 8/18, indicated .To provide routine preventive measures and care specific to resident's indivudual risk factors/needs .Avoid friction and shearing .Provision of other pressure redistributing devices such as pillows, linen rolls, heel and elbow protectors, roho cushions, gels cushions, splints, etc. to keep bony prominences from direct contact with one another or other unrelieved pressure .All staff will take preventative measures in an effort to stabilize or improve co-morbidities for residents at risk for skin breakdown . Based on observation, interview, and record review, the facility failed to provide services to prevent pressure injuries (localized pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for 2 of 34 sampled residents (Resident 3 and Resident 37) when: 1. Resident 3 did not have a foot cradle (device used to relieve pressure from the lower extremities by preventing blankets and linens from laying directly on the lower extremities) and sheepskin padding in place as ordered by physician; and, 2. Resident 37's foot cradle was used incorrectly when linens and towels were placed on top of the frame allowing bed linens and blankets to lay directly on lower extremities. These failures had the potential to result in Resident 3 and Resident 37 developing pressure injuries. Findings: 1. A review of the admission Record indicated Resident 3 was admitted with diagnoses including unspecified dementia (a progressive state of decline in mental abilities). A review of Resident 3's physician order's indicated orders for Foot cradle in bed dated 10/11/14, Sheepskin padding to bed hand rails dated 2/5/24, and Sheepskin padding to wheelchair arm rests dated 10/30/23. A review of Resident 3's care plan indicated the following: -a care plan initiated 12/26/2019 indicated, I have impaired cognitive function/dementia or impaired thought processes [related to] Dementia.; -a care plan for I have a higher potential for impairment to skin r/t [related to] fragile skin . and actual impairment to skin integrity . on 9/4, I have a discoloration to my [left anterior] forearm when I bumped my arm on bed handrail during repositioning. I have blanchable redness to my bilateral heels [due to] friction of rubbing heels on bedding . on 10/12 I sustained redness to my [left] great toe r/t friction from blankets. The interventions included sheepskin padding to protect the skin while in bed and while up in a chair. In an observation on 10/16/24 starting at 12 p.m., Resident 3 was sitting upright in bed while eating her pudding. Resident 3 was covered with a blanket from her waist to her feet. There was no foot cradle in bed, and there was no sheepskin padding on the bed hand rails and wheelchair arm rests. In a concurrent observation and interview on 10/16/24 at 12:18 p.m., the Certified Nursing Assistant 2 (CNA 2) confirmed Resident 3 had no foot cradle in bed and there was no sheepskin padding on the hand rail and the wheelchair arm rests. The CNA 2 further stated the foot cradle was requested last Friday due to redness on Resident 3's toe and heels. In an interview on 10/16/24 at 12:24 p.m., the Licensed Nurse 2 (LN 2) stated the foot cradle for Resident 3 will prevent pressure and the foot cradle should be used even when resident was in bed eating. The LN 2 further stated Resident 3 had the sheepskin on the wheelchair arm rests due to resident being prone to skin discoloration. A concurrent observation and interview was conducted on 10/17/24 at 10:35 a.m. with CNA 2 inside Resident 3's room. Resident 3 had slight redness on her left great toe and redness on both heels. The CNA 2 stated she took the sheepskin from the linen room yesterday and the LN 2 asked maintenance for a foot cradle for Resident 3 yesterday. In a concurrent observation and interview on 10/18/24 starting at 9:24 a.m., Resident 3 was up in her wheelchair in the main dining room. The Activity Assistant (AA) confirmed Resident 3's wheelchair arm rests had no sheepskin padding. The AA further stated she saw Resident 3 earlier today and resident was removing the sheepskin from her wheelchair. In a concurrent interview and record review on 10/18/24 at 10:16 a.m., the Director of Nursing (DON) confirmed Resident 3 had orders for foot cradle, and sheepskin padding for the bed hand rails and wheelchair arm rests. The DON stated her expectation was for physician orders to be followed and implemented. The DON further stated the sheepskin was used to prevent skin injury or trauma and the foot cradle was to prevent pressure on the toes. The DON added if staff observed Resident 3 removing the sheepskin, it should be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 45) received care and services to address her right hand contracture (a tightening of the muscles, tendons, and skin, causing resident's fingers to bend and curl towards the palm), when the facility did not implement preventative measures to maintain the resident's hand mobility and prevent worsening of Resident 45's contracture. This failure resulted in Resident 45 experiencing a severe right hand contracture leading to further decline in use of her hand and had the potential to result in pain and skin problems. Findings: A review of Resident 45's admission Record indicated the facility admitted the resident in 2016 with multiple diagnoses including hemiplegia (paralysis of one side of body) and hemiparesis (weakness of half of the body) following a stroke affecting the right dominant side). A review of the physician progress note dated 9/29/23 indicated Resident 45 was alert and oriented, cooperative, and interactive. The physician documented that the resident had right sided weakness with right upper extremity mild contracture. A review of Resident 45's Minimum Data Set (MDS, and assessment and care planning tool) dated 7/9/24 indicated she was cognitively intact. Resident 45's MDS dated [DATE], 4/8/24, 7/9/24 section O, indicated the resident did not use a brace or hand splint (medical devices that support and stretch the fingers and keep them in proper position preventing contractures). A review of Resident 45's clinical records did not contain any documented evidence the facility addressed the resident's right hand contracture and implemented preventative measures to maintain the resident's hand mobility and prevent further decline in her right hand. A review of Resident 45's clinical records failed to reveal a care plan addressing her hand contracture and measures to prevent further deterioration of the resident's hand. During an observations on 10/15/24 at 12:16 p.m., Resident 45 was sitting in the wheelchair in her room with her right hand held close to her body. Resident 45 was pleasant and responded to questions appropriately. Resident 45 stated she exercised her legs 2 or 3 times a week on a specialized bicycle. Resident 45 used her left arm to lift the right arm and showed her right hand closed into a fist with fingers curled tightly inside and nails digging into skin. The resident's right hand had no splint or brace. During a continued interview, Resident 45 stated her fingers curling had worsened over time and it was impossible to open her fist. Resident 45 added that it was painful to loosen the fingers when washing and drying her hand. Resident 45 stated she could not recall if the facility used any assistive devices such as brace or hand splint for her contracture. During a concurrent observation and interview on 10/16/24 at 3:02 p.m., Certified Nursing Assistant (CNA 1) stated she was familiar with the Resident 45's care. CNA 1 validated that Resident 45's right side was very weak and her right hand was contracted. CNA 1 stated it was difficult to open the resident's hand and wash inside of the palm because the resident's fingers were tightly curled inside. CNA 1 stated she had never seen the resident wearing a brace or splint to manage the hand contracture. During an interview on 10/16/24 at 3:25 p.m., Licensed Nurse (LN 1) stated that Resident 45 was admitted to the facility several years ago after she had a stroke, had right sided weakness and right hand contracture. LN 1 stated she could not recall seeing Resident 45 wearing a brace or hand splint for her hand contracture. During an interview on 10/16/24 at 3:30 p.m., a unit supervisor stated that Resident 45 had been in the facility for a long time. When the unit supervisor was asked what measures were implemented to manage the resident's hand contracture, she stated, I think she had a splint a while ago, but I don't know what happened to it. The unit supervisor confirmed that there was no hand splint or brace to manage the resident's contracture. During an interview and concurrent records review on 10/16/24 at 3:40 p.m., PT(Physical Therapist) stated that Resident 45 received physical therapy from 10/2016 through 12/2016. Upon reviewing physical therapy notes, the PT stated that Resident 45's therapists documented the resident's right upper extremity and hand were stiff and rigid during therapy. The PT explained that those conditions placed the resident at risk for developing contractures if not treated. The PT stated she was not able to find any documented evidence Resident 45 was assessed for hand splint or brace to prevent hand contracture. An interview with the Director of Rehab (DR), who was a Certified Occupational Therapy Assistant (COTA) was conducted on 10/17/24 at 9:25 a.m. The COTA stated that occupational therapists handled all residents with upper extremities limitations. The COTA stated, I have never worked with her [Resident 45], never assessed her right arm and hand limitations .I was never directed to address her contracture . She has been on Omnicycle [a specialized machine to exercise] which helps for her lower extremities, nothing for upper extremities. During a continued interview, the COTA stated, We have monthly rehabilitative nursing assistant meetings and we have never discussed her right hand contracture. The COTA stated she was unable to find any documentation addressing Resident 45's right hand contracture. During an interview and a concurrent record review on 10/16/24 at 3:50 p.m., the Director of Nursing (DON) stated Resident 45 had right hand contracture. The DON acknowledged that the resident's clinical records did not contain a care plan addressing her hand contracture. The DON stated that it was her expectation that the care plan with interventions to maintain resident's hand limitations and contracture should have been initiated upon resident's admission and revised as needed. The DON added that it was important to have a care plan which provided direction on the type of treatment and care the resident required. The DON stated she could not find any documentation addressing Resident 45's right hand contracture.The DON stated the resident has been in the facility for many years and she needed to look for more records. During a follow up interview with the DON on 10/17/24 at 1 p.m., the DON stated the facility focused on exercising Resident 45's lower extremities. The DON stated she was unable to find any documentation addressing the resident's right hand contracture. The DON stated her expectation was that the therapy identified and addressed the resident's right hand weakness. A review of the facility's 'Rehabilitative Nursing Care' policy revised 4/13, indicated, Our facility has an active program of rehabilitative nursing .The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain optimal level of self-care and independence.

