**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse when Resident 4 was punched in the face and all over the body at two separate incidents by Resident 3. This failure caused Resident 4 to sustain bleeding from his nose, redness above his right eyebrow and on the bridge of his nose, and a bluish/purplish discoloration on his left eye extending to his left cheekbone.Findings:Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/2021 showed the residents have the rights to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse.Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 7/7/25, showed Resident 3 physically assaulted Resident 4 by striking Resident 4 in the face. Shortly thereafter, Resident 3 physically assaulted Resident 4 a second time, striking Resident 4 multiple times in the body. Resident 4 sustained a bloody nose. a. Closed medical record review for Resident 3 was initiated on 7/8/25. Resident 3 was admitted to the facility on [DATE], and discharged to the acute care hospital on 7/6/25.Review of Resident 3's H&P examination dated 3/27/25, showed Resident 3 had the capacity to understand and make decisions. Resident 3 had a diagnosis of schizophrenia (chronic brain disorder that affects a person's ability to think clearly, manage emotions, make decisions and relate to others).Review of Resident 3's Order Summary Report from 3/27 to 7/7/25, showed a physician's order dated 6/25/25, to administer clozapine (antipsychotic medication) 300 mg by mouth at bedtime for schizophrenia. Review of Resident 3's progress notes showed the following:- On 7/2/25 at 1823 hours, Resident 3 was observed pacing and appearing more anxious. Resident 3 reported to the staff he was hearing auditory hallucinations, commanding him to annihilate the people who want to harm you (meaning the staff). Resident 3 was able to communicate to the staff when he was hearing voices. Resident 3 was administered Zyprexa (antipsychotic medication) 10 mg by mouth one time for auditory hallucinations. - On 7/3/25 at 1043 hours, Resident 3 verbalized to the licensed nurse he was feeling paranoid and hearing voices a little.- On 7/6/25 at 1341 hours, Resident 3 remained on every 15 minutes checks for safety. Resident 3 denied hearing voices and remained quiet and self-guarded. - On 7/6/25 at 1640 hours, RN 2 observed Resident 4 sitting in a chair close to the medication cart and Resident 3 walking in the hallway close to the nurse's station when Resident 3 punched Resident 4 in the face. Both residents were separated right away by the staff, and Resident 3 was brought to the dining area. When Resident 3 was asked about the incident, Resident 3 stated he was feeling paranoia (mental state characterized by intense suspicion and distrust of others) for the past two weeks. Resident 3 informed the staff that Resident 4 touched him on the back, so when he saw Resident 4 in the hallway, he punched Resident 4 in the face. Resident 3 was currently on close monitoring for change of behavior/mood/feeling. - On 7/6/25 at 1640 hours, when RN 3 interviewed Resident 3, Resident 3 stated for the past one to two weeks, he had been feeling paranoid and increased the thought that people were trying to harm him and did not feel safe around the other residents. Resident 3 stated Resident 4 was outside with him earlier in the day and had touched him on his back. Resident 3 stated he felt threatened but did not share his feelings with the staff or other residents. Resident 3 stated when he saw Resident 4 sitting on the chair by the nurse's station, he decided to react and defend himself against Resident 4. Resident 3 stated he punched Resident 4 on the left side of his cheek and eye. Resident 3 was placed on the one-to-one care by the staff. - On 7/6/25 at 1730 hours, RN 3 observed Resident 3 running at a high rate of speed and jumping on Resident 4 who was still sitting in a chair by the nurses' station. Resident 3 began punching Resident 4 all over his body multiple times. The CNA who was providing the one-to-one care for Resident 3 in the dining room was running behind Resident 3 but could not catch up with Resident 3 before Resident 3 jumped on Resident 4.Review of Resident 3's plan of care dated 7/6/25, showed a care plan problem addressing Resident 3's two episodes of aggressive behaviors (punching Resident 4 multiple times on the face and body). The interventions included safeguarding the others by removing Resident 3 from the situation and/or providing the one-to-one supervision and for the staff to position themselves closely to supervise the resident and peers when in high traffic areas and allow space between peers. b. Medical record review for Resident 4 was initiated on 7/8/25. Resident 4 was admitted to the facility on [DATE].Review of Resident 4's H&P examination dated 4/3/25, showed Resident 4 could make needs known but could not make medical decisions. Review of Resident 4's eINTERACT Change of Condition dated 7/6/25 at 1640 hours, showed Resident 4 was punched with a closed fist on the face on the left eye and cheek by Resident 3. The documentation further showed Resident 4 complained of pain at the level of 5 (on the pain scale of 0 to 10 with 0 = no pain and 10 = most pain) to his left cheek and left eye, indicating moderate pain. Review of Resident 4's Hospital Transfer Form dated 7/6/25, showed Resident 4 was sent to the acute care hospital. The reason for the transfer showed another resident had punched him multiple times all over his body, including his head, which caused bleeding from the nose.Review of Resident 4's progress notes showed the following:- On 7/6/25 at 1640 hours, Resident 4 was observed sitting on a chair in the hallway near the medication cart next to the nurses' station. Resident 3 was observed pacing back and forth in the hallway near Resident 4 when suddenly Resident 3 punched Resident 4 with a closed fist on Resident 4's left eye and left cheek. The CNA and the staff were able to separate Residents 3 and 4, and Resident 3 was taken to the dining room. - On 7/6/25 at 1700 hours, Resident 4 complained of pain at the level of 5 to his left eye and left cheek. The PRN pain medication was administered to Resident 4.- On 7/6/25 at 1730 hours, RN 2 heard a loud sound and observed Resident 3 running towards Resident 4 who was sitting on a chair by the medication cart close to the nurse's station. Resident 3 then punched Resident 4 multiple times all over the body, including the resident's head. Resident 4 was observed with a bloody nose and increased redness and swelling to his face. Resident 4 complained of a headache and thought his nose might be broken. Resident 4's physician was notified, and Resident 4 was transferred to the acute care hospital for further evaluation. - On 7/6/25 at 2355 hours, showed Resident 4 returned from the acute care hospital at around 2300 hours. Resident 4 was observed with the redness above his right eyebrow and on the bridge of his nose, and a bluish/purplish discoloration below his left eye extending to his left cheekbone. The acute care hospital's diagnosis included facial contusion (injured tissue or skin) and right wrist pain. - On 7/7/25 at 1312 hours, Resident 4 emerged from his room and asked the staff if the resident (Resident 3) who attacked him was in the facility. Resident 4 was concerned about the resident who attacked him and wanted to stay away from him.On 7/9/25 at 1026 hours, an observation and concurrent interview was conducted with Resident 4. Resident 4 was observed with a reddish and bluish discoloration on the left eye. When asked if his left eye hurt, Resident 4 stated, it still burns. Resident 4 was asked how he sustained the discoloration on his left eye, Resident 4 stated someone punched him in the face but did not know why the other person punched him. Furthermore, Resident 4 stated the incident happened two times, one before dinner and the other was after dinner. On 7/9/25 at 1328, a telephone interview was conducted with CNA 2. CNA 2 stated Resident 3 punched Resident 4's left side of the face. CNA 2 stated the first incident happened before the dinner in front of the nurses' station. The second incident happened after the dinner when Resident 3 ran from the TV room and hit Resident 4 multiple times in the body and face. CNA 2 stated he did not know which staff was supervising Resident 3 in the TV room. On 7/9/25 at 1502 hours, an interview was conducted with CNA 5. CNA 5 stated he did not observe the first incident when Resident 3 punched Resident 4. However, CNA 5 stayed with Resident 3 while the resident was in the dining area after the first incident. CNA 5 stated he sat behind Resident 3 in the dining room with a round dining table in between them. Resident 3 stood up and started pacing. When Resident 3 was closed to the door, CNA 5 asked the resident what he was doing and where he was going. Resident 3 then sprinted out of the dining room door and CNA 5 ran after the resident. Resident 3 then started punching Resident 4 close to the nurse's station.On 7/9/25 at 1456, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain a safe and secured environment for two of five sampled residents (Residents 1 and 2).* The facility failed to ensure there were systems in place to prevent Residents 1 and 2 from eloping. This failure placed the residents at risk for harm or injury. Findings:Review of the facility's P&P titled Behavioral Health Elopement revised on 5/1/24, showed the definition of elopement as a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle.Review of the incident report of the DON dated 6/23/25, showed at approximately 1950 hours on 6/20/25, Residents 1 and 2 had left the premises through the west exit door.1. Closed medical record review for Resident 1 was initiated on 7/8/25. Resident 1 was admitted to the facility on [DATE], and discharged on 6/20/25. Review of Resident 1's Elopement Risk dated 3/26/25, showed Resident 1 was placed in a locked/secured (egress) facility. Review of the Resident 1's Care Plan Report initiated on 4/21/25, showed a care plan problem addressing the resident's risk for elopement related to involuntary placement and history of elopement.Review of Resident 1's MDS assessment dated [DATE], showed the resident was independent in making decisions regarding tasks of daily life. Review of Resident 1's eINTERACT Change of Condition Evaluation dated 6/20/25, showed Resident 1 was observed leaving AMA through the back door during the smoke break. The resident left the facility by kicking the exit door. 2. Closed medical record review for Resident 2 was initiated on 7/8/25. Resident 2 was admitted to the facility on [DATE], and discharged on 6/20/25.Review of Resident 2's H&P examination dated 6/19/25, showed Resident 2 could make needs known but could not make medical decisions.Review of Resident 2's eINTERACT Change of Condition Evaluation dated 6/20/25, showed Resident 2 was observed leaving through the alarmed back door during the smoke break. Resident 2 had a history of leaving the previous facility with her partner.Review of Resident 2's Care Plan Report initiated on 6/19/25, showed a care plan problem addressing the resident's risk for elopement related to involuntary placement.On 7/8/25 at 0925 hours, a video of the elopement incident on 6/20/25 was shown by the Administrator. Resident 2 was seen trying to climb over the white fence and Resident 1 was kicking the exit door. Both Residents 1 and 2 were able to get out of the facility through the exit door. After a minute or two, two facility staff were observed running after the residents.On 7/8/25 at 1016 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director showed the two exit doors in the smoking area. The Maintenance Director stated an alarm could be heard if the door was forcefully opened and without a key. On 7/9/25 at 0924 hours, an interview was conducted with Resident 5. Resident 5 stated he saw Resident 1 kick the exit door and left the facility with Resident 2. Resident 5 stated there was no licensed nurse or facility staff by the exit door. Resident 5 stated the facility staff then ran after Residents 1 and 2 when they heard the banging of the exit door.On 7/9/25 at 1034 hours, a telephone interview was conducted with CNA 1. CNA 1 stated Residents 1 and 2 were observed walking around the courtyard until the facility staff heard a big bang towards the back gate/exit door. CNA 1 then observed Residents 1 and 2 running through the exit door. CNA 1 stated the exit door would make an alarm sound when someone tried to open, push, or touch it. However, at the time when Residents 1 and 2 left through the exit door, the facility staff just heard the banging of the exit door, but no alarm sound was heard.On 7/9/25 at 1136 hours, an interview was conducted with MHW 2. MHW 2 stated the elopement incident happened around 1950 hours on 6/20/25. MHW 2 stated he heard a door banging. MHW 2 then ran towards the exit door and saw Residents 1 and 2 running towards the street. MHW 2 stated if the exit door was pushed open, an alarm would sound. However, at the time of the incident, MHW 2 stated he just heard the banging of the door, and no alarm sound was heard.On 7/9/25 at 1627 hours, a telephone interview was conducted with the Maintenance Director. The Maintenance Director stated he checked all the doors everyday, especially the exit doors. When asked if there was a maintenance log to show when the exit doors were checked for proper function, the Maintenance Director stated no. On 7/9/25 at 1640 hours, an interview was conducted with the Administrator and DON. The Administer and DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure LVN 1 informed the physician of a change in condition for one of three sampled residents (Resident 598) reviewed for falls. This failure had the potential for Resident 598 to have a delay in care and treatment. Findings: Review of the facility's P&P titled Neurological Assessment (Routine) revised 10/2023 showed a routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury. Routine neurological exams include assessing the mental status and level of consciousness, pupillary response, motor strength, sensation, and gait. Under the section Pupillary Response, showed to test both the pupils to ensure they are equally round and reactive to light and accommodation. Under the section Reporting, showed to notify the physician of any change in a resident's neurological status and report other information in accordance with facility policy and professional standards of practice. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changed in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call when there has been a (an): accident or incident involving the resident, discovery of injuries of an unknown source, adverse reaction to medication, significant changes in the resident's physical/ emotional/mental condition, need to alter the resident's medical treatment significantly Medical record review for Resident 598 was initiated on 12/2/24. Resident 598 was admitted to the facility on [DATE]. Review of Resident 598's MDS assessment dated [DATE], showed Resident 598 had severely impaired cognition. Review of Resident 598's plan of care showed a care plan problem initiated on 11/30/24, addressing Resident 598's unwitnessed fall on 11/30/24. The interventions showed to initiate the neurological checks via neurological evaluations for 72 hours: every 15 minutes x 4 (four times), every 30 minutes x 4, every one hour x 4, and every eight hours x 8. Review of Resident 598's Neurological/Vital Sign Check- V 4 on 11/30/24 at 1400 hours, showed the nurse documented Resident 598's right and left pupils were equal. Review of Resident 598's Neurological/Vital Sign Check- V 4 on 11/30/24 at 1600 hours, showed the nurse documented Resident 598's right and left pupils were equal. Review of Resident 598's Neurological/Vital Sign Check- V 4 on 12/1/24 at 0600 hours, showed the nurse documented Resident 598's right and left pupils were equal. Review of Resident 598's Neurological/Vital Sign Check- V 4 on 12/1/24 at 1100 hours, showed the nurse documented Resident 598's right pupil was non-reactive and left pupil was equal and sluggish. Review of Resident 598's Progress Notes failed to show documentation the physician was notified of the change in Resident 598's pupillary responses for the neurological check on 12/1/24 at 1100 hours. Further review of the notes showed a Change in Condition Note dated on 12/1/24 at 1436 hours, documenting Resident 598 had another fall and was found on the floor with a left forehead skin laceration. On 12/4/24 at 1617 hours, a concurrent interview and medical record review for Resident 598 was conducted with LVN 1. LVN 1 stated the neurological checks and assessments were conducted and should be compared with the previous neurological assessment to check for any neurological impairments or changes related to the resident's fall. LVN 1 further stated upon comparison of the neurological assessments, if there were any changes in the pupillary response, motor function, or level of consciousness, the physician would be informed. LVN 1 reviewed Resident 598's neurological checks and verified she completed the neurological check for Resident 598 on 12/1/24 at 1100 hours. LVN 1 verified there was a change in Resident 598's pupillary responses for the neurological check on 12/1/24 at 1100 hours, compared to the neurological check on 12/1/24 at 0600 hours. When asked, LVN 1 stated she did not compare Resident 598's neurological check with the previous neurological assessment and should have compared the assessments and notified the physician of the change in the assessment findings. On 12/5/24 at 1511 hours, a concurrent interview and medical record review for Resident 598 was conducted with the DON. The DON stated when conducting neuro check assessments on the residents, she expected the nurse to compare the results of the neurological check with the previous neurological check assessment to determine if there was a change in the resident's neurological status. If there was a change in the assessments, the DON stated she expected the nurse to notify the physician and document the physician had been informed. The DON was informed and acknowledged the above findings. On 12/15/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plans were implemented for one of thirteen final sampled residents (Resident 298) and one nonsampled resident (Resident 301). * The facility failed to implement the bilateral floor mats in accordance with the Risk for Falls care plan for Resident 298. * The facility failed to administer Resident 301's Lidocaine 4% external patch for pain management in accordance with Resident 301's At Risk for Pain care plan. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: 1. Medical record review for Resident 298 was initiated on 12/2/24. Resident 298 was admitted to the facility on [DATE]. Review of Resident 298's care plan titled At Risk for Falls initiated 11/30/24, showed Resident 298 was at risk for falls related to generalized weakness, and a history of CVA and TIA. The care plan approaches included the placement of floor pads (mats) next to Resident 298's bed, when Resident 298 was in his bed. On 12/2/24 at 0930 hours, during an observation, Resident 298 was observed lying in bed. Resident 298's bed was observed with a floor mat in place on one side of Resident 298's bed. The opposite side of Resident 298's bed was observed without a floor mat in place. On 12/2/24 at 1213 hours, a concurrent observation, interview, and medical record review was conducted with LVN 4. Resident 298 was observed lying in bed. Resident 298's bed was observed with a floor mat in place on one side of Resident 298's bed. The opposite side of Resident 298's bed was observed without a floor mat in place. LVN 4 verified the findings. LVN 4 stated in accordance with Resident 298's Risk for Falls care plan approaches, a fall mat should have been placed on both sides of Resident 298's bed. Cross reference to F689, example #2. 2. Medical record review for Resident 301 was initiated on 12/2/24. Resident 301 was admitted to the facility on [DATE]. Review of Resident 301's care plan titled At Risk for Pain initiated 11/20/24, showed Resident 301 was at risk for pain related to a history of peripheral vascular disease, osteoporosis, and generalized body pain. The care plan approaches included to administer analgesia medications as ordered by the physician. On 12/4/24 at 0821 hours, a medication administration observation for Resident 301 was conducted with LVN 4. LVN 4 prepared and administered Resident 301's medications. During the medication administration observation for Resident 301, LVN 4 was observed having applied one lidocaine 4% external patch to Resident 301's hip. However, Resident 301's order for the lidocaine 4% external patch showed to apply two patches one time a day at the same time to the right hip and right foot topically for pain management. LVN 4 verified she applied one lidocaine 4% external patch to Resident 301's hip. On 12/4/24 at 1108 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 verified she failed to administer Resident 301's lidocaine pain medication in accordance with Resident 301's At Risk for Pain care plan. Cross reference to F759, example #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a new pressure ulcers and promote the healing of the existing pressure ulcers for two of two final sampled residents (Residents 598 and 599) reviewed for pressure ulcers. * The facility failed to ensure the LAL mattress setting was consistent with Resident 599's weight and failed to ensure the wound treatment was administered as per the physician's order for Resident 599. * The facility failed to ensure the LAL mattress setting was consistent with Resident 598's weight. These failures had the potential for Residents 598 and 599 to not benefit from the therapy provided by the LAL mattress, and potential for delayed wound healing or worsening of existing pressure ulcers for Resident 599. Findings: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown- Clinical Protocol revised 3/2014 showed the physician will authorize pertinent orders related to the wound treatments, including the wound cleansing and debridement approaches, dressings, and application of topical agents if indicated for type of skin alteration. Review of the facility's document titled Power Pro Elite Alternating Pressure with Low Air Loss Mattress system User Manual undated, showed the Power Pro Elite Mattress System is an alternating mattress replacement system used in the prevention and relief for (residents) with, or vulnerable to, pressure ulcers. The Power Pro Elite Mattress System offers (residents) a comfortable and relaxing support surface by using the established principles of alternating therapy, which can both prevent skin breakdown and enhance healing. The comfort level controls the air pressure output level. Press the firm button and the output pressure will increase and higher pressure output will support heavier weight (resident) . According to the weight of the (resident) adjust the pressure setting to the most suitable level without bottoming-out . Please consult with your physician for a proper setting. Further review of the user manual showed Table 1 Weight and Comfort Level Reference for the LAL mattress setting. For a 36-inch mattress, Light 1: 90 to 120 pounds, Light 2: 115 to 145 pounds Light 3: 120 to 175 pounds, Light 4: 145 to 200 pounds, Light 5: 175 to 230 pounds, Light 6: 200 to 265 pounds, Light 7: 230 to 300 pounds, and Light 8: 265 to 330 pounds. 1a. On 12/2/24 at 0840 hours, during the initial tour of the facility, Resident 599 was observed in bed, with a LAL mattress. Staff member was not observed in the room providing care to Resident 599. The LAL mattress unit was observed with the firmness level set at the 8th light bar (setting levels for firmness, level one: soft, and level 8: firm), and the static light on. A sticker titled Patient Weight Sticker was observed on the LAL mattress unit and showed for the 8th light bar, the weight indicated on the sticker was 300 to 330 pounds. When asked, Resident 599 stated she had a bedsore on her butt that had developed during her stay at the facility. When asked about the LAL mattress, Resident 599 stated the LAL mattress was supposed to help redistribute the air, but she did not felt the air being redistributed. When asked if the facility discussed the settings of the LAL mattress unit with her, Resident 599 stated the facility did not. Medical record review for Resident 599 was initiated on 12/2/24. Resident 599 was admitted to the facility on [DATE]. Review of Resident 599's MDS dated [DATE], showed Resident 599 was cognitively intact, and was totally dependent on the staff members assistance for bed mobility, to roll from left and right, and from sit to lying, and lying to sitting on the side of the bed. Further review of Resident 599's MDS, showed Resident 599 weighed 230 pounds, was at risk for developing the pressure ulcers/injuries, and Resident 599 did not have one or more unhealed pressure ulcers/injuries; however, the MDS showed Resident 599 had moisture-associated skin damage. Review of Resident 599's Order Summary Report dated 12/3/24, showed the following physician's orders: - dated 11/8/24, the resident was incapable of understanding the rights, responsibilities, and informed consent, - dated 11/20/24, to apply the LAL mattress for wound management, and - dated 11/23/24, for the Stage 2 pressure ulcer at the coccyx, to wash with soap and water, pat dry, apply Triad cream (a sterile, zinc oxide-based wound dressing cream that can be applied directly to broken skin or wounds) and cover with foam dressing, every day shift for 14 days. Review of Resident 599's plan of care showed the following care plan problems: - dated 11/8/24, addressing Resident 599's risk for skin impairment and further decline of skin integrity related to decreased mobility with high risk for friction, thin fragile skin, head of bed elevated most of the time. The interventions showed to apply the pressure reduction mattress to the bed. - dated 11/23/24, addressing Resident 599's Stage 2 pressure ulcer on the coccyx. The interventions did not include the use of a LAL mattress. Further review of Resident 598's plan of care failed to show a care plan problem addressing the use of a LAL mattress or the specific LAL mattress setting specific to Resident 599. Review of Resident 599's TAR for November and December 2024 failed to show documentation the LAL mattress was monitored for functionality and appropriate setting for the resident. On 12/2/24 at 1013 hours, an interview was conducted with LVN 2. LVN 2 stated she was scheduled as the treatment nurse for the day. When asked, LVN 2 stated the treatment nurses and the Maintenance Department were responsible for the set up and initial settings on the LAL mattress when first applied. LVN 2 stated the treatment nurses were responsible for adjusting the level/settings on the LAL mattress unit and the CNAs do not adjust the settings on the LAL mattress unit. When asked about the settings on the LAL mattress unit, LVN 2 stated the settings on the LAL mattress unit would be based on the resident's weight and the setting selected after comparing the resident's weight to the Patient Weight Settings sticker located on the LAL mattress unit. LVN 2 stated the licensed nurses should check the LAL mattress unit every shift, to ensure the LAL mattress unit was on and the settings were correct. On 12/2/24 at 1030 hours, a concurrent observation, interview and medical record review for Resident 599 was conducted with LVN 2. LVN 2 reviewed Resident 599's medical record and stated on 11/25/24, Resident 599 weighed 222 pounds. Resident 599 was observed in bed, and staff was not observed in the room providing care to Resident 599. LVN 2 verified Resident 599's LAL mattress unit was set at the 8th light bar and the static setting was on. LVN 2 reviewed the Patient Weight Settings sticker located on Resident 599's LAL mattress unit and stated the current LAL mattress setting was not appropriate for Resident 599's weight. When asked, LVN 2 stated not having the appropriate LAL mattress setting for the resident would put the resident at risk of not receiving the full benefits of alternating pressure to the wound and may affect wound healing. When asked, LVN 2 stated the checking and monitoring of the appropriate settings on the LAL mattress unit should be done every shift and documented in the TAR. LVN 2 reviewed Resident 599's medical record and stated there was no documentation in Resident 599's medical record to indicate the appropriate LAL mattress setting for the resident and no documentation the LAL mattress settings were checked. On 12/3/24 at 0903 hours, Resident 599 was observed in bed with the LAL mattress unit set at the 5th light bar. On 12/3/24 at 1517 hours, an interview was conducted with LVN 3. LVN 3 stated initially the treatment nurses were responsible for setting the firmness level on the LAL mattress unit. LVN 3 further stated the firmness settings for the LAL mattress was based on the resident's weight and the treatment nurses are responsible for checking the LAL mattress unit daily. LVN 3 stated the CNAs and charge nurses did not touch the settings on the LAL mattress unit. LVN 3 was asked about the static setting on the LAL mattress. LVN 3 stated in static mode, the pressure of the mattress would be the same. LVN 3 further stated the pressure would be alternating and the LAL mattress should not be on static mode, and the static mode should only be used when transferring or changing the resident. On 12/4/24 at 1453 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 599 had a pressure ulcer on her coccyx and was receiving daily wound treatment by the nurse. CNA 6 stated Resident 599 had a LAL mattress, however CNA 6 stated he did not know what the setting should be set at and he did not touch the settings on the LAL mattress unit. On 12/5/24 at 0906 hours, a concurrent interview and observation was conducted of Resident 599. Resident 599 was observed lying in bed, with the LAL mattress unit set at the 5th light. Resident 599 stated since the settings on the LAL mattress was changed a few days ago, she did feel air in the mattress being circulated more. Resident 599 was asked if the facility discussed the settings of the LAL mattress with her and what settings she was comfortable with, since the application of the LAL mattress. Resident 599 stated no. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated the licensed nurses should monitor the LAL mattress unit every shift, monitoring for functionality of the unit, and for any leaking, or service lights. The DON stated the monitoring of the LAL mattress unit should be documented on the TAR. When asked about the appropriate settings on the LAL mattress, the DON stated the LAL mattress unit had a sticker to show what the firmness level should be set at, and the setting should be based on the residents' weight. When asked about the potential risk of the LAL mattress setting being set at a level not appropriate for the resident's weight, the DON stated there was the potential to affect the wound healing. When asked about the LAL mattress settings specific to each resident, the DON stated the LAL mattress was an intervention for the residents with pressure injuries, or at risk for developing the pressure injuries, however if the resident had a LAL mattress, then there should be an individualized care plan for the use of the LAL mattress for the resident. 1b. Review of Resident 599's TAR for the month of November and December 2024 showed the wound care order dated 11/24/24, for the Stage 2 pressure ulcer on the coccyx, to wash with soap and water, pat dry, apply Triad cream, and cover with foam dressing, every day shift for 14 days. Further review of Resident 599's TAR for November and December 2024 showed the above wound treatment was administered to Resident 599's Stage 2 pressure ulcer on the coccyx from 11/24/24-12/3/24, during the day shift. Review of Resident 599's plan of care showed a care plan problem dated 11/23/24, addressing Resident 599's Stage 2 pressure ulcer on the coccyx. The care plan interventions showed to administer the medications as ordered, monitor and document for side effects/effectiveness, and for the Stage 2 pressure ulcer on the coccyx: to wash with soap and water, pat dry, apply Triad cream, and cover with foam dressing. On 12/3/24 at 1500 hours, a wound treatment observation for Resident 599 was conducted with LVN 3. LVN 3 was observed cleaning the coccyx wound bed with wipes saturated with water and chlorhexidine (antiseptic and disinfectant) solution. On 12/3/24 at 1517 hours, a concurrent interview and medical record review for Resident 599 was conducted with LVN 3. LVN 3 verified he used chlorhexidine to clean Resident 599's Stage 2 pressure wound on the coccyx. LVN 3 reviewed Resident 599's medical record and verified the physician's order was to clean the wound with soap and water. LVN 3 stated he had always used chlorhexidine to clean the wound instead of soap. LVN 3 was asked if the physician was aware he was using chlorhexidine instead of soap, as ordered. LVN 3 stated yes. However, when LVN 3 was asked to show the documentation the physician had been informed that the chlorhexidine was used instead of the soap to clean the wound, LVN 3 stated there were no documentation in the resident's medical record. LVN 3 stated if the physician was aware, then the order would have been clarified to accurately reflect the resident's current wound treatment. LVN 3 agreed the soap and chlorhexidine were not the same and stated the order would have been changed. On 12/5/24 at 1118 hours, a telephone interview was conducted with Physician 1. When asked if Physician 1 was aware the facility was using chlorhexidine instead of soap, as ordered to clean Resident 599's Stage 2 pressure ulcer on the coccyx, Physician 1 stated the facility may have mentioned to him. Physician 1 further stated chlorhexidine could be used to cleanse the wound, however if that was the case, the order should have been clarified to use the chlorhexidine instead of the soap. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated when providing wound treatments, the DON expected the nurse to administer treatments as ordered by the physician. The DON further stated if the treatment nurse was not using what was ordered by the physician, then there should be a clarification of the order to ensure the treatment accurately reflected the physician's order. On 12/5/24 at 1701 hour, the Administrator and DON were informed and acknowledged the above findings. 