Based on observation, interview, and record review, the facility failed to ensure proper storage, usage, handling, and labeling of respiratory care equipment were consistent with the facility's policy and procedures (P&P) for one of 34 sampled residents (Resident 13) when a nebulizer (a machine that turns medicine into a mist) mask and tubing were not properly stored and replaced as ordered, and nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was used and connected to a nebulizer machine. These failures had the potential to result in unsafe and unsanitary delivery of respiratory treatments to Resident 13. Findings: 1a. During a review of Resident 13's admission records, the records indicated Resident 13 was admitted in April 2023 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, diseases that block airflow and make it difficult to breath), shortness of breath, and dependence on supplemental oxygen. Resident 13's Minimum Data Set (MDS, an assessment tool) indicated Resident 13 had intact cognition. During a review of Resident 13's physician order revised 9/14/24, the order indicated, Change nebulizer mask/tubing storage bag monthly and PRN with date and initial . During a review of Resident 13's physician order revised 9/22/24, the order indicated, Change nebulizer mask and tubing weekly and PRN with date and initial . During a review of Resident 13's physician order dated 10/14/24, the order indicated, Ipratropium-Albuterol [used to control the symptoms of lung diseases such as asthma and emphysema] Solution .3 milliliter [a unit of measurment] inhale orally every 4 hours as needed for SOB (shortness of breath) or Wheezing via nebulizer. During a review of Resident 13's Medication Administration Record (MAR) for October 2024, the MAR indicated Ipratropium-Albuterol Solution via nebulizer was administered on 10/14/24 at 6:16 a.m. During a review of Resident 13's progress notes dated 10/14/24, the notes indicated, Resident had 1x (one time) episode of vomiting. Resident requesting a nebulizer treatment, given as ordered. During an observation on 10/15/24 at 9:42 a.m. in Resident 13's room, Resident 13's nebulizer mask and tubing were observed placed on top of the nightstand without a storage bag and the tubing was dated 9/22/24. During a concurrent observation and interview on 10/15/24 at 10:13 a.m. with Resident 13 and Licensed Nurse 4 (LN 4) in Resident 13's room, LN 4 confirmed the nebulizer mask and tubing were on top of the table and not stored in a bag while not in use. LN 4 stated, It should be in a bag. Resident 13 stated, I didn't have a bag for that. LN 4 confirmed the tubing was labeled 9/22/24, and stated, We have to change this one . LN 4 further stated, [It is an] infection control issue if it's just laying in there .line [tubing] is almost a month, it's infection control issue. During a concurrent interview and record review on 10/17/24 at 10:27 a.m. with the Infection Preventionist (IP), the IP stated, On storage of nebulizer kits, we put them on the clean black bag after cleaning, write their name, the date of first use, we change the bag once a month .we expect the staff to follow policy on changing kits. The IP verified Resident 13's physician order indicated to change nebulization mask and tubing weekly and PRN and stated, If not changed weekly, the problem is of course infection. If not stored properly, can cause possible respiratory infection to the resident .We have to throw everything away because it's not clean anymore and contaminated with organisms or bacteria. When a picture of the tubing label was shown to the IP, the IP stated, We are not compliant with the order and the policy .the date is almost a month. During an interview on 10/17/24 at 3:57 p.m. with the Director of Nursing (DON), the DON stated, Expectation on nebulization mask and tubing is to follow the order, that's why it's there .They are supposed to be in the black bag, if we don't have that, we can use ziplock (resealable) bag, supposed to be labeled with resident name and date opened .seven days for the tubing and mask and PRN, 30 days for the bag and PRN .That's an infection control issue, you don't know what contaminants can be introduced to the resident. During a review of the facility's P&P titled IIB8: Oral Inhalation Administration, revised 1/1/23, the P&P indicated, Purpose .To allow for safe, accurate, and effective administration of medication using an oral inhaler .or nebulizer .W. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it .X. Change equipment and tubing per manufacturer's recommendations. 1b. During a review of Resident 13's physician order revised 4/23/23, the order stated, Oxygen at 2 liters/minute [a measurement of volume] via nasal cannula every shift for COPD. During a review of Resident 13's MAR for October 2024, the MAR indicated oxygen was administered via nasal cannula on 10/18/24 day shift. During an observation on 10/18/24 at 10:11 a.m. in Resident 13's room, nasal cannula was observed hanging on top of the nightstand without storage bag and connected to nebulizer machine. During a concurrent observation and interview on 10/18/24 at 10:13 a.m. with the IP in Resident 13's room, the IP confirmed the observation and stated, Tubing should be in a bag .I'll change it because it's already contaminated. The IP confirmed the nasal cannula was connected to nebulizer machine and stated, That's the wrong one. During a concurrent interview and record review on 10/18/24 at 11:42 a.m. with the DON, the DON verified Resident 13 had orders for oxygen 2 liters via nasal cannula and was administered in the morning of 10/18/24. The DON stated, We use oxygen concentrators for oxygen therapy. When a picture of nasal cannula connected to nebulizer was shown, the DON stated, What in the world? I can't think that a nurse can do it, I can't really imagine, I just don't see it but connecting a nasal cannula, connected to nebulizer? During a review of the facility's P&P titled Oxygen Administration, revised 10/2010, the P&P indicated, 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter .b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose .7. Check the tubing connected to the oxygen cylinder to make sure it is free from kinks .9. Place appropriate oxygen device on the resident .

Based on interview and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice for one of 34 residents (Resident 34) when doses of Resident 34's PRN (as needed) pain medication were given without adequate indication. This failure had the potential to increase Resident 34's risk of exposure to side effects and dependence on pain medication. Findings: During a review of Resident 34's admission record, the record indicated Resident 34 was admitted in September 2024 with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of half of the body), and disorders of bone density (amount of minerals in the bone) and structure. Resident 34's Minimum Data Set (MDS, an assessment tool) indicated Resident 34 had moderate cognitive impairment. During a review of Resident 34's Pain Assessment, dated 9/5/24, the assessment indicated Resident 34 was able to self-report pain and could comprehend use of numerical pain scale. The assessment further indicated Resident 34's goal for pain management on a scale of 1-10 is 1. During a review of the facility provided document titled Descriptive Pain Grid, undated, the document indicated the 0-10 Numerical Pain Scale was implemented for residents who are verbal and alert with 0-1 as no pain, 2-4 as mild pain, 5-7 as moderate distressing pain, 8-9 as severe pain, and 10 as excruciating pain. During a review of Resident 34's physician order dated 9/7/24, the order indicated, Hydrocodone-Acetaminophen (Norco, used to treat moderate to severe pain) Oral Tablet 10-325 MG (milligrams, a unit of measure) .Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain . During a review of Resident 34's Medication Administration Record (MAR) for September 2024, the MAR indicated Resident 34's Norco was given on 9/7/24 at 8:46 p.m. with pain level of 3, on 9/8/24 at 4:01 p.m. with pain level of 1, on 9/9/24 at 7:50 p.m. with pain level of 1, and on 9/30/24 at 7:08 p.m. with pain level of 3. During an interview on 10/17/24 at 10:13 a.m. with LN 4, LN 4 stated, We ask where the pain is, use the pain scale 1-10, moderate pain is usually around 5-7. If the complaint is 1/10, I won't give Norco if the order is moderate pain. I'll check if there is an order for Tylenol [medication used for minor aches and pains] .but not Norco .because it is usually for moderate to severe pain. During an interview on 10/17/24 at 10:41 a.m. with LN 5, LN 5 stated, I'm very careful with narcotics, it affects [residents] a lot .will not give Norco if pain is 1/10 because it is not moderate pain at all. If it was given unnecessarily, it's a narcotic, the resident will sleep most likely, might have possible respiratory or breathing issues, and possible dependence. During a concurrent interview and record review on 10/17/24 at 3:27 p.m. with LN 1, LN 1 verified Resident 34 received Norco on September 7, 8, 9, and 30, 2024, and confirmed she gave the doses. LN 1 stated, I asked [Resident 34] if she wants Norco or Tylenol, she usually requests Norco .Moderate [pain] for me is 1-5 or 6 and severe [pain] is 7-10 .I haven't seen pain scale chart on my cart. LN 1 further stated, Resident requested it .I did not notify the doctor .the resident could become dependent on it, or the medication will not work anymore. During a concurrent interview and record review on 10/17/24 at 3:42 p.m. with the Unit Supervisor (US), the US confirmed Resident 34 received Norco on September 7, 8, 9, and 30, 2024, and stated pain levels were mild when the Norco doses were given on those dates. The US stated, I go by the number, if that's me, it should be Tylenol, then I'll follow up .They are going to be dependent on Norco, if you offer Tylenol, they will ask for Norco because they are getting dependent on it. During a concurrent interview and record review on 10/17/24 at 3:57 p.m. with the Director of Nursing (DON), the DON stated, The pain scale is embedded in the eMAR (electronic MAR), the system will ask the nurse, it will pop-up before giving the medication and the nurse will select the level of pain .System will not let you give the medication without selecting the pain level. It has numbers and it tells you what level of pain it is. The DON verified Resident 34 had an order for Norco for moderate to severe pain as needed. The DON confirmed Norco was given for pain levels of 1 to 3 on September 7, 8, 9 and 30, 2024, and stated, I don't think that's moderate. The DON confirmed that Norco was given without indication and stated, The medication was given, it could be unnecessary .Even if the resident wants Norco, doctor should be notified .because it's not within the doctor's order .Expectation is to always follow the doctor's order. During a review of the facility's policy and procedure (P&P) titled IIA2: Medication Administration-General Guidelines, revised 1/1/23, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .2) Medications are administered in accordance with written orders of the prescriber. During a review of the facility's P&P titled Pain Management, revised 5/2022, the P&P indicated, .To assure an accurate assessment and management of the resident's pain and response in a timely manner with administration of pain medication or non-drug intervention as appropriate for the resident .It is the policy of this facility to assess all residents for pain on admission; each time vital signs are monitored, when pain medication is given and as indicated .The licensed nurse shall assess the resident's pain utilizing one of the pain scales located on e MAR .

Based on observation, interview, and record review, the facility failed to ensure food storage and service was in accordance with professional standards for food service safety, for the 139 residents who ate facility prepared meals when: 1. The cook's refrigerator was found with the temperature varying anywhere from 42-50 degrees Fahrenheit; 2. The three-door freezer (used for meats) had ice buildup behind the second and third doors, around the top of the door frame; 3. The three-door freezer had an open box of vegetarian meatballs that was exposed to the air; 4. Three fans were found with discolored blades; 5. Two metal shelves in cook's preparation area found with rusted areas; and 6. Four cutting boards found with black staining and deep grooves on cutting surfaces. These failures had the potential of leading to food borne illness for the 139 residents eating facility prepared meals. Findings: 1. During the initial kitchen tour on 10/15/2024 at 8:15 a.m., the temperature for the cook's refrigerator was found varying between 42 degrees Fahrenheit (F, a unit of measurement) for the internal thermometer and 50 degrees F for the external thermometer. During a concurrent interview with the Dietary Services Supervisor (DSS), the DSS confirmed the observation and stated that he believed the high temperature was due to the refrigerator being opened multiple times during the breakfast preparation. During a revisit to the kitchen on 10/16/24 at 10:02 a.m., the cook's refrigerator internal thermometer read 44 degrees F. A cottage cheese and fruit cup located in the refrigerator had a temperature of 43.4 degrees F. The DSS concurred that the temperature was too high and asked staff to discard the cottage cheese cups. During a revisit to the kitchen on 10/17/2024 at 8:31 a.m., the cook's refrigerator was observed. The outside temperature read 36 F, and the inside temperature was found at 46 degrees F. The DSS confirmed the observation during temperature check. A review of facility policy titled Procedure For Refrigerator Storage dated 6/14/23 from Health Menus Direct, LLC. 2023 indicated that 1. Refrigerator- 41 degrees F or lower . 4. Refrigerator doors are to close tightly and should be opened as little as possible to prevent storage temperature fluctuations. Review of the United States Food and Drug Administration Food Code section 2-103.11 on Person in Charge indicated that upon delivery, all food must be appropriately stored in a safe and secure manner . For example, time/temperature control for safety foods must be stored within refrigeration units and held at temperature of 41 degrees F or below. Review of the United States (US) Food and Drug Administration (FDA) Food Code section 4-501.11 on Good Repair and Proper Adjustment indicated that Proper Maintenance of equipment to manufacturer specification helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violation of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. 2. During a concurrent observation and interview on 10/15/2024, within the initial kitchen tour at 8:56 a.m. with the DSS in the kitchen, the 3-door freezer was noted with ice buildup around the top of the door frame. The DSS confirmed the observations. A review of facility policy and procedure (P&P) titled Procedure For Refrigerator Storage dated 6/14/23 from Health Menus Direct, LLC. 2023 indicated that 4. Refrigerator doors are to close tightly and should be opened as little as possible to prevent storage temperature fluctuations. A review of the US FDA 2022 Food Code, section 3-305.11 titled Food Storage indicated (A) Except as specified in (B) and (C) of this section, Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; Review of Refrigerated Design Technologies (solutions.rdtonline.com) discussion on ice buildup indicated that Icing can prevent freezers from operating properly, causing compressors to work overtime in order to keep temperatures at ideal conditions. When frost forms and excessive defrost cycles are required, this inevitably causes energy bills to rise as temperatures are kept low . Frost and icing can also cause freezer burn. This ultimately damages the integrity of food. As ice crystals form on an operation's valuable ingredients, they damage the flavors, aromas and even the safety of food products being stored in the freezer. 3. During a concurrent observation and interview on 10/15/2024, within the initial kitchen tour at 8:56 a.m., with the DSS, the three-door freezer had an opened box of vegetarian meatballs that was exposed to the air and had visible ice buildup (freezer burn) on the surface. The DSS confirmed the observations and removed meatballs from the freezer. A review of the facility's P&P titled, Procedure For Refrigerator Storage, dated 2023, indicated, 13. Food that has been freezer burnt must be discarded. A review of the US FDA 2022 Food Code, section 3-305.13 titled Vended Time/Temperature Control for Safety Food, Original Container indicated that The possibility of product contamination increases whenever food is exposed. In addition, time/temperature control for safety foods . Once the original seal is broken, the food is vulnerable to contamination. A review of the US FDA 2022 Food Code, section 3-307.11 on Miscellaneous Sources of Contamination indicated that Food shall be protected from contamination . 4. During a concurrent observation and interview on 10/15/2024 within the initial kitchen tour at 9:15 a.m., a fan in the tray preparation room was found with discolored blades. The fan was positioned so that it blew down on the clean trays and eating utensils. The DSS confirmed the observation of the dusty blades and stated that the fans were to be cleaned by the maintenance department. During a revisit to the kitchen on 10/16/24 at 9:09 a.m., a fan in the cook's area by the window that residents visit was noted to have a dark, fuzzy coating on the blades. Later, during this same visit to the kitchen at 9:40 a.m., the fan in the dish room was observed to have a fuzzy, dark film on the outer blades. A review of facility P&P titled, Section 8 Sanitation, dated 8/1/2023 indicated, 11. All utensil, counters, shelves, and equipment shall be kept clean, maintained in good repair . A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 5. During a concurrent observation on 10/15/2024 within initial kitchen tour at 9:21 a.m., two metal shelves in the cook preparation area were found with rusted areas on the surface of up to 8 inches by 12 inches in diameter. During an interview on 10/17/24 at 3:11 p.m., with the DSS, the DSS concurred that rust on surfaces interfered with the cleaning and sanitizing of items, which could lead to cross contamination of food. A review of the facility's P&P titled, Section 8 Sanitation dated 8/1/2023 indicated, 11. All utensil, counters, shelves, and equipment shall be kept clean, maintained in good repair . A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 6. During a concurrent observation and interview on 10/16/2024 at 9:35 a.m., four cutting boards were found with black staining and deep grooves on the cutting surfaces. The DSS confirmed the observations. A review of the facility's P&P, titled, Section 8 Sanitation, dated 8/1/2023, indicated, 11. All utensil, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped area. A review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 4-501.12, titled Cutting Surfaces, 1/18/23 version, indicated, Cutting 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 foods that are prepared on such surfaces.

Based on observation, interview, and record review the facility failed to provide consistent guidance to staff regarding food brought to residents from outside sources. This failure had the potential of unsafe food items being distributed to the 139 residents leading to choking risk, allergic reactions, and food borne illness. Findings: During a review of facility policy and procedure (P&P) on 10/15/2024 at 1:18 p.m., from the survey binder titled Food Brought To Resident By Family/Friends/Activity Department revised 11/28/16 indicated that 6. Cooked left-over food be discarded after two (2) hours bedside. The policy did not include procedures for storing food for residents. During an interview with the Quality Assurance (QA) nurse on 10/15/24 at 3:20 p.m. in unit 2, the QA nurse stated that family can bring food into facility for resident. Food brought for the resident would be stored in the resident refrigerator. The QA nurse showed where the resident refrigerator was located in the hospitality suite. An observation of signage on the resident refrigerator indicated All staff must label; name and date on personal & resident food/beverage items. any unlabeled food found in fridge on cleaning days will be thrown away. Perishable foods are to be thrown away 3 days after the date labeled. During an interview of Licensed Nurse 6 (LN 6) on 10/15/2.4 at 3:37 p.m. in unit 1, LN 6 stated that food brought to residents from outside would be checked to make sure it is safe for the resident (such as ensuring it didn't have allergens that the resident may react to). The food would be labelled with the resident name and date brought to facility before storing in the refrigerator. LN6 further stated the food would be tightly sealed to prevent cross contamination. Once in the refrigerator the food could be kept for 24 hours before being discarded. During an interview of Certified Nursing Assistant (CNA) 6 on 10/15/24 at 3:55 p.m., CNA 6 stated that food from outside would be labeled with the resident name and date brought in and stored in the resident refrigerator for up 3 days. During an observation on 10/15/2024 at 4:11 p.m. of the resident's refrigerator/freezer located in the Hospitality Suite, expired and unlabeled foods were found. The refrigerator contained the following expired items: a box of 12 flavored Greek yogurts with a use-by date of October 11th, 2024, a jar of Kimchi best by date of July 2024, a cartoon of vanilla medication drink with a use-by date of September 12, 2024, and an opened apple juice carton labeled 1/17/24. The refrigerator also contained a chocolate shake without any labeling, a package of bologna without a date, 2 unlabeled black tea drinks, 1 unlabeled can of sparkling, white tea; and one unlabeled canned soymilk. The freezer contained an unlabeled, undated plastic container of frozen fruit, 3 unlabeled containers of ice cream, a bag of 4 sandwiches without a date, and half a sandwich in a brown bag with no date or name. During a concurrent observation and interview of the resident refrigerator on 10/16/2024 at 2:40 p.m. with the Director of Nursing (DON) and the QA nurse, the DON stated Our expectation is that housekeeping is checking this fridge and throwing any expired items out. Anything that doesn't have a name or is past 72 hours, housekeeping will discard it. If sealed, we may use the manufacturer's use-by date. The DON further confirmed the expired foods and went on to state that, My expectation is that all items have a last name, date, and room number. Housekeeping should be cleaning it out. The nursing department knows to name and date items. The DON further confirmed that staff would not know when food was no longer safe to eat without the inclusion of dates. Due to inconsistent staff practices, the policy for outside food was requested again in an attempt to understand facility practices. Review of 2nd policy received titled Food For Resident From Outside Sources (Healthcare Menus Direct LLC. dated 2023) indicated that If opened, the food must be sealed, dated to the date opened and disposed by the best by date or . disposed of in 2 days after opening. Frozen items, such as ice cream will be disposed of in 30 days. This policy differed from the first policy which did not allow resident food to be kept longer than 2 hours at bedside. It also differed from the resident refrigerator signage which indicated that food could be kept for 3 days after opening. This confusion could lead to unsafe practices with staff uncertain as to correct procedures.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety for one of three sampled residents (Resident 1), when he was verbally threatened and then hit and kicked by Resident 2. This failure resulted in Resident 1 sustaining skin tears to the bridge of his nose and right arm, large abrasion to his left shoulder, experienced pain, and had the potential to negatively affect his long term emotional well-being. Findings: A review of the facility's policy titled, Resident to Resident Abuse, dated 3/2017 indicated, Our facility will not condone resident abuse by anyone .Facility will monitor residents for aggressive/inappropriate behavior towards other residents .or the staff. A review of the admission Record indicated the facility admitted Resident 1 in the summer of last year with multiple diagnoses, including tremors (excessive shaking or trembling). Resident 1 scored 13 out of 15 in a Brief Interview for Mental Status (BIMS, tests memory and recall) dated 1/2/24, which indicated he was cognitively intact. According to the admission Record for Resident 2, he was admitted to the facility in 2019 with multiple diagnoses, including dementia and Alzheimers (a condition marked by memory disorders, personality changes, and impaired reasoning). Resident 2's BIMS, dated 12/28/23, indicated he scored 11 out of 15 which indicated he had moderate cognitive impairment. A review of physician progress notes, dated 12/12/23 indicated, [Resident 2] is currently oriented to person, place, date: no awareness of situation .According to staff [Resident 2] has days where he uses language that is not acceptable/appropriate towards staff .needs redirection. A review of 'Nursing Weekly Summary,' dated 1/11/24 at 10:13 p.m., and 1/18/24 at 2:17 p.m., contained the following documentation for Resident 2, Monitoring behavior for calling staff stupid/dumbass. Redirection needed. According to a report received by the Department on 1/22/24, Resident 2 was observed outside of his room, yelling and threatening to kick Resident 1 and break his neck. The report further indicated that Resident 2 was observed swinging fists at [Resident 1]. [Resident 1] was trying to defend himself but was too short and too weak. [Resident 1] ended up on the floor .[Resident 2] continued to swing and kick at [Resident 1]. During an interview on 1/30/24 at 11:05 a.m., the Laundry Staff (LS) explained that on 1/21/24 around 5:45 a.m., as she delivered linen to the hall, she observed Resident 2 standing in the hall by his room and screaming and shouting, threatening to hurt Resident 1. The LS stated that if she observed a resident to be aggressive, she would normally call the charge nurse for help, but there were several of the staff at the nursing station, close to Resident 2's room and she thought they would intervene. The LS stated that she had in the past witnessed Resident 2 being rude and verbally aggressive to staff. During an observation and interview on 1/30/24 at 11:20 a.m., Resident 1 was observed lying in his bed. Resident 1 stated he vividly remembered that morning when Resident 2 kicked his door open. Resident 1 explained, He [Resident 2] stood by the door, angry looking, puffing and huffing. This was not the first time that he yelled at me about the bathroom . Staff knows how inpatient he is .Unfortunately we are sharing a bathroom and he thinks he can control when I use the bathroom .I asked him, What's going on this time? He started screaming and yelling at me, calling me all kinds of names, cussing his head off. Resident 1 stated that he had not been to the bathroom that morning for more than 1 hour and 45 minutes. Resident 1 continued, .He grabbed my left foot and started to pull me out of bed. I managed somehow to escape his grip and got out on the other side of the bed. He .came around and started hitting me, beating the crap out of me .and then I went down. I was trying to defend myself, but he is stronger, and he easily overpowered me. He was .hitting me hard and kicking me. I was trying to cover my face and my head. Both of us were screaming and then the staff came in. During a continued interview on 1/30/24 at 11:20 a.m., Resident 1 stated that as a result of the altercation, he received small skin tears to his right arm, was hit on the face and pointed to the bridge of his nose where he had a small dry scab and got his eyeglasses messed up. Resident 1 pointed to his left shoulder and stated that the abrasion hurt for a while and he had to take pain medications. Resident 1 stated, Still scared of him, he's much stronger and tempered man. They moved him down the hall and I see him every time I go to gym .He's standing in the doorway watching .Gives me dirty looks .I feel safe as long as I don't see him. During an interview on 1/30/24 at 11:45 a.m., Resident 2 was sitting a wheelchair in his room. Resident 2 explained that a few nights ago, he woke up in the morning and needed to use the bathroom right away. Resident 2 stated when he saw the bathroom lights on, he assumed that next door resident was there. Resident 2 added, I was mad that I could not use it. Resident 2 stated he did not call staff before going to Resident 1's room and stated, I went to his room and tried to pull him out of his bed. Then I hit him 3 times. During a telephone interview on 2/7/24 at 2:50 p.m., Certified Nursing Assistant (CNA 1) stated on 1/30/24 around 6 a.m., she witnessed Resident 2 standing by the room entrance. CNA 1 stated Resident 2 was yelling and cursing everybody .his typical behavior. CNA 1 stated that Resident 2 yelled at her and used inappropriate words when she offered to weigh him. CNA 1 explained, I left .went looking for help . all happened so fast . we walked in [Resident 1] was sitting on the floor covering his head and [Resident 2] was kicking and hitting him. The other CNA .could not stop him hitting [Resident 1], he's a very tall and strong man. Then more staff . came and were able to separate them. CNA 1 stated she heard Resident 2 threatening to hurt Resident 1, saw him being verbally aggressive but had not seen him being physically aggressive. During an interview on 1/30/24 at 12:02 p.m., the Social Services Director (DSD) confirmed the incident when Resident 2 physically attacked Resident 1. The SSD stated, I know [Resident 2] has a difficult personality . he wants to be in control of everything. The SSD stated Resident 2 denied allegations initially when she talked to him, but then he admitted that he hit Resident 1 because he was angry. The SSD stated Resident 2 was not violent and had not attacked anyone physically in the past. A review of the facility's Supervision of Resident Care, undated policy, indicated the purpose of the policy was to assure that the resident's safety and well being are maintained. The policy indicated, All residents receive adequate supervision. During a concurrent interview and record review on 2/7/24 at 3:33 p.m., the Director of Nursing (DON) validated that Resident 2 had a known history of verbal aggression. The DON was asked how the facility ensured that residents' safety was maintained and the residents were protected from verbal and physical abuse. The DON stated, Supervise environment. If we see/hear that a resident becomes aggressive verbally or physically staff intervenes immediately. Residents with dementia are unpredictable, one minute they are okay and the next they strike out. Need close supervision.