2. During the initial tour of the facility on 12/2/24 at 0830 hours, Resident 598 was observed lying on a LAL mattress. The LAL mattress unit was observed with the firmness set at the 8th setting (level one: soft and level 8: firm). Resident 598's family member was observed at bedside. When asked about the LAL mattress, FM 1 stated the LAL mattress was for the prevention of the pressure ulcers. When asked, FM 1 stated she did not know what the settings should be set at and the facility did not discuss the settings of the LAL mattress with her. Staff member was not observed in the room providing care to Resident 598 at this time. Medical record review for Resident 598 was initiated on 12/2/24. Resident 598 was admitted to the facility on [DATE], with the diagnosis of hemiplegia (paralysis or weakness in one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a stroke) affecting the right dominant side. Review of Resident 598's Order Summary Report dated 12/3/24, showed the following physician's orders: - dated 11/26/24, the resident was incapable of understanding the rights, responsibilities, and informed consent, and - dated 11/26/24, to apply the LAL mattress for skin maintenance. Review of Resident 598's MDS dated [DATE], showed Resident 598 weighed 121 pounds, had severely impaired cognition, and was at risk for developing pressure ulcers/injuries. Further review of Resident 598's MDS showed Resident 598 was totally dependent on the staff members assistance for bed mobility, for rolling from left to right, for sitting to lying, for lying to sitting on the side of the bed, and for chair/bed-to-chair transfers. Review of Resident 598's plan of care showed the following care plan problems: - dated 11/26/24, addressing Resident 598's ADL self-care performance deficits. The intervention dated on 12/3/24, showed to apply the LAL mattress for skin maintenance. - dated 11/26/24, addressing Resident 598's risk for skin impairment and further decline of skin integrity. The intervention dated on 11/26/24, showed to apply the pressure reduction mattress to the bed, and dated 12/3/24, showed to apply the LAL mattress for skin maintenance. Further review of Resident 598's plan of care failed to show a care plan problem addressing the use of a LAL mattress or the specific LAL mattress setting specific to the resident. Review of Resident 598's TARs for November and December 2024 failed to show the monitoring of the LAL mattress unit. On 12/2/24 at 1013 hours, an interview was conducted with LVN 2. LVN 2 stated she was scheduled as the treatment nurse for the day. When asked, LVN 2 stated the treatment nurses and the Maintenance Department were responsible for the set up and initial settings on the LAL mattress when first applied. LVN 2 stated the treatment nurses were responsible for adjusting the level/settings on the LAL mattress unit and the CNAs did not adjust the settings on the LAL mattress unit. When asked about the settings on the LAL mattress unit, LVN 2 stated the settings on the LAL mattress unit would be based on the resident's weight and the setting selected after comparing the resident's weight to the Patient Weight Settings sticker located on the LAL mattress unit. LVN 2 stated the licensed nurses should check the LAL mattress unit every shift, to ensure the LAL mattress unit was on and the settings were correct. On 12/2/24 at 1020 hours, a concurrent interview, observation, and medical record review for Resident 598 was conducted with LVN 2. LVN 2 reviewed Resident 598's medical record and stated on 11/27/24, Resident 598 weighed 122 pounds. Concurrent observation of Resident 598's LAL mattress unit was conducted with LVN 2, at Resident 598 bedside. Resident 598 was observed lying in bed and the LAL mattress setting was observed set at the 8th light bar. LVN 2 verified the findings. LVN 2 reviewed the Patient Weight Settings sticker located on Resident 598's LAL mattress unit, and stated per Resident 598's weight, the LAL mattress should be set at 2 light bars, for the weight between 120 to 145 pounds. LVN 2 reviewed Resident 598's medical record and stated there were no documentation of the specific LAL mattress setting for Resident 598. LVN 2 reviewed Resident 598's TAR for November and December 2024, and stated there were no documentation the LAL mattress unit was monitored and the settings were checked. On 12/3/24 at 0852 hours, Resident 598 was observed lying in bed with the LAL Mattress unit set at 2 light bars. On 12/4/24 at 1453 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 598 had a special mattress, and that he did not touch the settings on the LAL mattress unit. On 12/5/24 at 0944 hours, a follow-up interview was conducted with FM 1. FM 1 stated the facility had discussed the use of the LAL mattress; however the facility did not discuss the specific setting for the LAL mattress. FM 1 stated, since the facility changed the setting on the LAL mattress on Monday, FM 1 noticed her mother complained less of discomfort in her bottom and appeared less fidgety in bed. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated the licensed nurses should monitor the LAL mattress unit every shift, monitoring for functionality of the unit, and for any leaking, or service lights. The DON stated the monitoring of the LAL mattress unit should be documented on the TAR. When asked about the appropriate settings on the LAL mattress, the DON stated the LAL mattress unit had a sticker to show what the firmness level should be set at, and the setting should be based on the residents' weight. When asked about the potential risk of the LAL mattress setting being set at a level not appropriate for the resident's weight, the DON stated there was the potential to affect the wound healing. When asked about the LAL mattress settings specific to each resident, the DON stated the LAL mattress was an intervention for the residents with pressure injuries, or at risk for developing the pressure injuries, however if the resident had a LAL mattress, then there would be an individualized care plan for the use of the LAL mattress for the resident. On 12/5/24 at 1701 hours, the Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 298 and 600) reviewed for accident hazards remained free from the accident hazards. * The facility failed to ensure CNAs 2 and 3 used a gait belt as per the fall risk evaluation and care plan when transferring Resident 600 to the commode. * The facility failed to implement the bilateral floor mats for safety and fall prevention in accordance with the physician's order for Resident 298. These failures have the potential to place Residents 298 and 600 at risk for serious injury. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed based on the previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person of if he or she had not caught him/herself, is considered a fall. Under the section Resident-Centered Approaches to Managing Falls and Fall Risk showed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 1. On 12/2/24 at 0939 hours, an interview was conducted with Resident 600. Resident 600 stated she had a fall on 11/28/24, during the transfer from her bed to the bedside commode. Medical record review for Resident 600 was initiated on 12/2/24. Resident 600 was admitted to the facility on [DATE]. Review of Resident 600's Fall Risk Evaluation dated 11/23/24, showed Resident 600 was at moderate risk for falls. Under the section Gait, showed Resident 600 had weak on walking and short, shuffle steps, lightly touching furniture for support. Under impaired gait, showed Resident 600 was at risk for falls related to generalized weakness. The approach selected showed Resident 600 had impaired gait/balance, to use the gait belt and the PT had recommended devices per the plan of care for the resident's transfers/ambulation. Review of Resident 600's IDT: Post Accident/Fall dated 11/28/24, showed Resident 600 had a fall on 11/28/24 at 0335 hours. The IDT determined the follow-up measures that were needed to reduce the risk of reoccurrence were to apply non-skid or appropriate footwear, room free of clutter and the use of the gait belt when transferring/ambulating. Review of Resident 600's Fall Risk Evaluation dated 11/28/24, showed Resident 600 was at moderate risk for falls. Under the section Gait, showed Resident 600 had weak in walking and short, shuffle steps, lightly touching furniture for support. Under impaired gait, showed Resident 600 was at risk for falls related to generalized weakness. The approach selected showed Resident 600 had impaired gait/balance, to use the gait belt and PT had recommended devices per the plan of care for the resident's transfers/ambulation. Review of Resident 600's plan of care showed the following care plan problems: - dated 11/26/24, addressing Resident 600's risk for falls related to her status post anterior and posterior lumbar fusion (a surgical procedure that joins two or more vertebrae in the lower back to relieve pain and restore function) on 11/19/24. The interventions showed Resident 600 had impaired gait/balance, to use the gait belt and PT had recommended devices per the plan of care for the resident's transfers/ambulation. - dated 11/28/24, addressing Resident 600's witnessed fall. The intervention initiated 12/2/24, showed to use the gait belt with resident's transfers and ambulation. Review of Resident 600's MDS dated [DATE], showed Resident 600 was cognitively intact and required substantial/maximal assistance to roll on the left and right, to move from sitting to standing, for chair/bed-to chair transfer, and for toilet transfers. On 12/4/24 at 1516 hours, a phone interview was conducted with CNA 2. CNA 2 stated she was Resident 600's CNA on 11/28/24, when Resident 600 had her fall. CNA 2 stated Resident 600 was alert and was able to verbalize her needs. CNA 2 stated she had previously assisted Resident 600 to the bedside commode prior to her fall. CNA 2 was asked about how she assisted Resident 600 to the bedside commode and CNA 2 stated she used Resident 600's walker. When asked about the use of the gait belt, CNA 2 denied using the gait belt. When asked if CNA 2 offered the use of the gait belt to Resident 600, CNA 2 stated she felt Resident 600 was steady for the use of the walker with the assistance from CNA 2. CNA 2 stated she assessed Resident 600 and the resident was stable and it did not occur to her to use the gait belt. CNA 2 was asked if she was informed by the nurse she needed to use the gait belt with Resident 600 during her transfers, CNA 2 stated no. CNA 2 stated the purpose of the use of the gait belt was to prevent falls. On 12/5/24 at 0914 hours, during an observation, Resident 600 was observed sitting in her wheelchair and informed CNA 3 she needed to use the bedside commode. CNA 3 was observed pulling the privacy curtain, donning gloves, and assisting Resident 600 to the bedside commode. CNA 3 was observed grabbing Resident 600's walker to use during the transfer to the bedside commode and assisted Resident 600 on to the bedside commode. The gait belt was observed on Resident 600's bed and was not observed used during the transfer. On 12/5/24 at 0927 hours, an interview was conducted with CNA 3. CNA 3 was asked if she was aware Resident 600 had a previous fall. CNA 3 stated she was informed Resident 600 had a previous fall during a transfer to the commode. CNA 3 stated Resident 600 was a fall risk and usually transferred with the gait belt. CNA 3 verified she did not use the gait belt when she transferred Resident 600 to the bedside commode. CNA 3 stated she was familiar with the resident and she felt confident in transferring Resident 600 without the use of the gait belt. When asked when the gait belt should be used, CNA 3 stated the gait belt should be used at all times when moving from one position to another, including from the bed to the wheelchair, and from the wheelchair to the commode. CNA 3 stated she was informed by the charge nurse to use the gait belt during transfers for Resident 600. CNA 3 stated she used the gait belt with Resident 600 in the past, however she was more comfortable with Resident 600 so she did not use the gait belt during the transfer. On 12/5/24 at 0935 hours, an interview was conducted with OT 1. OT 1 stated she was familiar with Resident 600 and was working with Resident 600 on transferring on and off of the toilet/commode, getting dressed and the use of adaptive equipment. OT 1 was asked about the protocol for transferring for Resident 600. OT 1 stated for Resident 600, the resident required partial to moderate assistance with one person assist during the transfers. OT 1 stated for the transferring for Resident 600 to the bedside commode, either from the bed or the wheelchair, Resident 600 must wear her back brace, non skid socks, and the staff assisting with the transfer should use a gait belt and the walker. On 12/5/24 at 1511 hours, a concurrent interview and medical record review for Resident 600 was conducted with the DON. The DON stated if the resident had a previous fall and the IDT recommended the use of the gait belt for transfers, she expected staff to transfer the resident using the gait belt. The DON reviewed Resident 600's fall risk evaluations and post fall IDT recommendations and verified the approaches and recommendations. The DON was asked and stated the use of the gait belt was for the safety of the resident and the CNA. On 12/5/24 at 1604 hours, an interview was conducted with Resident 600. Resident 600 stated staff were supposed to use the gait belt when they transfer her. When asked, Resident 600 denied refusing the use of the gait belt during her transfers. On 12/5/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings. 2. Medical record review for Resident 298 was initiated on 12/2/24. Resident 298 was admitted to the facility on [DATE]. Review of Resident 298's Order Summary Report showed a physician's order dated 11/30/24, for the bilateral floor mats for safety and fall prevention. Review of Resident 298's care plan titled At Risk for Falls initiated 11/30/24, showed Resident 298 was at risk for falls related to generalized weakness, and a history of CVA and TIA. The care plan approaches included the placement of floor pads (mats) next to Resident 298's bed when Resident 298 was in his bed. On 12/2/24 at 0930 hours, during an observation, Resident 298 was observed lying in bed. Resident 298's bed was observed with a floor mat in place on one side of Resident 298's bed. The opposite side of Resident 298's bed was observed without a floor mat in place. On 12/2/24 at 1213 hours, a concurrent observation, interview, and medical record review was conducted with LVN 4. Resident 298 was observed lying in bed. Resident 298's bed was observed with a floor mat in place on one side of Resident 298's bed. The opposite side of Resident 298's bed was observed without a floor mat in place. LVN 4 verified the findings. LVN 4 stated as per the physician's order, a fall mat should have been placed on both sides of Resident 298's bed to reduce the risk of injury as Resident 298 was at risk for falls. Cross reference to F656, example #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of 13 final sampled residents (Resident 398). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Resident 398. This failure had the potential to delay the identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Central Venous Catheter Care and Dressing Changes dated 2001 showed the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. For PICCs, measure arm circumference and compare to baseline when clinically indicated to assess for edema and possible deep-vein thrombosis. Medical record review for Resident 398 was initiated on 12/2/24. Resident 398 was admitted to the facility on [DATE]. Review of Resident 398's H&P examination dated 11/20/24 showed Resident 398 had the capacity to understand and make decisions but failed to show the information of the measurement and assessment of the PICC line was documented when the resident was admitted to the facility. Review of Resident 398's Order Summary Report for December 2024 showed a physician's order dated 11/25/24, for PICC line dressing and cap change every seven days and as needed with CVC dressing kit. Apply Biopatch (a chlorhexidine (CHG)-impregnated sponge that releases CHG continuously for up to seven days. It prevents skin organisms from entering the body at the insertion site and reduces the risk of catheter-related bloodstream infections) around catheter at insertion site. Transparent dressing placed over Biopatch dressing, no gauze over site. Measure the external length of the catheter and upper arm circumference (10 cm above insertion site) every day shift, every Sunday. Review of Resident 398's care plan dated 12/2/24, showed the resident had a PICC line on the right upper arm with two lumens. Under the section approaches/tasks showed to measure the external length of the catheter and upper arm circumference (10 cm above insertion site). Review of Resident 398's IV Administration Record dated 11/26/24, showed the measurements for the arm circumference of 32 cm and catheter was zero. Further review of Resident 398's medical record failed to show a documented evidence of the measurements of the length of the PICC line catheter above the insertion site and arm circumference were obtained upon admission. On 12/5/24 at 1327 hours, a concurrent interview and medical record review for Resident 398 was conducted with RN 1. RN 1 stated the dressing change for the PICC line was performed every seven days. RN 1 verified Resident 398's medical record did not show the PICC line external catheter and arm circumference measurements upon admission to the facility. RN 1 stated there should have been a measurement of the length of the catheter and arm circumference upon admission of the resident. In addition, RN 1 stated the arm circumference measurement would indicate signs and symptoms of infection such as swelling, and blood clots and the external catheter length would indicate dislodgement. On 12/5/24 at 1700 hours, the DON was informed and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care for one of three final sampled residents (Resident 12) reviewed for respiratory care. * The facility failed to ensure Resident 12's CPAP machine was cleaned as per the manufacturer's user cleaning guidelines. This failure had the potential to adversely affect the health and well-being Resident 12 and posed the risk for equipment contamination and respiratory complications. Findings: Review of the facility's P&P titled CPAP/BiPAP Support revised 3/2015 showed the specific cleaning instruction guidelines are obtained from the manufacturer of the PAP device. For the machine cleaning, to wipe the machine with warm, soapy water and rinse at least once a weeks and as needed. For the humidifier (if used), to use clean, distilled water, to clean the humidifier weekly and air dry, to disinfect, place vinegar-water solution (1:3) in the clean humidifier, soak for 30 minutes and rinsed thoroughly. For the components of the machine such as the masks, nasal pillows, and tubing, to clean daily by placing in warm, soapy water and soak/agitating for five minutes. Mild dish detergent is recommended. To rinse with warm water and allow to air dry between uses. For the headgear, to wash with warm water and mild detergent as needed and allow to air dry. On 12/2/24 at 0900 hours, a concurrent observation and