Based on interview and record review, the facility failed to provide a safe environment and ensure one of three sampled residents (Resident 1) was free from verbal abuse by a staff member, by failing to ensure the facility's staff (FS 1), was not raising his voice, arguing with Resident 1, and calling the resident inappropriate names. This failure had the potential for Resident 1 to be fearful and to negatively affect her psychosocial well-being. Findings: A review of the admission record indicated the facility admitted Resident 1 with multiple diagnoses, including herpes viral encephalitis (a neurological disorder characterized by inflammation of the brain, which can lead to mental confusion) and depression. A review of Resident 1's ' Incident Note,' dated 10/19/23, at 11:06 a.m., indicated, Nursing staff reported to Administrator, witnessed incident between resident [Resident 1] and another staff member .Resident [1] saw staff member's lunch bag .opened lunch bag and took a bag of chips .and started to eat them .At 11:06 [a.m.] Staff member [FS 1] saw that his lunch bag had been opened and saw Resident [1] was holding the chips from his lunch box and was eating them. Per CNA [Certified Nursing Assistant], male staff member [FS 1] raised his voice and stated She [Resident 1] knows exactly what she's doing, she probably thinks this is a five-finger discount .Resident .with confusion per her norm [sic] .resident did not recall above incident .Offered activities .resident chooses not to participate at this time. The incident note further indicated that Resident 1 was unable to describe the incident due to her diagnoses of brain dysfunction. A review of the facility reported incident (FRI) investigation report sent to the Department on 10/20/23, at 11:44 a.m., indicated the incident in dining room between FS 1 and Resident 1 was witnessed by a few of the facility's staff. The investigation report contained the following witnesses' accounts of how the incident in the dining room unfolded: 1. FS 2 reported that as she was walking through the dining room, she heard FS 1 yelling at [Resident 1], saying that this was his lunch and not hers. He said you are nothing but a five-finger discount because .she [Resident 1] took his chips. FS 2 reported that she took Resident 1 and calmed her down. 2. FS 3 reported that when FS 1 noticed that his things had been looked through, [FS 1] then became furious .he snatched the item [chips] .that belonged to him and then proceeded to call the resident a five-finger discount. During an interview on 10/27/23, at 11:05 a.m., CNA 1 described Resident 1 as confused and forgetful. CNA 1 stated Resident 1 liked to talk to other residents and was not aggressive. CNA 1 stated she did not witness the verbal altercation between Resident 1 and FS 1, but she heard from far away that the FS 1 was yelling at Resident 1 regarding his chips. CNA 1 added further, I did not hear [Resident 1] yell at [FS 1], she is quiet, she's not the type to yell. During an interview on 10/27/23, at 11:10 a.m., CNA 2 recalled the incident and stated that FS 1 repeatedly raised his voice when he saw Resident 1 holding a bag of chips and eating them. CNA 2 stated that FS 1 looked mad when he argued with Resident 1 regarding his chips. During an interview on 10/27/23, at 11:20 a.m., CNA 3 stated she witnessed FS 1 yelling at Resident 1 to give his chips back to him and then he snatched the opened bag of chips from her hands. CNA 3 stated she attempted to reason with FS 1 explaining that Resident 1 was confused and did not know what she was doing. According to CNA 3, Resident 1 was quiet, looked scared, and even more confused after the incident with FS 1 and added, She had no idea that she was doing something that she's not supposed to do. CNA 3 stated, What [FS 1] said and did was inappropriate and staff should not say offensive words to residents, no matter what the resident is doing. During an interview with FS 1 on 10/27/23, at 12:05 p.m., FS 1 explained that on 10/19/23, around 11 a.m., as he was getting ready to eat lunch, he noticed that Resident 1 had gotten into his lunch box and was eating his chips. FS 1 stated he had interacted with Resident 1 prior to the incident and stated, Sometimes she's not confused, some days she can talk normally. FS 1 added, She put a small photo album there [inside the lunch bag] and took the chips out . When I saw her holding the opened bag of chips, it was a natural reaction, 'hey, you're not supposed to get into other people's stuff, those are my chips. I think I also said you're five finger pickup. It means that someone is trying to steal another person's food .Later I realized that I should not have raised my voice at her and shouldn't be doing what I did. FS 1 stated that raising your voice at a resident, talking in anger in your voice, calling resident names were considered verbal abuse. During a phone interview on 10/25/23, at 2:55 p.m., the Administrator (ADM) acknowledged that witnesses reported that FS 1 raised his voice at Resident 1 and called the resident a 'five- finger discount,' a thief, someone who attempted or tried to steal other people's belongings. The ADM stated FS 1 should not have raised his voice at Resident 1 and it was totally inappropriate and offensive to call Resident 1 'five- finger discount.' The ADM added, It is never okay to say 'five- finger discount' to anyone. A review of the facility's 'Abuse Prevention Policy and Procedure,' revised 3/17, indicated that the purpose of the policy was to ensure that resident's rights were protected. The policy indicated, Abuse .will not be tolerated in this facility at any time .Each resident has the right to be free from verbal .abuse .Residents must not be subjected to abuse by anyone, including, but not limited to facility staff.

Based on interview and record review, the facility failed to ensure Range of Motion (ROM, the degree of movement that occurs at a given joint during an exercise program) exercises were provided as ordered for one resident (Resident 81), for a census of 115. This failure increased the potential for Resident 81 to experience further reduction in ROM. Findings: A review of Resident 81's clinical record indicated a diagnoses including dislocation of right hip and presence of right artificial hip joint. A Minimum Data Set (MDS, an assessment tool) dated 8/25/22, indicated Resident 81 had moderate cognitive impairment and functional limitation in ROM on both lower extremity. Review of Resident 81's physician's order dated 8/26/22 indicated, RNA [Restorative Nursing Assistant] for ROM 3x/week .every day shift . A concurrent interview and record review with the Licensed Nurse 3 (LN 3) was conducted on 10/14/22 at 12:51 p.m. LN 3 confirmed Resident 1 had no documented RNA for ROM from 10/1/22 to 10/12/22. There was no documented evidence in Resident 81's clinical records as to why ROM was not provided by RNA 3x a week from 10/1 to 10/12/22. In an interview on 10/14/22 at 12:53 p.m., the Director of Nursing (DON) stated a physician's order should be followed. The DON further stated if a resident refused a treatment, the refusals should be documented and the physician should be informed. A review of the facility policy revised April 2008 and titled, Charting and Documentation indicated, .All . services performed .must be documented in the resident's clinical records .Documentation of procedures and treatments shall include care-specific details and shall include .Whether the resident refused the procedure/treatment .Notification of .physician or other staff, if indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide 80 square feet of living space per resident in rooms 24, 33, 43, and 68. This failure had the potential to compromise the residents' care and privacy. Findings: Review of a facility request for the square footage room waiver dated 9/17/2019, indicated the following multiple resident bedrooms measured less than 80 square feet (sq. ft.) per resident: room [ROOM NUMBER] measured 74 sq. ft. per resident, Rooms 33 measured 71.5 sq. ft. per resident, Rooms 43 measured 77.5 sq. ft. per resident; and, Rooms 68 measured 73.5 sq. ft. per resident. During an interview on 10/11/22, at 12:47 p.m., with the Certified Nursing Assistant (CNA)1, CNA 1 stated residents in room [ROOM NUMBER] needed assistance with transfer. One resident requires Hoyer lift for transfers and CNA 1 stated they have enough space to maneuver the Hoyer lift and provide care for residents in this room. room [ROOM NUMBER], 43 and 68 did not have four residents during the recertification survey but were considered four-bed rooms. The rooms were observed to be clutter free and residents had enough room for privacy and individual space. None of the rooms were observed to inhibit the staff to provide care to the residents and the residents received adequate care. The staff and the residents moved freely in the rooms. The Department recommends a continuation of the room waivers for rooms 24, 33, 43, and 68.

Based on observation, interview and record review, the facility failed to follow their medication and pain management policy and procedure to ensure standards of professional practice were maintained during Medication Administration for a census of 115 when: 1. Pain was not assessed properly for Resident 66; 2. Glycolax powder (a medication used for constipation) was not administered as ordered for Resident 26; 3. Blood pressure (BP) was not checked as ordered prior to giving medication for Resident 85; 4. Medications administered or held were on not documented in a timely manner for Resident 16; and 5. Resident 16's electronic medical record was not protected during medication administration. These failures had the potential to negatively impact the resident's health outcomes. Additionally, failure to protect health records denied residents their rights to privacy of their information. Findings: 1. According to Resident 66's 'admission Record' he was admitted to the facility recently with multiple diagnoses that included fracture of the left ulna (a forearm bone) and unspecified pain. During a medication administration observation on 10/12/22, starting at 7:46 a.m., Licensed Nurse (LN) 1 was observed as she prepared and administered medications to Resident 66. LN 1 administered the scheduled medications and left the room to the hallway. LN 1 was observed standing next to the medication cart located in the hallway and loudly called out Resident 66's name and asked him if he was in pain and what the level of the pain was. LN 1 did not go inside Resident 66's room to assess his pain, it's origin or provide him with personal privacy. Resident 66 responded in a loud voice, '10' (most severe pain on a scale of 0-10). LN 1 prepared 2 tablets of Tylenol for a total of 650 milligrams (mg, unit of measurement) and gave to Resident 66 and proceeded to the next resident. A review of Resident 66's physicians 'Order Summary Report' indicated he was on Tylenol 325 mg ordered to be given 2 tablets every 6 hours as needed for pain or headache, order dated 5/24/22. In a follow up interview with LN 1 on 10/12/22, at 9:15 a.m., LN 1 stated she had asked Resident 66 if the Tylenol she gave him for pain was effective at 8:05 a.m., then stated at 9 a.m. LN 1 was asked if she had documented the pain in Resident 66's record and stated she had not because the computer network was down. LN 1 further confirmed her computer network was currently working but she had not documented Resident 66's pain, more than an hour following the administration of Tylenol for verbalized pain of 10 out of 10. A review of the facility's 'Pain Management' policy guidelines dated 4/2016 indicated, It is the policy of this facility to assess [resident] . when pain medication is given . Pain medication shall be given before the pain becomes severe. Response to pain shall be documented on the electronic Medication Administration Record (MAR) within half hour of administration of a pain medication. 2. According to Resident 26's 'admission Record' she was admitted to the facility in 2021 with multiple diagnoses that included dementia and weakness. On 10/12/22, starting at 8 a.m., LN 1 was observed as she prepared and administered medication to Resident 26. LN 1 mixed the glucolax powder with approximately 2.5 ounces (unit of measurement) of apple juice and used the mixture in administering other scheduled medications. LN 1 did not give Resident 26 water or juice after the administration. A review of Resident 26's physician's 'Order Summary Report' reflected an order dated 4/28/22 for glycolax powder to be given 17 grams (gm, unit of measure) mixed in 4-8 ounces of juice or water once daily for constipation. In a concurrent interview with LN 1 on 10/12/22, shortly after 8 a.m., she stated she did not measure the amount of apple juice she used to mix the glycolax powder as per the physician's orders and she should have used the measuring cup provided. LN 1 confirmed she used approximately 2.5 ounces and the order had directed to use 4-8 ounces of water or juice. A review of the facility's 'Medication Administration .' policy and procedure dated 5/16/2018, indicated, 'Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered in accordance with written orders of the prescriber . At least 4 ounces of water or other acceptable liquid are given with oral medications .' 3. According to Resident 85's 'admission Record' she was admitted to the facility originally over 3 years ago with multiple diagnoses which included diabetes and hypertension. On 10/12/22, starting from 8:31 a.m., LN 2 was observed as she prepared and administered medications to Resident 85. LN 2 did not check the resident's BP per the physician orders prior to giving her Lisinopril, a blood pressure medication. A review of Resident 85's physician 'Order Summary Report' contained an order for Lisinopril 20 mg to be administered daily for hypertension. The order directed staff to hold the medication when the SBP (systolic blood pressure; the UPPER number represents the pressure on the blood vessels as the heart contracts/beats) was less than 100. An interview conducted with LN 2 on 10/12/22, at 9 a.m., she stated she used the BP obtained by a nursing assistant before breakfast around 7 a.m. to determine if she was to hold or give the BP medication. LN 2 stated she only rechecked a resident's blood pressure if the one documented by the nursing assistant was out of the normal range. A review of the facility's 'Medication Administration .' policy and procedure dated 5/16/2018, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered in accordance with written orders of the prescriber. 4. Resident 16's 'admission Record' reviewed indicated the facility admitted her over 5 years ago with multiple diagnoses that included hypertension and atrial fibrillation (an irregular, often rapid heart rate). During a Medication Administration Observation on 10/12/22, starting from 8:21 a.m., LN 2 was observed as she prepared and administered medication to Resident 16. LN 2 stated she was to hold Resident 16's BP medications based on the BP documented by the nursing assistant before breakfast which was low. LN 2 then proceeded to the nurse's station and brought with her a BP machine and obtained the resident's BP and reported it was very low and held 3 BP medications. LN 2 administered one medication during this observation. Resident 16's physician's 'Order Summary Report' printed on 10/12/22 indicated the resident was on amlodipine 5 mg, lasix 20 mg and metoprolol 50 mg for hypertension to be given daily (scheduled at 8 a.m., on the MARs) and be held for SBP less than 110. The resident was also on apixaban/eliquis (a blood thinner) 5 mg twice daily for atrial fibrillation (scheduled at 8 a.m. and 5 p.m. on the MARs) A review of Resident 16's Medication Administration Record (MARs) printed on 10/12/22 at 10:18 a.m., reflected no documentation for the 3 BP medications that LN 2 had held and the eliquis that she administered. During an interview and concurrent MAR review with LN 2 on 10/12/22, shortly after 10:18 a.m., she confirmed she had not documented she had held the 3 BP medications. LN2 stated she should have documented soon after she completed administering medications to the resident. A review of the facility's 'Medication Administration .' policy and procedure dated 5/16/2018, indicated, The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given . If medication doses are withheld, . the physician is notified. Nursing documents the notification and physician response. 5. During a Medication Administration Observation on 10/12/22, starting from 8:21 a.m., LN 2 was observed as she prepared and administered medication to Resident 16. LN 2 entered Resident 16's room and left the computer screen open displaying the resident's information. The computer was mounted on the top surface of the medication cart. Two Certified Nursing Assistants (CNAs) were observed moving the cart away to gain entry into and out of the room to pick up the meal trays. An interview conducted with LN 2 on 10/12/22, at 9 a.m., she stated she should have used the lock screen option to protect the resident's information when she turned away from the medication cart where the computer was placed. A review of the facility's 'Medication Administration .' policy and procedure dated 5/16/2018 indicated, The cart [where the computer was placed] must be clearly visible to the personnel administering medications . must be inaccessible to residents or others passing by. In addition, privacy is maintained at all times for all resident information . by going to privacy screen on the computer. The Director of Nursing (DON) was interviewed on 10/12/22 at 3:25 p.m. and she stated she expected the Licensed Nurses to provide privacy while assessing the resident's pain and document the pain level before and after the medications are administered on the MAR. The DON further stated the nurse who gave the glucolax should have followed the physician orders for reconstituting the powder included in the body of the order. The DON stated she expected the nurses to obtain the vital signs including the BP prior to giving BP medications that have hold parameters stipulated by the prescriber in the body of the orders. The DON stated she expected the nurses to lock the computer screen before they walked away for the safety and security of residents' electronic medical records. During a follow up interview and review of Resident 16's MAR with the DON on 10/13/22, at 8:37 a.m., she stated she expected LN 2 to document medications held or administered on the MAR immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three residents (Resident 47, Resident 81, and Resident 113) were assisted with Activities of Daily Living (ADL) when fingernails were long and had blackish substance underneath the nails, for a census of 115. These failures increased the potential to result in skin problems or injuries. Findings: A review of Resident 47's clinical record indicated a diagnoses including dementia (memory loss that interferes with daily functions) and macular degeneration (a condition that causes vision loss). A Minimum Data Set (MDS, an assessment tool) dated 8/9/22, indicated Resident 47 had severe cognitive impairment and required assistance with personal hygiene. A concurrent observation and interview was conducted on 10/11/22 at 12:34 p.m. with Certified Nursing Assistant 1 (CNA 1). Resident 47 had long fingernails and had blackish substance underneath her nails. The CNA 1 confirmed the finding and stated Resident 47's fingernails were long and dirty. A review of Resident 81's clinical record indicated a diagnoses including Parkinson's disease (a progressive disease that affects movement). A MDS dated [DATE], indicated Resident 81 had moderate cognitive impairment and required assistance with personal hygiene. In an initial observation on 10/11/22 at 10:40 a.m., Resident 81's fingernails were long with blackish substance underneath her nails. A concurrent observation and interview was conducted on 10/11/22 at 4:24 p.m. with the CNA 2. The CNA 2 confirmed the finding and stated Resident 81's fingernails were a little bit long and dirty. The CNA 2 further stated Resident 81 had episodes of refusing to have her nails trimmed. A review of Resident 81's nursing progress note prior to 10/11/22 did not indicate refusal of care. A review of Resident 113's clinical record indicated a diagnoses including dementia and glaucoma (a condition that can cause vision loss). A MDS dated [DATE], indicated Resident 113 had severe cognitive impairment and required assistance with personal hygiene. During an initial observation on 10/11/22 10:03 a.m., Resident 113 had long fingernails with blackish substance underneath her nails. A concurrent observation and interview was conducted on 10/11/22 at 1:03 p.m. with the CNA 3. The CNA 3 confirmed the finding and stated Resident 113's fingernails were long and dirty and needed to be trimmed. An interview was conducted with the Director of Nursing (DON) on 10/14/22 at 8:25 a.m. The DON stated her expectation was for facility staff to assist dependent residents with ADL. The DON further stated, the CNA's should always check resident's fingernails daily. If a resident continues to refuse assistance with care, the CNA should report it to the charge nurse. A review of the facility's policy and procedure revised October 2010 and titled, Care of Fingernails/Toenails indicated, The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .The following information should be recorded in the resident's medical record .If the resident refused the treatment, the reason(s) why and the intervention taken .Notify the supervisor if the resident refuses the care.