interview was conducted with Resident 12. Resident 12's bedside drawer was noted to have a CPAP (ResMed Air Sense 11) machine, which was observed off with the CPAP mask observed on top of the CPAP machine. The mask was not observed stored in a plastic bag. Resident 12 was asked about his CPAP machine and stated he used his CPAP machine every night. Resident 12 was asked if the staff cleaned the CPAP machine, tubing and mask. Resident 12 stated no, he had not seen staff member clean it since he started using the CPAP at the facility. Review of the ResMed Air Sense 11 (CPAP machine) user guide, undated showed under the section Cleaning and Caring For the Device, showed to clean the device and its components according to the schedules shown in this guide, to maintain the quality of the device and to prevent the growth of germs that can adversely affect your health. Medical record review for Resident 12 was initiated on 12/2/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 had moderately impaired cognition and was coded for the use of the CPAP machine. Review of Resident 12's Order Summary Report dated 12/3/24, showed the following physician orders: - dated 10/14/24, the resident was capable of understanding the rights, responsibilities, and informed consent - dated 10/14/24, to apply the CPAP at 5.5 cm H2O with the oxygen concentrator every evening and night shift. The Order Summary Report failed to show a physicians order for the cleaning of the CPAP machine and its components. Review of Resident 12's plan of care showed a care plan problem dated 10/27/24, addressing Resident 12's CPAP Therapy. The interventions showed to educate the resident on the importance of the CPAP therapy and to encourage the resident's use of the CPAP. The care plan problem failed to show the specific CPAP setting for Resident 12 and failed to show interventions for the maintenance and care of the CPAP machine and the components. On 12/3/24 at 0841 hours, a concurrent observation and interview was conducted with Resident 12. Resident 12's CPAP mask was observed on top of a pillow on the bedside drawer. The CPAP mask was not observed inside a storage bag. Resident 12 was asked if a staff member had cleaned his CPAP mask this morning, Resident 12 stated no. On 12/4/24 at 0826 hours, a concurrent observation and interview was conducted with CNA 4. Resident 12's CPAP mask was observed on Resident 12's bedside drawer. The CPAP mask was not observed inside a storage bag. The CPAP tubing was observed on top of the CPAP mask, and an ice bag inside of the sling was observed on top of the CPAP mask. Resident 12 stated at home, he cleaned his CPAP machine and mask once a week or as needed. CNA 4 stated he assisted Resident 12 to remove his CPAP mask in the mornings. CNA 4 stated he did not clean the CPAP mask and was not sure who was responsible for the cleaning of the CPAP mask, and how often it should be cleaned. On 12/4/24 at 0842 hours, a concurrent interview and medical record review for Resident 12 was conducted with the DSD. The DSD stated for the use of a CPAP machine, there should be a physician's order for how to clean and the frequency of the cleaning of the CPAP machine and its components. The DSD stated the cleaning of the CPAP masks are done by the licensed nurses after each use and upon removal of the CPAP mask in the morning. The DSD stated the CPAP masks should be rinsed with warm water and pat dry daily, after every use, for infection control purposes. The DSD stated the oxygen tubings should be changed and labeled every seven days and when not in use, the CPAP masks and tubing should be stored inside a storage bag for infection control. The DSD also stated, the cleaning of the CPAP machine and the CPAP mask should be documented in either the progress notes or the MAR. The DSD reviewed Resident 12's medical record and verified there were no orders for the cleaning of Resident 12's CPAP machine and its components, there were no documentation of the cleaning of Resident 12's CPAP machine and its components, and Resident 12's care plan addressing his CPAP therapy did not specify the CPAP settings, or did not include the interventions for the cleaning of the CPAP machine and its components. On 12/4/24 at 0900 hours, a concurrent interview and observation was conducted with the DSD at Resident 12's bedside. The DSD verified the above findings. When asked about the oxygen tubing connecting the oxygen concentrator to the CPAP mask, the DSD verified the oxygen tubing was not labeled and stated he did not know how long the oxygen tubing have been in use. The DSD stated the oxygen tubings should be changed and labeled every seven days. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated both the CNAs and the LVNs could clean the CPAP mask, however, it should be documented on the MAR by the licensed nurses, to monitor the cleaning of the CPAP machine and its components. The DON stated the CPAP mask and machine should be cleaned routinely, and when not in use, the CPAP make should be stored in a storage bag for infection control purposes. On 12/5/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management for two of two final sampled residents (Residents 12 and 599) reviewed for pain management. * The facility failed to administer pain medication according to the physician's order for Resident 12 and failed to ensure non-pharmacological interventions for pain (NPI) were provided/documented prior to the administration of pain medications. * The facility failed to ensure Resident 599 was consistently provided non-pharmacological interventions for pain prior to the administration of narcotic pain medication. These failures put Residents 12 and 599 at risk for ineffective pain management. Findings: Review of the facility's P&P titled Administering Medications revised 9/2019 showed the medications are administered in accordance with the prescriber orders, including any required time frame. Review of the facility's P&P titled Pain Assessment and Management revised 10/2022 showed non-pharmacological interventions may be appropriate alone or in conjunction with medications. Pharmacological interventions may be prescribed to manage pain, however; they do not usually address the cause of pain and can have adverse effects on the resident. When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. 1. On 12/2/24 at 0900 hours, an interview was conducted with Resident 12. Resident 12 stated he was at the facility following a surgery on his left shoulder. Resident 12 stated he had pain in his left shoulder and the facility was administering the oxycodone (opioid) and Tylenol (analgesic) for his pain. Medical record review for Resident 12 was initiated on 12/2/24. Resident 12 was admitted the facility on 10/14/24 with the diagnoses including presence of a left artificial shoulder joint and aftercare following joint replacement surgery. Review of Resident 12's MDS assessment dated [DATE], showed Resident 12 had moderately impaired cognition. Further review of the MDS assessment showed Resident 12 was coded for occasional moderate pain. Review of Resident 12's Order Summary Report dated 12/3/24, showed the following physician's orders: - dated 10/14/24, the resident was capable of understanding his rights, responsibilities, and informed consent. - dated 10/14/24, to administer acetaminophen 500 mg two tablets by mouth every eight hours as needed for mild pain (pain level of 1-3 out of 10). - dated 10/14/24, to record the NPI every shift, using the 0 to 10 scale which was coded as follows: was coded as follows: 0 = no non-drug intervention needed, 1 = re-positioning/limb elevation, 2 = reassurance/emotional support, 3 = provide distraction/diversionary activities, 4 = exercise/ROM/ambulation/stretching, 5 = rest period/quiet environment, 6 = deep breathing/relaxation exercises, 7 = guided imagery/meditation, 8 = laughter/socialization, 9 = music, 10 = other, specify - dated 10/15/24, to monitor for the presence of verbal/nonverbal pain, every shift using the pain scale 0 to 10, 0 for no pain, 1-3 for mild pain, 4-6 for moderate pain, 7-9 for severe pain, 10/10 for very severe pain. - dated 10/22/24, to administer oxycodone 5 mg, to give ½ (half) tablet by mouth every four hours as needed for moderate pain (pain level 4-6 out of 10). - dated 10/22/24, to administer oxycodone 5 mg, to give one tablet by mouth every four hours as needed for severe to very severe pain (pain level 7-10 out of 10). Review of Resident 12's plan of care showed a care plan problem initiated on 10/15/24, addressing Resident 12's risk for pain related to generalized body pain, neuropathy, and left shoulder arthroplasty. The interventions showed to monitor for the presence of pain every shift, to administer analgesia medications as ordered by the physician, and to provide non-pharmacological pain interventions every shift. Review of Resident 12's MAR for November and December 2024 showed Resident 12 was administered the acetaminophen medication 500 mg, two tablets by mouth every eight hours as needed for mild pain (pain level of 1-3/10) on the following dates and times when the resident's pain level was not within the pain levels of 1-3 as ordered: - On 11/7/24 at 1539 hours, a pain level of 4. - On 11/8/24 at 0719 hours, a pain level of 4. - On 11/11/24 at 0530 hours, a pain level of 4. - On 11/26/24 at 1709 hours, a pain level of 0. - On 11/30/24 at 0327 hours, a pain level of 5. Further review of the MAR for November and December 2024 showed Resident 12 was administered the following medications on the following dates and times, for the following pain levels: * Resident 12 was administered the acetaminophen medication 500 mg, two tablets by mouth every eight hours as needed for mild pain (pain level of 1-3/10): - on 11/12/24 at 0500 hours, for a pain level of 3. - on 11/13/24 at 0600 hours, for a pain level of 3. - on 11/14/24 at 0515 hours, for a pain level of 3. - on 11/15/24 at 0500 hours, for a pain level of 3. - on 12/1/24 at 0900 hours, for a pain level of 3. * Resident 12 was administered the oxycodone medication 5 mg, ½ (half) tablet every four hours as needed for moderate pain: - on 11/13/24 at 0045 hours, for a pain level of 6. - on 11/22/24, at 1600 hours, for a pain level of 7. Further review of Resident 12's MAR for November and December 2024 showed the following NPIs documented for the following dates and shifts: - from 11/11/24 to 11/15/24, for the NOC shift (from 2300 to 0700 hours), the NPI was documented as 0, - on 11/22/24, for the evening shift (from 1500 to 2300 hours), the NPI was documented as 0, and - on 12/1/24, for the day shift (from 0700 to 1500 hours), the NPI was documented as 0. On 12/4/24 at 1445 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 12 was alert and oriented and was able to verbalize his needs. CNA 4 stated whenever Resident 12 complained of pain in his shoulder, CNA 4 would inform the nurse and the nurse would administer the pain medication to the resident. On 12/ 5/24 at 1031 hours, a concurrent interview and medical record review for Resident 12 was conducted with LVN 2. LVN 2 stated upon notification of a resident's pain, LVN 2 would assess the resident's pain and attempt to offer the NPIs prior to the administration of the pain medication. LVN 2 further stated the NPIs provided and the effectiveness of the interventions were documented in the MAR. LVN 2 stated for the administration of the pain medications, the pain medications should be administered as ordered by the physician and within the ordered pain parameters. LVN 2 stated, if the pain medications were administered outside of the ordered parameters, the physician should be informed, and the nurse should document in the resident's progress notes. LVN 2 reviewed Resident 12's MAR and verified the above findings. LVN 2 stated if pain medications were administered, there should be documentation of the NPIs that were implemented. LVN 2 stated the NPI should not be documented as 0 and if NPIs were refused by the resident then there should be documentation of the resident's refusal in the resident's medical record. LVN 2 further reviewed Resident 12's medical record and stated there were no documentation the physician was informed Resident 12 was administered the pain medication outside of the ordered pain parameter on the above dates and no documentation Resident 12 refused offered NPIs prior to the administration of pain medications for the above dates. 2. On 12/2/24 at 0840 hours, an interview was conducted with Resident 599. Resident 599 stated she had a bedsore on her butt that had developed during her stay at the facility. Resident 599 stated the facility administered the pain medications whenever she informed them of her pain. Medical record review for Resident 599 was initiated on 12/2/24. Resident 599 was admitted to the facility on [DATE]. Review of Resident 599's MDS dated [DATE], showed Resident 599 was cognitively intact. Review of Resident 599's Order Summary Report dated 12/3/24, showed the following physician's orders: - dated 11/8/24, to administer acetaminophen tablet 325 mg, to give two tablets by mouth every six hours as needed for mild pain (pain level of 1-3 out of 10), not to exceed three grams in 24 hours. - dated 11/8/24, to monitor for the presence of verbal/nonverbal pain, every shift, using the pain scale 0 to 10, 0 for no pain, 1-3 for mild pain, 4-6 for moderate pain, 7-9 for severe pain, and 10/10 for very severe pain. - dated 11/8/24, to record the NPIs every shift, using the 0 to 10 scale which was coded as follows: 0 = no non-drug intervention needed, 1 = re-positioning/limb elevation, 2 = reassurance/emotional support, 3 = provide distraction/diversionary activities, 4 = exercise/ROM/ambulation/stretching, 5 = rest period/quiet environment, 6 = deep breathing/relaxation exercises, 7 = guided imagery/meditation, 8 = laughter/socialization, 9 = music, 10 = other-specify - dated 11/14/24, to administer Roxicodone (narcotic) 5 mg, one tablet every four hours as needed for moderate to severe pain (pain level of 4 to 10 out of 10). Review of Resident 599's plan of care showed a care plan problem initiated on 11/8/24, addressing Resident 599's risk for pain related to generalized body pain. The interventions showed to provide NPIs every shift. Review of Resident 599's MAR for November 2024, showed Resident 599 was administered Roxicodone 5 mg, one tablet every four hours as needed for moderate to severe pain on the following dates: - on 11/12/24 at 0300 hours, a pain level of 7. - on 11/13/24 at 0155 hours, a pain level of 7. - on 11/14/24 at 0500 hours, a pain level of 7. - on 11/15/24 at 0615 hours, a pain level of 7. - on 11/15/24 at 1342 hours, a pain level of 6. - on 11/15/24 at 2022 hours, a pain level of 6. - on 11/16/24 at 1330 hours, a pain level of 4. - on 11/19/24 at 0200 hours, a pain level of 7. - on 11/22/24 at 1905 hours, a pain level of 7. - on 11/23/24 at 0912 hours, a pain level of 7. - on 11/26/24 at 0500 hours, a pain level of 7. Further review of Resident 599's MAR for November 2024 failed to show the documented evidenced the non-pharmacological interventions were attempted prior to the administration of the Roxicodone pain medication on the above listed dates. On 12/5/24 at 1031 hours, a concurrent interview and medical record review for Resident 599 was conducted with LVN 2. LVN 2 verified the above findings. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated medications should be administered to the residents as ordered by the physician. The DON stated for the administration of the pain medication, the licensed nurses were expected to assess the resident's pain, to implement and document the non-pharmacological interventions prior to the administration of the pain medication, and to administer the pain medications as ordered by the physician and within the ordered parameters. When asked, the DON stated if the residents requested for the pain medication and refused the offered non-pharmacological interventions, the nurse should document the refusal. On 12/5/24 at 1701 hours, the Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmacy services as per the facility P&P for seven nonsampled residents (Residents 14, 42, 302, 303, 305, 601, and 602). * LVN 2 failed to ensure the medications scheduled for 0900 hours were administered timely within the 60 minutes of the scheduled time for two nonsampled residents (Residents 601 and 602). This failure had the potential to place the residents at risk for delays in treatment and increased risk of adverse events. * LVN 4 failed to ensure the resident medications scheduled for 12/4/24 at 0900 hours, were administered timely within the 60 minutes of the scheduled time for three nonsampled residents (Residents 42, 302, and 305). This failure had the potential to place the residents at risk for delays in treatment and increased risk of adverse events. * The facility failed to ensure the accurate documentation of three controlled medications on the Drug Control Receipt/ Record/ Disposition Form for three nonsampled residents (Residents 14, 302, and 303). This failure had the potential for drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in accordance with prescriber orders, including any required time frame. The medications are administered within one hour of their prescribed time unless otherwise specified (for example, before and after meal orders). 