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two residents, (Resident 269) who received renal hemodialysis (HD, a treatment necessary for kidney failure to remove unwanted toxins, waste products, and excess fluids by filtering the blood), when the facility failed to communicate and collaborate with the transport agency. This failure resulted in fatigue and frustration when transportation was delayed for an hour or more on multiple occasions. Findings: A review of the admission Record indicated Resident 269 was admitted to the facility earlier this year with multiple diagnoses which included the after care after right hip surgery, end stage kidney failure resulting in the need for dialysis. A review of the Minimum Data Set, (MDS, resident assessment and care screening tool), dated 9/25/22 indicated Resident 269's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 13 (a score of 13-15 indicated intact cognition). Resident 269 was totally dependent on the staff for transfer and locomotion. Resident 269 received hemodialysis prior to entering the facility and continued treatments while residing in the facility. A review of Resident 269's physician's order, dated 9/20/22, indicated dialysis at the local dialysis center every Monday, Wednesday and Friday at 9:00 a.m. During an observation and interview on 10/11/22 at 2:20 p.m., Resident 269 was observed sitting in a wheelchair in her room with her husband at the bedside. Resident 269 looked tired and stated she had just returned from the dialysis center. Resident 269 stated that normally she was getting dialysis three days per week, but today she had an additional dialysis per her physician's order. Resident 269 added, she was completely wiped out. [I] had to wait for transportation for 50 minutes after I completed dialysis. Resident 269 stated the transport did not come to pick her up after she had finished her dialysis and the dialysis nurse had to call the facility to inquire regarding the transportation delay. Resident 269 stated the facility informed the nurse that the transport will pick the resident up in 15-20 minutes as he was in a different city. Resident 269 stated, I was too tired to wait for him, was hungry . so I called my husband to pick me up. Lucky that he was at home. Resident 269 stated that this was not the first time she had to sit and wait for the transportation to bring her back to the facility. Resident 269's husband confirmed that on multiple occasions the transportation company did not pick his wife from the dialysis center in a timely manner. Resident 269 stated she was constantly late for lunch and even though the facility sent a sandwich with her, she was still hungry. During an observation on 10/12/22, at 3:45 p.m., Resident 269 was observed being wheeled into her room by her husband. Resident 269 stated she was not picked up from dialysis center as soon as her dialysis was completed and she did not want to wait, so her husband brought her back from the dialysis center. Resident 269's husband stated it was very disappointing that his wife had to wait for transportation and that they could not rely on the facility's process with arranging the transport. A review of Resident 269's, I need dialysis, care plan dated 9/20/22, indicated staff was to encourage the resident to go for the scheduled dialysis appointments every Monday, Wednesday and Friday at 9 a.m. The care plan did not include any interventions to ensure the timely transportation arrangements to and from dialysis center. During an interview on 10/13/22, at 8:40 a.m., the Unit Clerk (UC) stated it was her responsibility to arrange transportation for all residents, including transporting Resident 269 to and from the dialysis center. The UC stated she was aware that the transportation company used by the facility sometimes was late to pick up Resident 269. The UC stated the resident informed her that she did not like to sit and wait for transportation once dialysis was done. The UC stated if the transportation company was not able to pick up the resident from the dialysis center, she arranged to have the facility's courtesy van to transport Resident 269 to or from the dialysis. The UC stated on Tuesday, 10/11/22 at 1:15 p.m., the nurse from dialysis center notified the facility that the resident had completed dialysis and was waiting for a ride back to the facility, but the transport was not there yet. The UC stated sometimes Resident 269's husband brought the resident back from dialysis center. During an interview on 10/13/22, at 8:57 a.m., the Receptionist stated that on 10/11/22 Resident 269 called the facility around 1 p.m., and told [name of the transport company] was supposed to pick her up, but didn't come, and she was already waiting. I told her I will send our orderly [van], but she didn't want to wait. A review of clinical records had no documented evidence of collaboration and communication between the facility and transport company in ensuring that Resident 269 was transported to and from dialysis in a timely manner. During an interview on 10/13/22, at 9:40 a.m., the Administrator stated the facility did not have a contract or agreement with the transport company. During an interview on 10/14/22, at 10:05 a.m., the dialysis center nurse (DCN) stated Resident 269 was the center's patient prior to being admitted to the facility and that she provided dialysis treatment to the resident on a regular basis. The DCN stated Resident 269 started dialysis treatment at 9:15 a. m., and was ready for pick up around 12:40 p.m. The DCN stated since Resident 269 was admitted to the facility, most of the time she had been picked up late. The DCN stated that once Resident 269 completed her dialysis treatment, the dialysis staff took her to the general area in lobby and she had to wait for transportation. The DCN stated that Resident 269 did not like to sit and wait for her ride back to the facility and complained of being tired. The DCN stated sometimes the dialysis center staff had to assist Resident 269 with her care needs while she was waiting for the transport. The DCN stated very frequently the dialysis center staff had to call the transportation company and the facility to remind them that they needed to send the transport to pick the resident from the center. The DCN stated that sometimes the transport company told them that the resident needed to wait an hour or longer because they were busy or out of area. The DCN added, If her husband is available, he'll pick her up. If not, she had to wait longer. A review of the nursing progress notes indicated that on 9/21, 9/23, 9/28, 10/7, and 10/11/22, Resident 269 arrived back from the dialysis center between 2:15 - 2:30 p.m., and on 10/12/22 she arrived at 3:30 p.m., which indicated that Resident 269 had to wait for her ride for one and a half hours or longer. A review of the dialysis service agreement between the facility and dialysis center provider, dated 10/31/12, indicated that the facility had the sole responsibility for arranging all of the facility resident transportation to and from the dialysis clinic. During an interview on 10/13/22, at 1:55 p.m., the Director of Nursing (DON) stated she was not aware of any concerns related to Resident 269's delays with transporting her from dialysis center. The DON stated the unit clerk was responsible for arranging the transportation to make sure the resident was picked up from the dialysis center in a timely manner. The DON stated the facility did not have the policy regarding arranging for transportation.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in sanitary condition by failing to ensure the Quaternary Ammonium sanitizing solution (a chemical agent used to destroy germs) used for sanitizing kitchen surfaces and equipment had the required concentration to be effective and Dietary Aide 2 failed to follow proper hand hygiene between tasks. These failures had the potential to result in foodborne illness to 114 vulnerable residents receiving food from the facility kitchen. Findings: On 10/11/22 at 8:25 a.m., during an initial kitchen tour accompanied by the Dietary Supervisor and [NAME] 1 a red bucket containing clear solution inside was observed on the shelf. [NAME] 1 explained the solution in the red bucket was filled with Quaternary Ammonium solution to sanitize the clean surfaces after they were cleaned with soap and water. On 10/11/22, at 8:55 a.m., the Dietary Aide 1 stated the concentration of the chemical should be 200 ppm (parts per million, the concentration of the solution). After DA 1 dipped an orange test strip into the bucket to check the concentration of the sanitizer, the test strip got wet, and did not change the color of the strip. DA 1 compared the wet test strip with the control indicator on the test strip container. DA 1 stated if there was the required chemical concentration of 200 ppm, the test strip would have changed the color from orange to green, but it did not. The DA 1 used a second test strip to check the chemical sanitizer concentration in the red bucket and the strip did not change color. [NAME] 1 validated that the test strip did not change color as there was not enough sanitizer in the bucket. On 10/11/22, at 9 a.m., [NAME] 1 was asked to check the level of the sanitizing solution concentration in the bucket stored in the dishwashing room. When [NAME] 1 dipped the test strip into the sanitizing solution, the strip turned light green. [NAME] 1 compared the test strip color to the container's label and stated the concentration was about 100 ppm. [NAME] 1 explained that test strip indicated the sanitizing concentration was not at the required concentration and should be at 200 ppm. [NAME] 1 stated the concentration of the sanitizer solution was checked earlier that morning around 5:30 a.m., and the solution was replaced later after sanitizing the kitchen surfaces. During an interview on 10/11/22, at 9:05 a.m., the Registered Dietician (RD) acknowledged that both buckets with sanitizing solution were not at the required level for sanitizing kitchen's clean surfaces. RD stated it was very important to have sanitizing solution with correct concentration to disinfect kitchen surfaces and to prevent possible foodborne illness. A review of the facility's policy titled, QUATERNARY AMMONIUM LOG POLICY, revised 2018, indicated the facility will test the concentration of the ammonium in the quaternary sanitizer to ensure the effectiveness of the solution . The quaternary solution for sanitizing clean work surfaces in the kitchen will be made according to the instructions on the product container .The solution will be replaced when the reading is below 200 ppm. The replacement solution will be tested prior to usage. On 10/13/22, 9:05 a.m., during the dishwashing process DA 2 was observed picking up clean dishes from the dishwashing machine, placing them on the dish rack and taking them to the storage area. DA 2 was wearing gloves. In between handling the clean dishes, DA 2 was observed using a rag from the sanitizing solution to sanitize the soiled food carts. Wearing the same gloves, DA 2 proceeded to handle clean glasses and tray covers without performing hand hygiene and putting new gloves on. During a follow up interview DA 2 acknowledged that she should have washed her hands and replaced gloves after handling the soiled food cart. During an interview on 10/13/22, at 9:20 a.m., the RD stated that it was her expectation that the handwashing and glove change was done in between different tasks, including handling clean dishes and sanitizing dirty food carts. A review of the facility's 'GLOVE USE POLICY,' dated 2020, indicated that the appropriate use of gloves was essential in preventing food borne illness. The policy directed the kitchen staff to wash hands when changing to a fresh pair. Gloves must never be used in place of hand washing. The policy indicated that gloves needed to be changed before beginning a different task. The 2017 Federal Food Code, Section 2-301.14, titled, When to Wash, indicated, Food employees shall clean their hands .including working with .clean equipment and utensils .and (E) After handling soiled EQUIPMENT .

2. A review of the admission Record indicated Resident 268 was admitted to the facility earlier this year with multiple diagnoses which included inflammation of the large intestine and Clostridium Difficile (C-Diff, an easily spread bacteria, that causes diarrhea and stomach pain). Resident 268's clinical records indicated that the resident continued having diarrhea and received a laboratory result that was positive for C-Diff on 10/10/22. According to the clinical records, Resident 268 was on Contact Isolation Precautions. During an observation on 10/11/22, at 1:40 p.m., the door to Resident 268's room was closed. An isolation cart containing gloves, blue isolation gowns and other garments or equipment designed to protect the wearer from infection was observed outside of the room. There was a sign posted on the wall outside the room indicating, PLEASE REPORT TO NURSES' STATION BEFORE ENTERING ROOM. There was no signage indicating that the two residents residing in the room were on Contact Isolation precautions. During the interview on 10/11/22, at 1:42 p.m., LN 4 stated one of the residents residing in the room, Resident 268 was on Contact Isolation precautions due to recent diagnosis of C-Diff. LN 4 stated Resident 268's roommate, Resident 269 was not on isolation precautions. LN 4 stated Resident 269 went to dialysis treatment today. LN 4 stated there was no need to separate Resident 269 in a different room because Resident 268 was non-ambulatory and there was no contact between these residents. LN 4 stated there was no need to post the contact isolation precaution sign as long as there was a sign to report to nurses before entering the room. A review of the admission Record indicated Resident 269 was admitted to the facility earlier this year with multiple diagnoses which included end stage kidney disease resulting in the need for dialysis. A review of the Minimum Data Set, (resident assessment and care screen tool), dated 9/25/22 indicated Resident 269's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 13 (a score of 13-15 indicated intact cognition). During an observation on 10/11/22, at 2:05 p.m., Resident 269's husband was stopped by LN 4 while attempting to wheel the resident in wheelchair into her room. LN 4 explained to the resident and her husband that the resident had been moved to a different room. During an interview on 10/11/22, at 2:20 p.m., Resident 269 was sitting in wheelchair in her new room with husband at bedside. Resident 269 stated she just came back from dialysis and found out that the facility moved her to a different room. Resident 269 stated the nurse explained she was moved because my roommate is on quarantine. Resident 269 stated she hoped that whatever her roommate had was not contagious and did not get transmitted to her while she resided in the same room with Resident 268. Resident 269 stated it was upsetting that nobody talked to her regarding her roommate having infection and being on quarantine. During an interview with the DON on 10/13/22, at 1:50 p.m., the DON stated the facility received results of laboratory testing indicating that Resident 268 was C-Diff positive more than 24 hours ago. The DON stated Resident 269 was vulnerable with compromised immunity and to protect her from highly contagious C-Diff infection, she should have been moved to a different room immediately. The DON stated it was a standard practice to move the resident to a different room as soon as the facility found that Resident 268 was positive for C-Diff. The DON stated, As soon as I found out in our morning stand up meeting, I directed staff to move the roommate [Resident 269] to a different room. The DON stated having 'report to nursing' sign posted by the room was not adequate to inform the staff and visitors about contact isolation. The DON stated there should be a visible contact isolation sign posted next to the room entrance to warn the visitors to put isolation gown and gloves before entering the room. During an interview on 10/14/22, at 12:20 p.m., the Infection Preventionist (IP) stated C-Diff infection was highly contagious and the infection control goal was to protect residents and visitors from spreading the infection to others. The IP stated the measures to prevent the infection from spreading included posting a contact isolation precaution sign, wearing isolation gowns, gloves, and handwashing. The IP stated she was not aware there was no contact isolation sign posted by Resident 268's room. The IP was asked