1a. On 12/3/24 at 1030 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 stated she had seven residents remaining to pass morning medications. On 12/3/24 at 1040 hours, a medication administration observation for Resident 601 was conducted with LVN 2. LVN 2 prepared and administered the following medications to Resident 601: - one tablet of amlodipine (to treat high blood pressure) 5 mg, - one tablet of carvedilol (to treat high blood pressure) 3.125 mg, - one tablet of Eliquis (anticoagulant) 5 mg, - one tablet of hydralazine (vasodilator) 100 mg, - one tablet of Jardiance (antidiabetic) 10 mg, - one tablet of clonidine (antihypertensive) 0.1 mg, and - one tablet of isosorbide mononitrate (to treat high blood pressure) 120 mg. On 12/13/24 at 1103 hours, an interview was conducted with LVN 2. LVN 2 stated the morning medications were usually scheduled at 0900 hours, and the nurses have a window for the administration of 0900 hours medication between 0800 to 1000 hours. LVN 2 stated the medications administration for Resident 601 was considered late. LVN 2 stated Resident 601 recently had a stroke and was administered medications to control her blood pressure and thin her blood. LVN 2 further stated it was important to administer Resident 601's medications on time to ensure her blood pressure was regulated and to prevent the occurrence of another stroke. On 12/3/24 at 1112 hours, an interview was conducted with Resident 601. Resident 601 stated she recently had a stroke and was taking Eliquis to thin her blood and taking blood pressure medications to control her blood pressure. Resident 601 further stated it was important for her to take her medications on time. Medical record review for Resident 601 was initiated on 12/2/24. Resident 601 was admitted to the facility on [DATE]. Review of Resident 601's Order Summary Report dated 12/3/24, showed a physician's order dated 11/21/24, showed the resident was capable of understanding rights, responsibilities, and informed consent. Review of Resident 601's Medication Administration Audit Report dated 12/4/24, showed on 12/3/24 for the 0900 hours scheduled medications, the following medications were not administered as ordered: amlodipine, carvedilol, Eliquis, hydralazine, Jardiance, and clonidine. Review of Resident 601's Progress Notes showed a Health Status Note dated 12/4/24 at 1238 hours, documentation for 12/3/24 for the 0900 hours, showed the medications were given at 1108 hours due to unexpected circumstances. The physician was made aware with no new orders. b. On 12/3/24 at 1158 hours, a medication administration observation for Resident 602 was conducted with LVN 2. During the medication administration, Resident 602 asked LVN 2 why he was getting his morning medications at noon. LVN 2 informed Resident 602 she had interruptions and had to deal with a resident emergency this morning. On 12/3/24 at 1203 hours, an interview was conducted with Resident 602. Resident 602 was asked about his expectations for the administration of his medications and Resident 602 stated he expected to have his medications administered on time. Medical record review for Resident 602 was initiated on 12/3/24. Resident 602 was admitted to the facility on [DATE]. Review of Resident 602's H&P examination dated 11/29/24, showed Resident 602 had the capacity to understand and make decisions. Review of Resident 602's Medication Administration Audit Report dated 12/4/24, showed on 12/3/24 for the 0900 hours scheduled medications, the following medications were not administered as ordered: lidocaine external patch (analgesic), vitamin C (supplement), tamsulosin (to treat symptoms of enlarged prostate), clopidogrel (antiplatelet), ferrous sulfate (iron supplement), aspirin (anti-inflammatory), allopurinol (to treat gout), [NAME]-Vite (supplement), and Senna S (laxative). Review of Resident 602's Progress Notes dated 12/3/24 at 1304 hours, showed the physician was made aware about medications not given on time. On 12/3/24 at 1550 hours, an interview was conducted with the DON. The DON stated the licensed nurses were expected to administer the scheduled medications on time, within the appropriate window. On 12/5/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the findings. 3a. Review of the facility's P&P titled Controlled Substances dated 2001 showed the controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/ diversion, and detection/follow up. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: A. Records of personnel access and usage; B. Medication administration records; C. Declining inventory records; and D. Destruction, waste and return to pharmacy records. Medical record review for Resident 14 was initiated on 12/2/24. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 14's Order Summary Report for December 2024 showed a physician's order dated 10/8/24, for hydrocodone-acetaminophen oral tablet 5-325 mg (opoid) give one tablet by mouth every four hours as needed for severe to very severe pain (7-10, using the pain scale from 0 to 10 with 0 = no pain and 10 = worst pain). Review of Resident 14's bubble pack for hydrocodone/ APAP 5-325 mg showed a count of 12 tablets. However, review of Resident 14's Drug Control Receipt/ Record/ Disposition Form for hydrocodone/ APAP 5-325 mg showed there were 13 tablets remaining. The document failed to show the date, time, and licensed nurse's signature for the removal of one hydrocodone/ APAP 5-325 mg tablet, after the entry on 11/29/24 at 0744 hours. On 12/5/24 at 0831 hours, a concurrent interview and document review of the Drug Control Receipt/ Record/ Disposition Form for Hydrocodone/ APAP 5-325 mg for Resident 14 was conducted with the DON. The DON verified the above findings. The DON was asked about her expectations of the staff for removal of the narcotics and controlled drugs for administration. The DON stated the nurse was expected to record and sign on the narcotic count sheet after removal of the controlled drugs and to ensure the narcotic count sheet and bubble pack for the medication matched. b. Medical record review for Resident 302 was initiated on 12/2/24. Resident 302 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 302's Order Summary Report for December 2024 showed a physician's order dated 11/22/24, for oxycodone HCL oral tablet 5 mg (analgesic) give one tablet by mouth every four hours as needed for moderate to very severe pain (4-10, using the pain scale level 0 meaning no pain and 10 meaning worst pain). Review of Resident 302's bubble pack for oxycodone IR 5 mg showed a count of five tablets. However, review of Resident 302's Drug Control Receipt/ Record/ Disposition Form for Oxycodone IR 5 mg showed there were six tablets remaining. The document failed to show the date, time, and licensed nurse's signature for the removal of one oxycodone IR 5 mg tablet, after the netry on 12/1/24 at 1738 hours. On 12/5/24 at 0831 hours, a concurrent interview and document review of the Drug Control Receipt/ Record/ Disposition Form for oxycodone IR 5 mg for Resident 302 was conducted with the DON. The DON acknowledged the above findings. The DON was asked about her expectations of the staff for removal of the narcotics and controlled drugs for administration. The DON stated the nurse was expected to record and sign on the narcotic count sheet after removal of the controlled drugs and to ensure the narcotic count sheet and bubble pack for the medication matched. c. Medical record review for Resident 303 was initiated on 12/2/24. Resident 303 was admitted to the facility on [DATE]. Review of Resident 303's Order Summary Report for December 2024 showed a physician's order dated 11/18/24, for Pregabalin oral capsule 75 mg (nerve pain medication) give one capsule by mouth three times a day for neuropathy pain. Review of Resident 303's bubble pack for pregabalin 75 mg showed a count of 21 capsules. However, review of Resident 303's Drug Control Receipt/ Record/ Disposition Form for pregabalin 75 mg showed there were 22 tablets remaining. The document failed to show the date, time, and licensed nurse's signature for the removal of one pregabalin 75 mg tablet; after the entry on 12/1/24 at 1700 hours. On 12/5/24 at 0831 hours, a concurrent interview and document review of the Drug Control Receipt/ Record/ Disposition Form for pregabalin 75 mg for Resident 303 was conducted with the DON. The DON acknowledged the above findings. The DON was asked about her expectations of the staff for removal of the narcotics and controlled drugs for administration. The DON stated the nurse was expected to record and sign on the narcotic count sheet after removal of the controlled drugs and to ensure the narcotic count sheet and bubble pack for the medication matched. 2. On 12/4/23 at 1007 hours, a concurrent observation and interview was conducted with LVN 4. LVN 4 was observed administering medications to the facility residents. LVN 4 stated she had seven residents (which included Residents 42, 302, and 305) remaining who had yet to receive their morning medications, which were scheduled to be administered at 0900 hours . LVN 4 stated in accordance with the facility's P&P, resident medications were to be administered within one hour of their prescribed time. LVN 4 stated she was unable to administer the morning medications scheduled for 0900 hours, to Residents 42, 302, and 305, due to having to provide nursing care to a resident (Resident 43) who had an episode of vomiting. a. Review of Resident 42's Order Summary Report dated 12/2024, showed the following medications were ordered to be administered on 12/4/24 at 0900 hours: - Lidoderm Patch 5% (analgesic), apply to right knee topically once a day for pain management, - Cardizem extended release (antihypertensive) 120 mg tablet orally once a day for hypertension, - divalproex sodium extended release (anticonvulsant) 500 mg tablet orally once a day for mood disorder, - telmisartan (antihypertensive) 80 mg tablet orally twice a day for hypertension, and - sertraline (antidepressant) 50 mg tablet orally once a day for depression. Review of Resident 42's Medication Administration Audit Report dated 12/4/2024, showed the above listed medications were administered on 12/4/24 at 1341 hours. b. Review of Resident 305's Order Summary Report dated 12/2024, showed the following medications were ordered to be administered on 12/4/24 at 0900 hours: -Clonidine 0.1 mg tablet orally twice a day for hypertension, -Ascorbic acid (Vitamin C) 500 mg tab orally once a day for supplement, -Ferrous Sulfate 325 mg tablet orally once a day for supplement, -Vitamin D3 25 mcg tablet orally once a day for supplement, -Azllsartan Medoxomil (antihypertensive) 40 mg tablet orally twice a day for hypertension, and -Aspirin tablet 81 mg orally twice a day for DVT prophylaxis. Review of Resident 305's Medication Administration Audit Report dated 12/4/24, showed the above listed medications were administered on 12/4/24 at 1040 hours. c. Review of Resident 302's Order Summary Report dated 12/2024, showed the following medications were ordered to be administered on 12/4/24 at 0900 hours: - carvedilol 3.125 mg tablet orally twice a day for hypertension, - furosemide (diuretic) 40 mg tablet orally once a day for congestive heart failure, - Solifenacin (bladder relaxant) 10 mg tablet orally once a day for urinary retention, - Farxiga (used to treat heart failure) 10 mg tablet orally once a day for congestive heart failure, - lisinopril (used to treat high blood pressure) 20 mg tablet orally once a day for hypertension, and - spironolactone (diuretic) 50 mg tablet orally once a day for congestive heart failure. Review of Resident 302's Medication Administration Audit Report dated 12/4/24, showed the above listed medications were administered on 12/4/24 between 1024 hours and 1027 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 16.13%. * LVN 2 failed to administer three medications as ordered by the physician for Resident 602. * Resident 301 had a physician's order for Calcitriol 0.25 micrograms two capsules orally one time a day for supplement, however, LVN 4 administered two capsules of Calcitriol 0.5 micrograms orally (twice the ordered dose). * Resident 301 had a physician's order for Lidocaine 4% external patch to apply to the right hip and right foot topically for pain management, apply two patches one time a day at the same time, however, LVN 4 applied one lidocaine 4% external patch to Resident 301's hip. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in accordance with the prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. On 12/3/24 at 1137 hours, a medication administration observation for Resident 602 was conducted with LVN 2. LVN 2 prepared and administered the following medications to Resident 602: - one ½ (half) tablet of allopurinol (to treat gout) 100 mg, - one tablet of clopidogrel (anti-platelet) 75 mg, - two capsules of tamsulosin (to treat symptoms of an enlarged prostate) 0.4 mg, - one ½ tablet of vitamin C (supplement) 500 mg, - one tablet of Senna S (laxative) 50 mg-8.6 mg, - one tablet of [NAME]-Vite (supplement) - one tablet of aspirin (anti-inflammatory) 81 mg, - one tablet of ferrous sulfate (iron supplement) 325 mg, and - one patch of lidocaine (analgesic) 4 %. During the medication administration for Resident 602, LVN 2 applied one lidocaine 4% external patch to Resident 602's right posterior neck area. Medical record review for Resident 602 was initiated on 12/3/24. Resident 602 was admitted to the facility on [DATE]. Review of Resident 602's Order Summary Report showed the following active physician's orders: - dated 11/28/24, to administer calcium carbonate-vitamin D (supplement) 500-5 mg one tablet orally one time a day for supplement, - dated 11/28/24, to swab povidone-iodine (antiseptic) 10%, one swab in each nostril two times a day every Monday, Tuesday, Wednesday, Thursday, and Friday for prophylaxis, - dated 11/29/24, to apply lidocaine 4% external patch to the affected area topically for pain management, to apply two patches one time a day and remove per the schedule. However, LVN 2 was observed applying only one lidocaine 4% external patch, and did not administer the calcium carbonate-vitamin D 500-5 mg and the povidone-iodine swabs to Resident 602 during the medication administration observation. On 12/3/24 at 1309 hours, a concurrent interview and medical record review for Resident 602 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 verified she applied the one patch instead of two lidocaine 4% external patches, did not administer the povidine-idoine swabs, and did not administer the calcium carbonate-vitamin D 500-5 mg during the medication administration observation. LVN 2 stated she did not have the correct calcium carbonate-vitamin D dose in her medication cart or central supply and did not know when the facility ran out of the medication. LVN 2 further stated the physician have been informed and have made changes to the order. On 12/5/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings. 2. Medical record review for Resident 301 was initiated on 12/2/24. Resident 301 was admitted to the facility on [DATE]. On 12/4/24 at 0821 hours, a medication administration observation for Resident 301 was conducted with LVN 4. LVN 4 prepared and administered Resident 301's medications. During the medication administration for Resident 301, LVN 4 administered two capsules of calcitriol 0.5 micrograms orally. LVN 4 also applied one lidocaine 4% external patch to Resident 301's hip. Review of Resident 301's active physician's orders showed the following two orders: - dated 11/20/24, for calcitriol 0.25 micrograms two capsules orally one time a day for supplement, and - dated 11/21/24, for lidocaine 4% external patch, apply two patches one time a day at the same time to the right hip and right foot topically for pain management. On 12/4/24 at 1108 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 reviewed Resident 301's active medication orders. LVN 4 verified Resident 301's physician's order showed to administer two capsules of calcitriol 0.25 micrograms orally; however, LVN 4 administered two capsules of calcitriol 0.5 micrograms orally (twice the ordered dose). LVN 4 then verified Resident 301's order for the lidocaine 4% external patch, showed to apply two patches one time a day at the same time to the right hip and right foot topically for pain management. LVN 4 verified she applied one lidocaine 4% external patch to Resident 301's hip. Cross reference to F656, example #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to store the drugs, biologicals, and medical supplies in a safe manner as evidenced by the following: * The facility failed to ensure the opened medical supplies in Medication Carts B and C were properly disposed. * The facility failed to ensure the discontinued medications were properly disposed. These failures had the potential for the drug diversion and to result in an unsafe handling and storage of the residents' medications. Findings: 1a. Review of the facility's P&P titled Discarding and Destroying Medications dated 2001 showed for unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. On 12/2/24 at 0823 hours, a concurrent inspection of Medication Cart B and interview was conducted with LVN 5. One sterile glove was opened and observed in the cart. LVN 5 verified the above findings and stated sterile glove should not be in the cart, it was unsealed and considered not sterile. b. On 12/2/24 at 0835 hours, a concurrent inspection of Medication Cart C and interview was conducted with LVN 5. The following was observed: - One optiform non adhesive foam dressing (a foam dressing that has a silicone adhesive border) was opened (breaking sterility). - One abdominal pad dressing was opened. - One xeroform petrolatum (non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with a petrolatum blend) dressing was opened. - One foam wound dressing was opened. - One 15 Fr urethral catheterization tray was opened. LVN 5 verified the above findings and stated all licensed nurses are responsible in cleaning the cart, opened items were compromised, should have been discarded, all dressings and treatment items should have been sealed. 2. On 12/2/24 at 0807 hours, a concurrent observation and interview was conducted with LVN 5 in Medication room [ROOM NUMBER]. One medication disposal bin was noted with multiple whole pills not fully dissolved, one unidentified bottle, two insulin pens, nasal spray, inhaler and four syringes. LVN 5 acknowledged the medication disposal bin had medications not fully dissolved and the lid was removable. LVN 5 stated liquids should have been emptied and container should have been disposed, whole pills and narcotics should have been crushed. On 12/5/24 at 0831 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. The DON acknowledged the pills in the medication disposal bin were to be fully diluted. The DON stated liquids should have been poured and the bottles should have not been kept in the medication disposal bin.