if it was appropriate to keep a C-Diff positive resident in the same room with the resident who had no C-diff infection, the IP stated that the individual assessment was necessary before making that decision. The IP stated she was not aware if the facility assessed Resident 269 or discussed a need to move her to a different room after the facility received report of C-diff positive roommate. A review of the undated facility's policy and procedure titled, INFECTION CONTROL CLOSTRIDIUM DIFFICILE, indicated that the goal for implementing infection control measures was to prevent the spread of communicable diseases and conditions. The policy indicated that Clostridium difficile infection (CDI) was the most frequent cause of diarrhea in adults. According to the policy the risks factors for developing of CDI included age greater than 65 years .antibiotic therapy .severe underlying disease .confinement in a long-term care .Residents with active diarrhea diagnosed as having CDI should be placed in Contact Isolation .Patients can be grouped (cohorted) with other patients with C-diff. Individual resident assessment is always necessary to determine appropriate roommates for those with C-Diff. Based on observation, interview and record review, the facility failed to ensure proper infection control practices were followed for a census of 115 when: 1. Reusable equipment was not sanitized after use and between residents for (Resident 16, Resident 26, and Resident 85) and, proper hand hygiene was not followed during medication administration for Resident 85; 2. Resident 268, who had an infectious condition, shared a room with a vulnerable resident, and 3. There was no Contact Isolation Precautions signage posted informing visitors that the resident was on isolation precautions (measures taken to prevent the spread of germs/infection from one person to another). These failures had the potential to spread infection between and among the residents. Findings: 1. According to Resident 66's 'admission Record' he was admitted to the facility recently with multiple diagnoses that included hypertension and unspecified pain. According to Resident 26's 'admission Record' she was admitted to the facility last year with multiple diagnoses that included dementia and hypertension. According to Resident 85's 'admission Record' she was admitted to the facility originally over 3 years ago with multiple diagnoses which included diabetes and hypertension. Resident 85 had a surgically placed stomach tube for administering medications and artificial nutrition. Resident 16's 'admission Record' reviewed indicated the facility admitted her over a 5 years ago with multiple diagnoses that included hypertension and atrial fibrillation (an irregular, often rapid heart rate). During a 'Medication Administration Observation' on 10/12/22 starting from 7:46 a.m., Licensed Nurse (LN) 1 was observed as she prepared and administered medications to residents in hall #4. LN 1 was observed as she checked the blood pressure for Resident 66 after which she placed the BP cuff on top of the medication cart next to the medication preparation area. LN 1 did not clean or sanitize the BP cuff after use or clean the preparation area prior to proceeding to prepare the medications for Resident 26. LN 1 was observed as she checked Resident 26's BP in another room without sanitizing the cuff prior to using it and placed it back near the medication preparation area. A concurrent interview with LN 1 on 10/12/22 shortly after 7:46 a.m., LN 1 stated she should have sanitized the BP cuff after each use and between residents before placing it on the medication preparation area using the sani cloth wipes. During a 'Medication Administration Observation' on 10/12/22 starting from 8:21 a.m., LN 2 was observed as she prepared and administered medications to residents in hall #6. LN 2 walked to the nurse's station and got a blood pressure (BP) cuff and checked Resident 16's BP. LN 2 then placed the BP cuff on top of the medication cart next to the medication preparation area without sanitizing it. LN 2 then proceeded to prepare medication for Resident 85 who was in another room. LN 2 was wearing gloves. LN 2 brought in the prepared medications and placed them on the resident's table. LN 2 then re-adjusted the resident's chair, pulled the privacy curtains, left the room to bring a stethoscope, checked the resident's stomach tube placement using the stethoscope (an instrument used to listen to the heart beats, lung sounds and bowel sounds), proceeded to the bathroom to get some more water twice and completed the medication administration. LN 2 did not perform hand hygiene or sanitize her hands during this observation. LN 2 was ready to proceed to the next room without sanitizing the stethoscope that she had used for Resident 85. During an interview with LN 2 on 10/12/22, at 9 a.m., LN 2 stated she should have sanitized the BP cuff and stethoscope after each use using the sani cloth wipes before placing them on the medication cart. LN 2 further stated she should have performed hand hygiene, changed her gloves between tasks while administering medications to Resident 85 to prevent the spread of infections. A review of the facility's policy titled, 'Medication Administration -General Guidelines' dated 5/16/18 indicated, Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of medications given via [stomach] tubes. The facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 2/20/18 indicated, Non-Critical items are those that come in contact with intact skin . blood pressure cuffs . Most non-critical reusable items can be decontaminated where they are used . Reusable items are cleaned and disinfected or sterilized between residents . stethoscope, durable medical equipment . During an interview with the Director of Nursing (DON) on 10/12/22 at 3:25 p.m. the DON stated she expected the Licensed Nurses to sanitize reusable equipment after use and to practice hand hygiene during medication administration as per the infection control policies.

Based on observation, interview, and record review, the facility failed to accommodate the needs of one of 27 sampled residents (Resident 4), when Resident 4 was not able to use a Spanish translation board independently; and the board was not used by non-Spanish speaking staff, in order to understand Resident 4's request for assistance. This failure resulted in Resident 4 not being repositioned for comfort and feeling anxious when staff were scheduled who did not speak Spanish. Findings: Resident 4 was admitted to the facility in 2015 with diagnoses including Parkinson's disease (A disease which affects the nerve cells in the brain. Symptoms include muscle rigidity, tremors, and changes in speech and movement). During an interview on 2/5/20, at 5:16 p.m., with a family member (FM), the FM indicated there are staff during the day who speak Spanish but not consistently during the evening and night. The FM stated, .They should have a way to communicate with her . During an interview on 2/6/20, at 8:43 a.m., with the social services director (SSD), the SSD indicated if Spanish speaking staff were not available, staff were to use a board with pictures labeled with Spanish and English words, to communicate with Resident 4. During a concurrent observation and interview on 2/6/20, at 9:11 a.m., Certified Nursing Assistant (CNA) 1 removed the translation picture board from Resident 4's nightstand. CNA 1 translated for the Department and asked Resident 4 if she was able to use the board. Resident 4 indicated she could not see the words on the board but could see pictures. Resident 4 was lying in bed. Resident 4's right hand was contracted (the joints are tightened, stiff, and mobility is affected). Resident 4 indicated she had tremors in her left hand. She was not able to hold the board to look at the pictures. Resident 4 indicated some staff at night did not understand her and did not ask for help with translation. Resident 4 described a night when she was uncomfortable and wanted to be repositioned. The staff did not understand. They did not offer any alternatives to find out what she asked. She was unhappy and upset. Resident 4 indicated she has never been offered use of the translation board. During an interview on 2/6/20, at 9:57 a.m., with the activities director (AD), the AD indicated the translation board was to be kept out and accessible. The AD stated, .It wasn't supposed to be in her nightstand . Review of the minimum data set (MDS-an assessment and care screening tool) dated 1/16/20, indicated, .Language .Does the resident need or want an interpreter to communicate with .healthcare staff .Yes .Spanish . Review of Resident 4's care plan titled, I have a communication problem r/t [related to] Language barrier (Spanish Speaking) initiated 4/18/19, indicated, .Provide translator as necessary to communicate .Use alternative communication tools as needed, such as communication book/board .

Based on observation, interview, and record review, the facility failed to implement care plan interventions for one of 27 sampled residents (Resident 118), when blood in Resident 118's urine was not addressed timely. This failure had the potential Resident 118 would have complications from untreated bleeding. Findings: Resident 118 was admitted to the facility in 2016 with diagnoses including Parkinson's disease (a disease that affects the nerve cells in the brain. Symptoms include muscle rigidity, tremors, and changes in speech and movement), a stage four pressure ulcer (damage to tissue from pressure, extending to muscle and/or bone), deep vein thrombosis (a blood clot), and bladder dysfunction (the bladder does not empty and/or leaks urine). Review of the minimum data set (MDS-a resident assessment and care screening tool) dated 9/24/19, indicated Resident 118 had a urinary catheter (a tube inserted into the bladder to allow urine to drain into a bag). The MDS further indicated Resident 118 received an anticoagulant (a blood thinning medication to reduce the risk of blood clots). Review of physician orders for Resident 118, dated 11/6/19, indicated, [brand name rivaroxaban-an anticoagulant which blocks the activity of certain clotting substances in the blood] 10 mg [milligram-a unit of measure] .one time a day . Review of a physician progress note dated 12/9/19 in Resident 118's clinical record indicated, .Continue current [anticoagulant] and monitor for evidence of bleeding . Review of Resident 118's care plan, I am on anticoagulant therapy . initiated 9/30/2016, indicated, .Monitor/document/report to [physician] [as needed] [signs and symptoms] of anticoagulant complications: blood tinged or frank blood in urine . Review of Resident 118's care plan, I have Indwelling .Catheter . initiated 9/30/16, indicated, .Monitor/record/report to [physician] for [signs and symptoms] [urinary tract infection] .blood tinged urine .deepening of urine color . Review of the brief interview for mental status (BIMS) conducted on 9/24/19, indicated Resident 118 had a BIMS score of 15. A score of 13-15 indicated Resident 118's memory was intact. During a concurrent observation and interview on 2/4/20, at 10:47 a.m., Resident 118 was lying in bed. A catheter drainage bag hung from the right side of her bed. The urine in the tubing was reddish brown in color and the urine in the drainage bag was dark reddish brown. Resident 118 indicated staff instructed her to drink more when her urine became dark. During a concurrent observation and interview on 2/6/20, at 10:07 a.m., Resident 118's urine observed in the catheter tubing and drainage bag was reddish brown. The Department asked Licensed Nurse (LN) 4 to observe Resident 118's urine color and LN 4 confirmed Resident 118's urine looked reddish brown. LN 4 stated, .We do notify the doctor if there is blood in the urine. I'm not sure if we did . LN 4 indicated Resident 118 required monitoring for signs of bleeding every day and a progress note should have been completed when Resident 118's urine changed color. LN 4 indicated a supervisor needed to assess Resident 118. During a concurrent observation and interview on 2/6/20, at 10:27 a.m., with LN 1, the nursing supervisor, LN 1 indicated Resident 118's urine looked red. During a subsequent interview and concurrent record review, LN 1 reviewed Resident 118's clinical record and stated, .no progress notes with any description of urine .the nurses monitor her [Resident 118] for signs and symptoms of bleeding from [brand name rivaroxaban]. It's care planned for the nurses to monitor .blood tinged urine is to be monitored for, in the catheter care plan . LN 1 indicated monitoring was to be performed every shift and any abnormality should be documented in the progress notes. LN 1 also indicated a change of condition note should be written and there was no documented evidence this was done. LN 1 indicated nurses needed to monitor the color of urine and certified nursing assistants (CNA)'s charted the amount of urine output, not the color. During an interview on 2/6/20, at 12:13 p.m., CNA 2 indicated she worked on 2/4/20 and 2/5/20. CNA 2 stated, .urine was dark. I tell the nurse. They knew about it. It happens off and on. This time it's been a while, over a week or so . Review of resident 118's clinical record, Total Intake and Output Record with an entry on 1/28/20, completed by a licensed nurse indicated, .Urine color: dark amber . There was no evidence Resident 118's urine color was followed up between 1/28/20 and 2/6/20. Review of the clinical record, Nurses Note dated 2/6/20, at 11 a.m., indicated, .catheter is patent draining dark amber urine . Review of a lab result for urine collected on 2/6/20 at 12:16 p.m., indicated there was a moderate amount of blood in Resident 118's urine and the red blood cell quantity was 21-50. The reference range for this test was 0-3. During an interview on 2/6/20, at 2:10 p.m., with the consultant pharmacist (CP), the CP indicated Resident 118's anticoagulant dose was lowered in November 2019 due to hematuria (blood in urine). The CP stated, .Monitoring for side effects of [brand name rivaroxaban] comes in the care plan . During an interview on 2/7/20, at 12:18 p.m., with the director of nursing (DON), the DON indicated the nurses were expected to monitor Resident 118 for blood in her urine from complications of her anticoagulant and monitor for possible sign of urinary tract infection (UTI). The DON indicated there was a form titled, Stop and Watch to report any unusual occurrences and indicated the CNA should have completed this form when they noticed any unusual color. The DON stated, .The nurses need to follow the care plan monitoring signs and symptoms of bleeding .