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the microwave utilized to warm up the food was in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the countertop mounted can opener was in sanitary condition and free of residue. * The facility failed to ensure the heavy-duty blender used for puree preparation and the stainless-steel bucket were cleaned and air dried prior to storing. * The facility failed to ensure the expired foods were discarded. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Patient Diet List dated 12/2/24, showed 39 of 41 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Ice Machine and Storage Chests revised date 10/2017 showed the ice machines and ice storage/ distribution chests will be used and maintained to assure a safe and sanitary supply of ice. Clean and sanitize the ice machine per manufacturer's guidelines. The Maintenance Director/ designee will maintain a copy of these procedures; including a cleaning log. According to the USDA Food Code 2017, Section 4-601.11, the equipment food-contact surfaces and utensils shall be clean to sight and touch. On 12/2/24 at 0850 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Environmental Services Director. The ice machine's interior top portion to the water curtain located directly above the ice bin, was observed with pinkish residue. The Environmental Services Director acknowledged the findings and stated was unknown what the pink residue from, and the ice would not be used because it was dirty and to prevent cross contamination. 2. Review of the facility's P&P titled Cleaning Instructions: Microwave Oven dated 2023 showed the microwave oven will be kept clean, sanitized, and odor free. The microwave oven interior should be cleaned after each use as needed, and at minimum, after each meal service. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 12/2/24 at 0905 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The microwave on a stainless-steel shelf was observed dirty with dry, crusted food residue inside the microwave's door and had dry food residue inside the microwave. The Dietary Supervisor verified the findings and stated the microwave should have been clean daily after each used and deep cleaned weekly by the Dietary staff. 3. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed all food service equipment should be cleaned, sanitized, air-dried and reassembled after each use. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 12/2/24 at 0905 hours, during the kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The kitchen hood over the stove had black, grease residue. The Dietary Supervisor acknowledged the findings and stated the dietary staff member cleaned the hood once a week to prevent grease residue from dropping into the food and cleaned every six months by an outside company and was last serviced on 8/29/24. 4. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed the plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed of. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 12/2/24 at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The following was observed and verified by the Dietary Supervisor: - Two stainless whisk with gray/ purple handles were worn out, rubber handles were chipped and cracked. - One white basting brush used for butter was worn out and bristles was frayed. - Three mesh strainers were deformed and worn out with rusty discoloration. - One black rolling pin used to make pizza had degraded coating, handles peeling and worn out. - One black egg slicer was worn out, discolored, dirty, and had dry crusted food residue. - Three rubber spatulas with red handles were dirty, discolored and had chipped edges. - One stainless steel spatula with black handle was partially burnt. - One stainless steel spatula with wooden handle discolored and partially burnt. - One dough cutter/ scraper with wooden handle was worn out, discolored and had uneven edges. The Dietary Supervisor acknowledged the above findings and stated all should not be use, will be discarded and replaced because it could get mix with the food and cause cross contamination. 5. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed all the food service equipment should be cleaned, sanitized, air-dried and reassembled after each use. Review of the facility's P&P titled Handling Clean Equipment and Utensils dated 2023 showed clean equipment and utensils will be handled properly to prevent contamination. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 12/2/24 at 0905 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The following was observed and verified by the Dietary Supervisor: - One stainless whisk with gray/ purple handle had dry, crusted black residue. - Three rubber spatulas with red handles were dirty and had dry food residue. - Two stainless steel slotted spoons were dirty and had dry, crusted residue. - Two cutting knives with black handles were dirty, fuzzy with cloudy stains on the blades. - One stainless steel spatula with wooden handle was dirty and had dry water spots. - One black egg slicer was dirty and had dry food residue. - One small size stainless steel bucket was dirty and had dry water spots. The Dietary Supervisor acknowledged the above findings and stated it needed to be washed to prevent from residue getting mix with food, prevent food contamination and some needed to be discarded and replaced. 6. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed separate the cutting boards for raw and uncooked food and for raw fruits and vegetables will be used. The cutting boards should be of hard rubber construction (not wood) and must be dishwasher safe. The cutting boards should be cleaned and sanitized after each use, following the dish machine or three compartment sink method and will be air dried before storing. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 12/2/24 at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The white and green cutting boards were observed discolored, fuzzy, heavily marred and had deep groves. The Dietary Supervisor verified the findings and stated the cutting boards were not acceptable and should have been discarded and replaced. 7. Review of the facility's P&P titled Cleaning Instructions: Can Opener dated 2023, showed the can opener will be cleaned after each use. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 12/2/24 at 0905 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The countertop mounted can opener had rusty discoloration on the blade and peeled coating. The Dietary Supervisor verified the findings and stated the can opener would not be used to avoid food contamination. 8. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed all food service equipment should be cleaned, sanitized, air-dried and reassembled after each use. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 12/2/24 at 0905 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The following was observed and verified by the Dietary Supervisor: - One heavy-duty blender stored on the counter shelf was still wet with visible water inside and had white food residue inside. - One medium size stainless steel bucket stored wet. The Dietary Supervisor acknowledged the above findings and stated it needed to be washed and air dried to prevent bacteria growth and food contamination. 9. Review of the facility's P&P titled Food Storage dated 2023 showed all foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. According to the FDA Food Code 2017, Section 3-501.17 Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking: Marking the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed. On 12/2/24 at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The following was observed and verified by the Dietary Supervisor: - One small bowl of egg salad stored in the refrigerator dated 10/29/24. - Multiple individual fruit cups covered w/ saran wrap all placed in a gray serving tray stored in the refrigerator with label showed, Item: Fruit, Prep date 11/28/24 and use by date 12/1/24. - Multiple styrocups w/ prunes and apple sauce all placed in a gray serving tray stored in the refrigerator with label showed, Item: Prunes & Apple sauce, Prep date 11/29/24 and use by date 12/1/24. - Multiple styrocups w/ pudding all placed in a gray serving tray stored in the refrigerator with label showed: Item: Reg pudding, Prep date 11/27/24 and use by date 11/30/24. The Dietary Supervisor verified the above findings and stated above items should have been labeled accurately and expired items should have been discarded. On 12/5/24 at 1700 hours, the DON and the Administrator was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to prevent the development and transmission of diseases and infections. * The facility failed to show documentation of the Legionella facility risk assessment and testing protocols for Legionella and other opportunistic waterborne pathogen. * CNA 1 failed to remove the gown and gloves and perform hand hygiene after touching Resident 498 and before touching Resident A's environment. * The facility failed to ensure a N95 respirator was stored in a sanitary manner, at the entrance to a resident COVID-19 isolation room. * CNA 6 placed Resident 298's shower bin (which contained a clean towel and bathrobe belt) on top of a soiled linen cart during Resident 298's shower. * The residents' clean linen cart was observed with several bath robe belts lying on top of the clean linen cart. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: 1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to the policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; - Develops and implements a water management program that considers the ASHRAE (American Society of Heating Refrigerating and Air-Conditioning Engineers) industry standards and the CDC (Centers for Disease Control and Prevention) toolkit; and - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. Review of the facility's P&P titled Legionella Water Management Program revised 9/2022 showed as part of the infection prevention and control program, the facility has a water management program. The purposes of the water management program were to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. Further review of the facility's P&P showed the water management program includes the following elements: b. A detailed description and diagram of the water system in the facility, including the following: 1. Receiving; 2. Cold water distribution; 3. Heating; 4. Hot water distribution; and 5. Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: 1. Storage tanks; 2. Water heaters; 3. Filters; 4. Aerators; 5. Showerheads and hoses; 6. Misters, atomizers, air washers and humidifiers, 7. Hot tubs; 8. Fountains; and 9. Medical devices such as CPAP machines, hydrotherapy equipment, etc.; d. The identification of situations that can lead to Legionella growth; e. Specific measures used to control the introduction and/or spread of Legionella; f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. The facility failed to show documentation a facility risk assessment was conducted to identify, test, and prevent Legionella and other opportunistic waterborne pathogens in the facility. On 12/5/24 at 1416 hours, the Administrator was asked about the facility's diagram of the water system entering the facility and identified areas of potential pathogen growth and spread. The Administrator stated the facility did not have a flow chart of the water system entering the facility and the water fountain located outside the facility was the only identified risk. On 12/5/24 at 1435 hours, an interview was conducted with the EVS Director. The EVS Director stated his role in the water management program was to check and clean the water fountain weekly. The EVS Director stated the facility had four water heaters, two shower rooms with two shower heads in each room, and an ice machine. The EVS Director stated an outside source comes to the facility to test the water fountain and stated the company did not test any other areas in the facility. The EVS Director was asked if he tested for Legionella or other potential pathogens in areas that are potential risks for standing water and the EVS Director stated he did not conduct any testing protocols. On 12/5/24 at 1612 hours, a follow-up interview was conducted with the Administrator. The Administrator stated the purpose of the water management program was to monitor for and check surfaces/areas in the facility that have the potential to have Legionella growth. The Administrator reviewed the facility's P&P and CDPH's AFL 18-39 and verified the above findings. On 12/5/24 at 1701 hours, the Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 498 was initiated on 12/2/24. Resident 498 was admitted to the facility on [DATE]. Review of Resident 498's Order Summary Report showed a physician's order dated 11/26/24, to provide EBP for high contact resident care activities related to indwelling medical devices: g-tube; Foley catheter; to perform hand hygiene and apply PPE: gloves, gown and/or goggle/face shield worn if risk of splash or spray during high contact resident care activities; to remove PPE and perform hand hygiene prior to exiting the room to prevent the transmission of MDROs. On 12/2/24 at 0935 hours, a concurrent observation and interview was conducted with CNA 1 in Resident 498's room. CNA 1 was observed wearing a gown and gloves and touched Resident 498's arm to check for Resident 498's identification verification band. CNA 1 verified Resident 498 was not wearing an ID band and was observed placing the ID band on Resident 498. CNA 1 was then observed going to Resident A's bedside to remove the diaper from the diaper package and was observed touching Resident A's bed linen. CNA 1 was not observed removing her gown or gloves after contact with Resident 498 and before coming in contact with Residents A's environment. CNA 1 verified she did not change her gown and gloves and did not perform hand hygiene before assisting Resident A. CNA 1 stated she needed to change the PPEs and perform hand hygiene between the residents to avoid contamination. On 12/4/24 at 1517 hours, an interview was conducted with the IP. The IP stated for the residents placed on enhanced barrier precautions, the staff members were expected to perform hand hygiene and don gown and gloves for high contact activities, when changing linen/perineal care, transferring, or during contact with the resident, to prevent the transfer of MDROs. The IP stated the staff member were expected to change gown and gloves in between the residents and if the gown and gloves were not changed in between the residents, there may be the risk of transmission of infection. On 12/5/24 at 0947 hours, an interview was conducted with the DON. The DON stated for the residents on enhanced barrier precautions, gowns and gloves were needed when touching the resident or their linens. The DON stated staff members were expected to remove the gown and gloves before working with another resident to prevent the contamination from one resident to the next. On 12/5/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings. 3. On 12/2/24 at 0825 hours, a concurrent observation and interview was conducted with RN 2. Resident Room A was observed with a plastic container (which contained PPE) located at the entrance of the room. An N95 respirator was observed unpackaged lying on top of the plastic PPE container. RN 2 stated Resident Room A was currently being used to isolate residents who tested positive for COVID-19. RN 2 was asked to whom the N95 respirator belonged and if it was used or unused. RN 2 stated she did not know if the N95 respirator belonged to a resident, a resident family member, or a facility staff member. RN 2 stated she was uncertain as to whether the N95 respirator had been used or not. RN 2 stated if the N95 respirator had been used it should not be stored on top of the plastic PPE container and should have been discarded, to ensure infection control. Furthermore, RN 2 stated if the N95 respirator had not been used it needed to be stored in a clean package and should not be stored on top of the plastic PPE container, for infection control. On 12/5/24 at 1337 hours, an interview was conducted with the IP. The IP stated the used N95 respirators needed to be discarded. The IP stated clean N95 respirators needed to be stored in the original packaging or when distributed for staff use, the N95 respirator would be stored in a clean bag. The IP stated these facility practices were to avoid the transfer of pathogens. 4. On 12/2/24 at 0755 hours, a concurrent observation and interview was conducted with CNA 6. CNA 6 was observed inside the residents' shower room. CNA 6 stated she had just finished assisting Resident 298 take a shower. Resident 298's plastic bin was observed lying on top of the soiled linen cart. CNA 6 verified Resident 298's plastic bin contained a clean towel and a clean bathrobe belt. CNA 6 stated she had placed Resident 298's plastic bin on top of the soiled linen cart while assisting Resident 298 with his shower. CNA 6 stated the soiled linen cart was located close to the location where Resident 298 had showered, which allowed her access to the contents of Resident 298's bin throughout his shower. CNA 6 verified the soiled line cart contained soiled linen. On 12/5/24 at 1337 hours, an interview was conducted with the IP. The IP stated the resident's shower bins which contained clean linens (towels, resident bath robes, and bath robe belts) should not be stored on top of the soiled linen cart for infection control. 5. On 12/2/24 at 0755 hours, a concurrent observation and concurrent interview was conducted with CNA 6. A clean linen cart which contained clean resident towels, bathrobes, and bathrobe belts was observed inside of the shower room. Several bathrobe belts were observed lying on top of the clean linen cart. CNA 6 verified the findings and stated the resident bathrobe belts had yet to be used by the residents and should have been stored inside the clean linen cart for infection control. On 12/5/24 at 1337 hours, an interview was conducted with the IP. The IP stated the clean residents bathrobe belts should not be stored on top of the clean linen cart for infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for two of 17 final sampled residents (Residents 27 and 497) to self-administer the medications. * Resident 497 was observed with a bottle of Carboxymethylcellulose Ophthalmic Solution 0.5% (a medication used to relieve dry and irritated eyes) at the bedside table. Resident 497 did not have a physician's order to keep the medication at his bedside. Resident 497 did not have an assessment, or a care plan problem addressing the self-administration of medication. * Resident 27 was observed with ACT dry mouth lozenges (formulated with xylitol to help soothe dry mouth and moisturize mouth tissue) at the bedside. Resident 27 did not have an assessment, physician's order, or a care plan problem addressing the self-administration of medication. In addition, there was no physician's order to administer the lozenges. These failures had the potential for Residents 27 and 497 to administer the medications inaccurately. Findings: Review of the facility's P&P titled Resident Self Administer Medications dated March 2018 showed a resident may only self-administer medication after the IDT has determined which medication may be self-administered. Determination of a resident's ability to self-administer medications shall be documented in resident's medical record and care plan. 1. On 4/4/23 at 0945 hours, a concurrent observation and interview was conducted with Resident 497. A bottle of Carboxymethylcellulose Ophthalmic Solution 0.5% was observed at Resident 497''s bedside table. Resident 472 stated he brought this eye drop bottle from home, had been taking the eye drops for years, and had been administering the eye drops by himself since he was admitted to the facility. Medical record review for Resident 497 was initiated on 4/4/23. Resident 497 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 497's physician's H&P examination dated 4/4/23, showed Resident 497 had the capacity to understand and make decisions. Review of Resident 497's Order Summary Report showed an order dated 4/3/23, to administer Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5% one drop in both eyes every one hour as needed for dry eyes. However, Resident' 497's April 2023 Order Summary Report failed to show an order of Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 to be kept at Resident 497's bedside. Review of Resident 497's evaluations failed to show Resident 497 was assessed for medication self-administration. Review of Resident 497's care plan failed to show a care plan problem was developed to address the resident's self-administration of the Carboxymethylcellulose Ophthalmic Solution 0.5% eyedrops. On 4/4/23 at 1007 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the findings above. RN 1 reviewed Resident 497's orders and did not find an order for Resident 497 to self-administer Carboxymethylcellulose Ophthalmic Solution 0.5% eye drops. RN 1 stated the facility must assess Resident 497's capability of self-administration of his medications. 2. On 4/4/23 at 1015 hours, an observation and concurrent interview was conducted with Resident 27. Two lozenges were observed in a silver blister pack (a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil to take the medication). Resident 27 stated she had been taking the lozenges because of dry mouth. Resident 27 stated the nurses were aware she had these lozenges at bedside. Medical record review for Resident 27 was initiated on 4/4/23. Resident 27 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 27 was cognitively intact and had no upper extremity impairment. Review of Resident 27's Order Summary Report failed to show a physician's order to administer the ACT dry mouth lozenge and for self-administration of medications. Review of Resident 27's plan of care failed to show a care plan problem was developed to address the resident's self-administration of the lozenges. Further review of Resident 27's medical record failed to show an assessment was conducted for self-administration of medication. On 4/4/23 at 1055 hours, an observation and concurrent interview and medical record review for Resident 27 was conducted with LVN 4. LVN 4 verified the findings. LVN 4 stated any medications including lozenges should have a physician's order. LVN 4 verified Resident 27 had lozenges at bedside. LVN 4 verified there were no physician's orders to administer the lozenges and self-administer the medications for Resident 27. On 4/4/23 at 1306 hours, a follow-up interview and concurrent medical record review for Resident 27 was conducted with LVN 4. LVN 4 stated the residents needed to be assessed in order for them to have any medications at bedside and a physician's order to self-administer the medications. LVN 4 verified Resident 27 did not have an assessment to self-administer the medications. On 4/6/23 at 0832 hours, an interview and concurrent medical record review for Resident 27 was conducted with the DON. The DON verified the findings and stated when a resident insisted to administer own medications, the facility would have to assess the resident. The DON stated the assessment, care plan problem, and physician's order were needed to address the resident's self-administration of the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the quality of care was provided to two of 17 final sampled residents (Residents 41 and 296) as evidenced by: * No information related to Resident 296's pacemaker was documented. The apical pulse for Resident 296's pacemaker was not monitored and recorded. * Resident 41's anti-embolism stockings were not consistently placed on the resident. These failures had the potential for the residents to not receive quality of care. Findings: 1. On 4/4/23, medical record review for Resident 296 was initiated. Resident 296 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 296's H&P examination dated 3/30/31, showed Resident 296 was admitted to the facility with diagnoses including high blood pressure, coronary artery disease, and permanent atrial fibrillation. Review of Resident 296's March 2023 Order Summary Report showed an order dated 3/27/23, for Resident 296's left upper chest pacemaker. Review of Resident 296's plan of care showed a care plan problem to monitor Resident 296's apical pulse daily and notify Resident 296's physician when Resident 296's pulse was less than 60 beats per minute or greater than 100 beats per minute. On 4/7/23 at 1314 hours, a concurrent interview and medical record review was conducted with RN 3. RN 3 verified Resident 296's apical pulse was not documented and was supposed to be monitored and documented. RN 3 also verified there was no information in Resident 296's medical record related to the resident's pacemaker. 2. On 04/06/23 at 1451 hours, a concurrent observation and interview was conducted with LVN 3 and Resident 41's responsible party. Resident 41 was observed wearing non skid socks and no anti-embolism stockings. LVN 3 verified Resident 41 was not wearing his anti-embolism stockings. When Resident 41's socks were removed, Resident 41's feet were observed swollen and with markings at the ankles and top of feet. When asked about Resident 41's anti-embolism stockings, Resident 41's responsible party stated Resident 41 was not wearing them the day before or on this date. Medical record review for Resident 41 was initiated on 4/4/23. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's H&P examination dated 3/11/23, showed Resident 41's diagnoses included high blood pressure and status post hip surgery. Review of Resident 41's March and April 2023 Treatment Administration Records showed Resident 41 was to wear his knee high anti-embolism stockings during the day and removed at bedtime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary treatment and services were provided to help improve or correct performance or prevent further deformity for one of 17 final sampled residents (Resident 10). * Resident 10 was observed wearing cervical collar (commonly used by those who have had a surgical intervention of the cervical spine, to immobilize the neck) while in bed. The facility failed to ensure Resident 10 followed the physician's order to apply TLSO (thoracic lumbar sacral orthosis, brace used to limit motion in the thoracic, lumbar and sacral regions of the spine) brace when the resident was out of bed. In addition, the facility failed to monitor Resident 10's application of the cervical collar while in bed. This failure had the potential for Resident 10 to develop complications from the orthotic device application. Findings: On 4/5/23 at 0933 hours, and 4/7/23 at 0808 hours, Resident 10 was observed in bed wearing a cervical collar. Medical record review was initiated on 4/4/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination (undated), showed Resident 10 had the capacity to understand and make decision. Review of Resident 10's Order Summary Report showed a physician's order dated 3/16/23, for weight bearing status: weight bearing as tolerated with TLSO brace while out of bed every shift. Further review of Resident 10's medical record did not show a physician's order for the use of the cervical collar while in bed. In addition, there was no documentation of the monitoring of Resident 10 for the cervical collar application. On 4/7/23 at 0810 hours, an observation for Resident 10 and concurrent interview was conducted with CNA 4. CNA 4 verified Resident 10 had a cervical collar on while in bed. CNA 4 stated Resident 10 was able to put the cervical collar on himself, but he needed the back brace when he was out of bed. On 4/7/23 at 0812 hours, an interview was conducted with Resident 10. Resident 10 was observed in bed wearing a cervical collar. Resident 10 stated he put the cervical collar on himself to minimize mobility of his neck because of surgery. On 4/7/23 at 0944 hours, a follow-up interview was conducted Resident 10 with the Rehabilitation Director present. Resident 10 was observed sitting in a wheelchair, with a cervical collar and TLSO brace applied. Resident 10 stated he wore the cervical collar with the brace when he was out of bed, and he also wore the cervical collar alone while in bed. On 4/7/23 at 0947 hours, an interview and concurrent medical record review for Resident 10 was conducted with the Rehabilitation Director. The Rehabilitation Director verified the above findings. The Rehabilitation Director verified the physician's order was for the TLSO while the resident was out of bed. The Rehabilitation Director verified there was no physician's order for the resident to wear the cervical collar while in bed. The Rehabilitation Director stated Resident 10 was non-compliant. When asked if there was any documentation of Resident 10's non-compliance, the Rehabilitation Director could not find any. On 4/7/23 at 0953 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 2. RN 2 verified the above findings. When asked if Resident 10 was reported to be non-compliant with wearing his cervical collar and TLSO brace, RN 2 stated she was not aware of Resident 10's non-compliance. When asked for any documentation of monitoring when Resident 10 had a cervical collar on while in bed, RN 2 could not find any documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 17 final sampled residents (Resident 37). * The facility failed to ensure Resident 37's oxycodone hydrochloride (a narcotic pain medication) Drug Control Receipt/Record/Disposition Form did not match Resident 37's MAR. This failure posed the risk for diversion of controlled medications. Findings: Review of the facility's P&P titled Controlled Substances revised April 2019, under the section for Administration, showed the nurse administering the medication is responsible for recording the time of administration. On 4/5/23 at 1110 hours, review of Resident 37's Drug Control Receipt/Record/Disposition Form and MAR was conducted with the IP. Review of Resident 37's oxycodone Drug Control Receipt/Record/Disposition Form showed Resident 37 was administered oxycodone 5 mg two tablets on 3/19/23 at 2044 hours. Medical record review for Resident 37 was initiated on 4/5/23. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's March 2023 MAR, under the Administration Details section, failed to show documentation of administration of oxycodone on 3/19/23 at 2044 hours. The March 2023 MAR failed to show documentation of administration of oxycodone on 3/19/23 at 2044 hours. The IP acknowledged Resident 37's Drug Control Receipt/Record/Disposition Form did not match Resident 37's MAR for March 2023. Review of Resident 37's Order Summary Report showed a physician's order dated 2/28/23, to administer oxycodone hydrochloride 5 mg two tablets by mouth every three hours as needed for severe to very severe pain. On 4/6/23 at 1341 hours, an interview and concurrent medical record review of Resident 37's Drug Control Receipt/Record/Disposition Form and MAR was conducted with the DON. The DON acknowledged the above findings. On 4/7/23 at 0720 hours, an interview and medical record review for Resident 37's Drug Control Receipt/Record/Disposition Form and MAR was conducted with LVN 6. LVN 6 verified and acknowledged the above findings. LVN 6 further stated she forgot to document in Resident 37's MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five unnecessary medication sampled residents (Resident 41) was free from unnecessary psychotropic medication (any drug that affects brain activity). * The facility failed to monitor the side effects for Resident 41's use of Trazadone (anti-depressant medication). This had the potential for inaccurate side effect monitoring for Resident 41's physician not having the necessary information if Resident 41 had side effects from medication. Findings: Review of the facility's P&P titled Psychotropic Medication Use revised July 2022 showed the residents, families, and/or the representative are involved in the medication process. Psychotropic medication management includes indication for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences. Medical record review for Resident 41 was initiated on 4/7/23. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's April 2023 Order Summary Report showed a physician's order dated 3/23/23, to administer Trazadone HCl 50 mg one-half tablet (25 mg) by mouth at bedtime for depression manifested by inability to sleep (25 mg). Review of Resident 41's MAR for April 2022 showed Resident 41 was administered Trazadone 25 mg at bedtime as ordered by the physician. Further review of the medical record failed to show an order or documentation to monitor for side effects of the Trazadone. On 4/7/23 at 1023 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 reviewed the orders for Trazadone and verified there was no order or documentation to show monitoring of side effects for the Trazadone order. On 4/7/23 at 1031 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified the above findings. RN 2 stated the purpose of having an order for monitoring the side effects of Trazadone was to anticipate if Resident 472 would exhibit the side effects of the medication and to notify the physician for accurate information with Resident's 472's Trazadone use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 15.38%. Two licensed nurses (LVNs 4 and 5) who were observed during the medication administration were found to have made errors. * LVN 4 failed to administer the correct dose of Clearlax oral powder (medication to treat occasional constipation) to Resident 294. * LVN 5 failed to administer Resident 24's medications as ordered by the physician. In addition, LVN 5 failed to administer Resident 344's medications with food or meals as ordered by the physician. These failures had the potential to negatively affect the residents' health. Findings: According to the facility's P&P titled Administering Medications dated June 2016 showed it is the facility's policy that medications shall be administered in a safe and timely manner, and as prescribed. Further review of the policy showed that medications must be administered in accordance with the orders. 1. On 4/4/23 at 0755 hours, a medication administration observation was conducted with LVN 4 for Resident 294. LVN 4 prepared and administered the following medications to Resident 294: - one capsule of Omega-3 (supplement) 1000 mg, - two tablets of vitamin C (supplement) 500 mg, - one tablet of vitamin D3 (supplement) 400 IU 10 mcg, - one tablet of Mucinex Extended Release (cough medicine) 600 mg, - one capsule of stool softener 250 mg, - one cap of Clearlax powder (bowel management) 17 gm mixed with 4-5 ounces of water in a five-ounce cup, - one half tablet of sotalol (antihypertensive) 80 mg, - one tablet of prednisone (steroids) 10 mg, - one tablet of losartan potassium (antihypertensive) 50 mg, - one capsule of furosemide (antihypertensive) 40 mg, - one tablet of folic acid (supplement) 1 mg, - one capsule of fluoxetine (antidepressant) 40 mg, - one capsule of duloxetine hydrochloride (antidepressant) 60 mg, - one tablet of carbidopa-levodopa (medication to treat Parkinson's disease (a progressive disorder that affects the nervous system and parts of the body)) 25-100 mg, - one nebule of levalbuterol hydrochloride (medication to treat bronchospasm) 0.63 mg/3 ml, and - one tablet of doxycycline hyclate (antibiotic) 100 mg. After administering the medications, LVN 4 was observed adding a small amount of water to the five-ounce cup with the Clearlax powder, stirred, and gave it to Resident 294; however, Resident 294 did not drink all the mixture. LVN 4 placed the cup on top of Resident 294's over bed table. On 4/4/23 at 0834 hours, LVN 4 was asked about the cup with the Clearlax mixture, LVN 4 showed the cup, and a small amount of whitish residue was left in the cup. On 4/4/23 at 1501 hours, an interview was conducted with LVN 4. LVN 4 acknowledged and verified the above findings. LVN 4 stated she tossed the cup with the medication residue in the trash. LVN 4 further stated it should not have any residue left in the cup because Resident 24 would not have the proper medication dosage. 