Based on observation, interview, and record review, the facility failed to ensure one of 27 sampled residents (Resident 118), received care needs in accordance with her care plan, when blood in Resident 118's symptoms of bleeding was not addressed or monitored timely. This failure had the potential Resident 118 may have complications from untreated urinary tract bleeding. Findings: Resident 118 was admitted to the facility in 2016 with diagnoses including Parkinson's disease (a disease that affects the nerve cells in the brain. Symptoms include muscle rigidity, tremors, and changes in speech and movement), a stage four pressure ulcer (damage to tissue from pressure, extending to muscle and/or bone), deep vein thrombosis (a blood clot), and bladder dysfunction (the bladder does not empty and/or leaks urine). Review of the minimum data set (MDS-a resident assessment and care screening tool) dated 9/24/19, indicated Resident 118 had a urinary catheter (a tube inserted into the bladder to allow urine to drain into a bag). The MDS further indicated Resident 118 received an anticoagulant (a blood thinning medication to reduce the risk of blood clots). Review of physician orders for Resident 118, dated 11/6/19, indicated, [brand name rivaroxaban-an anticoagulant which blocks the activity of certain clotting substances in the blood] 10 mg [milligram-a unit of measure] .one time a day . Review of a physician progress note dated 12/9/19 in Resident 118's clinical record indicated, .Continue current [anticoagulant] and monitor for evidence of bleeding . Review of Resident 118's care plan, I am on anticoagulant therapy . initiated 9/30/2016, indicated, .Monitor/document/report to [physician] [as needed] [signs and symptoms] of anticoagulant complications: blood tinged or frank blood in urine . Review of Resident 118's care plan, I have Indwelling .Catheter . initiated 9/30/16, indicated, .Monitor/record/report to [physician] for [signs and symptoms] [urinary tract infection] .blood tinged urine .deepening of urine color . Review of the brief interview for mental status (BIMS) conducted on 9/24/19, indicated Resident 118 had a BIMS score of 15. A score of 13-15 indicated Resident 118's memory was intact. During a concurrent observation and interview on 2/4/20, at 10:47 a.m., Resident 118 was lying in bed. A catheter drainage bag hung from the right side of her bed. The urine in the tubing was reddish brown in color and the urine in the drainage bag was dark reddish brown. Resident 118 indicated staff instructed her to drink more when her urine became dark. During a concurrent observation and interview on 2/6/20, at 10:07 a.m., Resident 118's urine observed in the catheter tubing and drainage bag was reddish brown. The Department asked Licensed Nurse (LN) 4 to observe Resident 118's urine color and LN 4 confirmed Resident 118's urine looked reddish brown. LN 4 stated, .We do notify the doctor if there is blood in the urine. I'm not sure if we did . LN 4 indicated Resident 118 required monitoring for signs of bleeding every day and a progress note should have been completed when Resident 118's urine changed color. LN 4 indicated a supervisor needed to assess Resident 118. During a concurrent observation and interview on 2/6/20, at 10:27 a.m., with LN 1, the nursing supervisor, LN 1 indicated Resident 118's urine looked red. During a subsequent interview and concurrent record review, LN 1 reviewed Resident 118's clinical record and stated, .no progress notes with any description of urine .the nurses monitor her [Resident 118] for signs and symptoms of bleeding from [brand name rivaroxaban]. It's care planned for the nurses to monitor .blood tinged urine is to be monitored for, in the catheter care plan . LN 1 indicated monitoring was to be performed every shift and any abnormality should be documented in the progress notes. LN 1 also indicated a change of condition note should be written and there was no documented evidence this was done. LN 1 indicated nurses needed to monitor the color of urine and certified nursing assistants (CNA)'s charted the amount of urine output, not the color. During an interview on 2/6/20, at 12:13 p.m., CNA 2 indicated she worked on 2/4/20 and 2/5/20. CNA 2 stated, .urine was dark. I tell the nurse. They knew about it. It happens off and on. This time it's been a while, over a week or so . Review of resident 118's clinical record, Total Intake and Output Record with an entry on 1/28/20, completed by a licensed nurse indicated, .Urine color: dark amber . There was no evidence Resident 118's urine color was followed up between 1/28/20 and 2/6/20. Review of the clinical record, Nurses Note dated 2/6/20, at 11 a.m., indicated, .catheter is patent draining dark amber urine . Review of a lab result for urine collected on 2/6/20 at 12:16 p.m., indicated there was a moderate amount of blood in Resident 118's urine and the red blood cell quantity was 21-50. The reference range for this test was 0-3. During an interview on 2/6/20, at 2:10 p.m., with the consultant pharmacist (CP), the CP indicated Resident 118's anticoagulant dose was lowered in November 2019 due to hematuria (blood in urine). The CP stated, .Monitoring for side effects of [brand name rivaroxaban] comes in the care plan . During an interview on 2/7/20, at 12:18 p.m., with the director of nursing (DON), the DON indicated the nurses were expected to monitor Resident 118 for blood in her urine from complications of her anticoagulant and monitor for possible sign of urinary tract infection (UTI). The DON indicated there was a form titled, Stop and Watch to report any unusual occurrences and indicated the CNA should have completed this form when they noticed any unusual color. The DON stated, .The nurses need to follow the care plan monitoring signs and symptoms of bleeding .

Based on observation, interview, and record review, the facility failed to label an intravenous (IV- an infusion which delivers liquid medication directly into a vein) tubing with date, time, and initial when it was put into service and administered for one of 29 sampled residents (Resident 404). This failure increased the potential to diminish resident safety, promote adverse events and infections. Findings: Resident 404 was admitted to the facility with multiple diagnoses which included methicillin resistant staphylococcus aureus infection (caused by bacteria and required antibiotic treatment), and sepsis (a life-threatening complication when bacteria infect the bloodstream). During an observation on 2/6/20, at 9 a.m., Resident 404 was observed in bed able to make pleasant conversation. An IV bag with tubing was hanging on an IV pole beside the resident's bed. The IV tubing had no label with date, time, or initial when it was hung and administered. During an interview on 2/6/20, at 9:10 a.m., with Licensed Nurse (LN) 1, LN 1 stated, the IV tubing should have been labeled with date, and time when it was hung and administered, and be initialed by the LN who administered the IV medication. During an interview on 2/6/20, at 9:52 a.m., with the Director of Nursing (DON), the DON acknowledged the Licensed Nurse should have labeled the IV tubing with date, time, and initial during medication administration. During a record review of the facility's policies and procedures (P&P) titled, Specific Medication Administration Procedures revised 5/16/18, the P&P indicated, To provide for the safe, accurate, and effective administration of parenteral [medications administered directly into the vascular system] .Complete .label . According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing- Guidelines for Starting an Intravenous Infusion (Textbook), 12th edition, volume 1, p. 305 by Smeltzer, Bare, Hinkle and Cheever, the Textbook indicated, .Label with .date, time and initials .Labeling facilitates assessment and safe discontinuation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an accurate account and reconciliation of a controlled medication for 1 of 29 sampled residents (Resident 72) when a controlled narcotic medication (CN- a regulated medication with a high risk for illicit use) was not reconciled correctly. This failure resulted in an increased potential for diversion of a Controlled Narcotic II. Findings: Resident 72 was admitted to the facility on [DATE] with multiple diagnoses which included systemic inflammatory response syndrome (SIRS-a body's inflammatory response to an infection that may lead to multiple organ failure). During a record review of Resident 72's Order Summary(OS), dated 1/18/20, the OS indicated, 5 ml (ml-a unit of measurement) [of] Morphine Sul IR 20 mg/ml Solution. Take 0.25 ml (5 mg by mouth at bedtime for pain management). During a record review of a facility document titled, Packing Slip (PS), dated 1/18/20, the PS indicated, 5 ml [milliliter-fluid volume/quantity] [of] Morphine Sul [sulfate] IR [immediate release] 20 mg [milligram-weight]/ml Soln [solution]. The PS was signed by the Licensed Nurse (LN) who received the narcotic medication. During a record review of Resident 72's narcotic count sheet (NCS) for Morphine Sulfate solution, dated 2/5/20, the NCS indicated LN received 5 ml of Morphine solution from the pharmacy. The NCS indicated a balance of 3.25 ml after 7 doses were administered to the resident with 0.25 ml each dose [{7 x 0.25 ml} - 5 ml = 3.25 ml]. During a concurrent observation and interview on 2/5/20, at 2:45 p.m., with Licensed Nurse (LN) 2, Resident 72's Morphine Sulfate Solution bottle was noted to have an actual quantity/balance of approximately 0.2 ml below 8 ml. LN 2 acknowledged the actual balance on the medication bottle which was 0.2 ml below 8 ml. During an interview on 2/5/20, at 2:50 p.m., LN 2 confirmed there was discrepancy between the actual quantity/balance in the narcotic medication bottle and the balance written in NCS. LN 2 stated, [The] LN [receiver] should have checked the medications received [from the pharmacy] especially with narcotics. LN 2 also stated, the receiving LNs were expected to check the accuracy of the medication, and quantity on the manifest [packing slip] before they sign the manifest. During an interview on 2/5/20, at 2:55 p.m., with the Director of Nursing (DON), the DON confirmed there was a discrepancy between the actual quantity in the narcotic medication bottle and the balance written in NCS. The DON stated, That's weird. The DON further stated, LN receiving the medication should have checked the accuracy of the record with the medication before she signed the manifest [packing slip]. During an interview on 2/5/20, at 3 p.m., with the Consultant Pharmacist (CP), the CP acknowledged there was discrepancy between the medication quantity in the packing slip and the actual narcotic medication quantity delivered by pharmacy and stated, [It was a] human error, [and] not reconciled; Pharmacy made an error in dispensing the medication and [the] nurse made a mistake; [the] nurse should have checked before accepting the CN II medication and should have returned it. The CP indicated the morphine liquid was dispensed in 10 ml bottles rather than 5 ml. The CP confirmed the initial quantity of morphine dispensed to the facility for Resident 72 was 10 ml. During a record review of the facility's policies and procedures (P&P) titled, Medication Ordering and Receiving from Pharmacy revised 5/15/18, the P&P indicated, The authorized [facility] staff person and [pharmacy] courier review the packing slip and inspect the shipment to confirm the count on the packing slip correlates to the quantity received. During a record review of the facility's policies and procedures (P&P) titled, Medication Monitoring and Management revised 1/29/18, the P&P indicated, Record of receipt (e.g., delivery receipt, drug refusal form) must be maintained and stored for all controlled medications and have sufficient details to allow for reconciliation including the .strength of medication, [and] the quantity received .The consultant pharmacist or nurse should evaluate and monitor that the facility maintains an accurate account of all controlled medications and completes reconciliation .The pharmacy .should ensure the controlled medication records are accurate and complete.