2.a. On 4/4/23 at 0932 hours, a medication administration observation was conducted with LVN 5 for Resident 24. LVN 5 prepared and administered the following medications to Resident 24: - one drop to both eyes of brimonidine tartrate/timolol solution (medication to treat glaucoma (a condition of increased pressure within the eyeball, causing gradual loss if sight)) 0.2-0.5%, - one tablet of vitamin C (supplement) 500 mg, - one tablet of baby aspirin (medication to lower the risk of heart attack and stroke) 81 mg, - one tablet of calcium-vitamin D (supplement) 600 mg-5 mcg, - one tablet of B12 (supplement) 500 mcg, - one tablet of folic acid (supplement) 1 mg, and - one capsule of hydroxyurea (medication to treat leukemia (blood cancer), head, and neck cancer) 500 mg. Medical record review for Resident 24 was initiated on 4/4/23. Resident 24 was admitted [DATE], and readmitted on [DATE]. Review of Resident 24's Order Summary Report showed an order dated 3/15/23, to instill one drop of brimonidine tartrate/timolol solution 0.2-0.5% to left eye two times a day. Further review of the medical record showed an order dated 8/11/22, to administer one tablet of multiple vitamins and minerals one time a day. However, during the medication administration observation, LVN 5 administered one drop of brimonidine tartrate/timolol solution 0.2-0.5% to both eyes, instead of only the left eye as ordered, and multiple vitamins and minerals was not administered to the resident as ordered On 4/4/23 at 1525 hours, an interview was conducted with LVN 5. LVN 5 was informed and LVN 5 acknowledged the above findings. b. On 4/4/23 at 1001 hours, a medication administration observation was conducted with LVN 5 for Resident 344. LVN 5 prepared and administered the following medications to Resident 344: - one tablet of ferrous sulfate (iron supplement) 325 mg, - one tablet of metformin (oral diabetes medication) 1000 mg, - one tablet of vitamin C (supplement) 500 mg, - one tablet of famotidine (medication to treat stomach ulcers) 20 mg, - one tablet of lisinopril (antihypertensive) 10 mg, - one tablet of meloxicam (nonsteroidal anti-inflammatory medication) 15 mg, - one tablet of Senna Plus (stool softener) 8.6 mg-50 mg, and - one prefilled syringe of enoxaparin sodium (a blood thinner delivered via injection) 40 mg/0.4 ml. Medical record review for Resident 344 was initiated on 4/4/23. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's Order Summary Report showed an order dated 3/11/23, to administer one tablet of metformin 1000 mg two times a day with breakfast and dinner; and an order dated 3/11/23, to administer one tablet meloxicam 15 mg one time a day with food; and an order dated 3/12/23, to administer one tablet of ferrous sulfate 325 mg two times ad day with breakfast and dinner. Review of the MAR for the month of April 2023, showed ferrous sulfate and metformin were supposed to be administered at 0800 hours. Further review of the medical record showed that meloxicam was supposed to be given with food. However, the medication administration was performed by LVN 5 at 1001 hours on 4/4/23. On 4/4/23 at 1513 hours, a concurrent interview and medical record review was conducted with LVN 5. When asked what time breakfast was served to residents, LVN 5 stated breakfast was served between 0800-0830 hours. LVN 5 stated Resident 344 had already eaten breakfast when she administered the medications. LVN 5 verified and acknowledged Resident 344's ferrous sulfate, metformin, and meloxicam tablets were supposed to be given with meals or food. LVN 5 further stated she should have offered snacks to Resident 344.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to store Resident 24's difluprednate emulsion (an eye drop medication to treat eye swelling and pain) 0.05% in a locked compartment at bedside. This failure had the potential for the residents, staff, and visitors to have an easy access to the medication. * Multiple outdated Indicaid Covid-19 (a respiratory disease caused by SARS-CoV-2) Rapid Antigen Test buffer solution bottles were observed in Medication Cart A. This had the potential for use of expired medications or biologicals. * Multiple outdated intravenous (into or within a vein) insertion needles were observed in Medication Cart B. This had the potential for use of expired medical supplies. * Medication Cart C had Resident 24's bottle of rhopressa (eyedrops medication) was stored at room temperature. This had the potential for administration of deteriorated medication. Findings: According to the facility's P&P titled Resident Self Administer Medications with effective date March 2018 showed medications self-administered by the resident and which the resident has been determined safe to be maintained at bedside, shall be stored in a locked container to maintain safety. According to the facility's P&P titled Receipt and Storage of Supplies and Equipment revised November 2009 showed all supplies and equipment must be stored in accordance with the manufacturer's recommendations. 1. On 4/4/23 at 0932 hours, a medication administration observation and concurrent interview was conducted with Resident 24 and LVN 5. During the observation, Resident 24 had one bottle of difluprednate emulsion 0.05% at the resident's bedside. When Resident 24 was asked about the medication at the bedside, Resident 24 stated she self-administer the medication and further stated she had the medication for four years. LVN 5 acknowledged Resident 24 was using the medication. Medical record review for Resident 24 was initiated on 4/4/23. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the Order Summary Report showed an order dated 4/3/23, to instill one drop of difluprednate emulsion 0.05% to the left eye three times a day to prevent eye pain and swelling, unsupervised, and self-administration. On 4/4/23 at 1520 hours, an interview was conducted with the MDS Coordinator. When asked about Resident 24's difluprednate medication storage at bedside, the MDS Coordinator stated the medication was kept inside Resident 24's bedside table drawer at night and the resident had the medication at bedside during the day to be accessible. On 4/5/23 at 1505 hours, an interview was conducted with the DON. The DON acknowledged Resident 24 was self-administering the difluprednate medication. The DON was informed of the facility's policy regarding the storage of medications at bedside, the DON acknowledged Resident 24 had no locked cabinet at bedside for her difluprednate medication. 2. On 4/5/23 at 0907 hours, an observation of Medication Cart A and concurrent interview was conducted with the IP. There were nine unopened bottles of the Indicaid Covid-19 Rapid Antigen Test buffer solution with the expiration date of 2/6/23. The IP verified the expired supplies. 3. On 4/5/23 at 0919 hours, an observation of Medication Cart B and concurrent interview was conducted with RN 1. The following was identified: - six Covidien Monoject Hypodermic safety needles 18 Gauge x 1 1/2 inch, with the expiration date of 2/27/23, - one Covidien Magellan Hypodermic safety needle 23 Gauge x one inch, with the expiration date of 12/31/22, - three Covidien Magellan Hypodermic safety needles 18 Gauge x one inch, with the expiration date of 5/31/22, - two Covidien Magellan Hypodermic safety needles 18 Gauge x one inch, with the expiration date of 11/30/21, - one B/[NAME] Introcan Safety intravenous catheter 18 Gauge x 1 ¼ inch, with the expiration date of 11/2017, - one B/[NAME] Introcan Safety intravenous catheter 22 Gauge x one inch, with the expiration date of 12/1/22, and - one Med Stream intravenous administration set (secondary), with the expiration date of 9/2019. RN 1 stated she was responsible for checking Medication Cart B for expired supplies. RN 1 verified the above findings. 4. Review of the Lexicomp (clinical drug resource) guide updated 1/24/23, showed to store at two degrees Celsius to eight degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit) until opened. After opening, may store refrigerated at two degrees Celsius to eight degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit) until the manufacturer's expiration date or at less than or equal to 25 degrees Celsius (less than or equal to 77 degrees Fahrenheit) for less than or equal to six weeks. Medical record review of Resident 24 was initiated on 4/4/23. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MAR for the month of April 2023 showed an order with the start date of 3/7/23, and discontinued date of 4/3/23, to administer rhopressa ophthalmic solution 0.02% one drop in both eyes one time a day. On 4/5/23 at 1046 hours, an observation of Medication Cart C and concurrent interview was conducted with LVN 1. Resident 24's rhopressa medication was stored at room temperature inside Medication Cart C; however, the label showed to keep medication in the refrigerator. LVN 1 verified and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and facility document review, the facility failed to ensure the food served to one of 17 final sampled residents (Resident 296) was attractive to the resident. This failure had the potential for the resident not enjoying his meals. Findings: Medical record review for Resident 296 was initiated on 4/4/23. Resident 296 was readmitted to the facility on [DATE]. Review of Resident 296's H&P examination dated 3/30/31, showed Resident 296 had the capacity to understand and make decisions. Review of Resident 296's April 2023 Order Summary Report showed an order dated 4/1/23, for Resident 296's diet as soft and bite size texture, solid bread okay. On 4/4/23 at 0825 hours, Resident 296 was served pureed bread. Resident 296 stated he did not know what to do with the pureed bread. On 4/4/23 at 1302 hours, Resident 296 was served minced main entrée and pureed bread. Per the facility's menu, the main entrée was supposed to be chicken salad. Resident 296 stated the salad served was too dry and not appealing or appetizing. Resident 296 stated he had been assessed by the facility's ST and was told he was able to eat regular bread. Consequently, Resident 296 declined to eat the lunch served and requested a soup instead. On 4/5/23 at 1309 hours, Resident 296 was served minced main entrée, mashed potatoes, minced green vegetables, pureed bread, and regular diet lemon cake. However, review of the facility's menu, the main entrée was supposed to be farmer's pot roast and the vegetables, green beans. Resident 296 was observed not touching his meal. When asked about the meal served to him, Resident 296 stated he did not like what was served and declined to eat the meal served to him. On 4/6/23 at 1125 hours, a concurrent observation and interview was conducted with the ST. The ST verified Resident 296 was served minced meal with puree bread instead of chopped and regular bread.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed for the residents on the soft-and-bit-sized diet. * The facility failed to ensure the chopped pot roast and chopped green beans were served to the residents on the soft-and-bite sized diet. This failure had the potential for the residents not liking the food based on the dietary modification and could affect the residents' quality of life. Findings: Review of the facility's P&P titled Therapeutic Diets revised 10/2017 showed the therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and treatments. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. Review of the facility's document titled Soft and Bite Size Texture (undated) showed five residents were on soft-and-bite size diet with no restrictions to the pot roast and green beans. Review of the facility's document titled Diet Spreadsheet for Wednesday Week 2 for lunch showed soft-and-bite size diets should be served with chopped pot roast, and chopped green beans. Review of the facility's document titled Aspiration Precaution Soft and Bite-Sized (undated) showed bite-sized pieces no bigger than 1.5 cm x 1.5 cm in size, which is about the width of a standard dinner fork. Food can be mashed/ broken down with pressure from for. A knife is not required to cut the food. Review of the facility's document titled Aspiration Precaution Minced and Moist (undated) showed soft and moist, but with no liquid leaking/ dripping. Biting is not required. Minimal chewing required. Lumps of 4 mm in size for adults. Lumps can be mashed with the tongue. On 4/5/23 at 1149 hours, during the tray line observation, [NAME] 1 was observed serving minced pot roast and minced green beans. The DSS verified the above findings. The DSS stated these were served for the soft-and-bite size diet. On 4/5/23 at 1459 hours, an interview and facility document review was conducted with the RD. The RD verified the above findings. The RD verified the spreadsheet showed chopped pot roast and chopped green beans were to be served for soft-and-bite size diet. The RD verified minced pot roast and minced green beans were served to residents on the soft-and-bite size diet instead of the chopped food. On 4/5/23 at 1526 hours, an interview and facility document review was conducted with the DSS. The DSS verified the above findings. The DSS verified the pot roast and the green beans were served to the residents on the soft-and-bite size diet were more than chopped. The DSS acknowledged the food texture was confusing and would have to ask the ST. On 4/6/23 at 1125 hours, an interview and facility document review was conducted with the ST. The ST verified the above findings. The ST stated she did not access the spreadsheet and was not aware of what was supposed to be served for the residents on the soft-and-bite size diet. The ST stated the goal was safety so it was still safe to serve the minced food instead of chopped food, however, the residents on the soft-and-bite size diet should have been served with the chopped food based on the prescribed food texture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record, facility P&P, and facility document review, the facility failed to follow the residents' preferences when the facility ran out of a food items to be served for breakfast. The facility failed to served fruit cups for one of 17 final sampled residents (Resident 344) and two nonsampled residents (Residents 345 and 346). This failure posed the risk of the residents' nutritional needs not being met and the residents' preferences not being honored. Findings: Review of the facility's P&P titled Menus dated 11/17 showed resident preferences and needs are incorporated into the development of the individual food plan. 1. On 4/4/23 at 0853 hours, during the initial tour of the facility, Resident 344 was observed with her breakfast tray. Resident 344's meal ticket card showed fruit cup, oatmeal. Fruit cup was not observed in Resident 344's breakfast tray. Resident 344 stated she wanted her fruit cup. When asked if the dietary staff offered something else other than a fruit cup, Resident 344 answered no. Medical record review for Resident 344 was initiated on 4/4/23. Resident 344 was admitted on [DATE]. Review of Resident 344's H&P examination dated 3/14/23, showed Resident 344 had the capacity to understand and make decisions. Review of Resident 344's Diet: History and Food Preferences dated 3/13/23, showed, fruit cup under preferences. 2. On 4/4/23 at 0853 hours, during the initial tour of the facility, Resident 345 was observed with her breakfast tray. Resident 345's meal ticket card showed, fruit cup, prunes. Resident 345 stated she was not served fruit cup. Resident 345 stated she would like to have prunes or a fruit cup, and did not have to be both so she asked the CNA to asked the kitchen and the CNA was told by the kitchen staff that they ran out. Resident 345 was not informed of the missing the fruit cup or prunes, and she had to ask the CNA to ask for it from the kitchen. Medical record review for Resident 345 was initiated on 4/4/23. Resident 345 was admitted on [DATE]. Review of Resident 345's H&P examination dated 3/24/23, showed Resident 345 had the capacity to understand and make decisions. Review of Resident 345's Diet: History and Food Preferences dated 3/24/23, showed, fruit cup, prunes under special request for breakfast. 3. On 4/4/23 at 0844 hours, during the initial tour of the facility, Resident 346 was observed with her breakfast tray. Resident 346 stated her fruit cup and butter were missing. Resident 346's meal ticket card showed, fruit cup, prunes, butter ok. Resident 346 stated, the butter was missing but that was okay, but I want my fruit cup. They did not offer anything else. Medical record review for Resident 346 was initiated on 4/4/23. Resident 346 was admitted on [DATE]. Review of Resident 346's H&P examination dated 3/26/23, showed Resident 346 had the capacity to understand and make decisions. Review of Resident 344's Diet: History and Food Preferences dated 3/24/23, showed, fruit cup, prunes under special request for breakfast. On 4/4/23 at 0859 hours, an interview was conducted with the DSS. The DSS verified the above findings. The DSS stated they ran out of fruits because the fruits were delivered late. The DSS acknowledged she did not inform the residents and did not provide any alternative or substitution for the fruit cup. On 4/7/23 at 0832 hours, an interview was conducted with the RD. The RD stated she was not informed the kitchen ran out of fruits to be served for breakfast on 4/4/23, and she was only informed later that day. The RD stated for the food deliveries, the DSS managed the kitchen, and she let the DSS run the kitchen so the RD spent more hours on clinical.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. On 4/4/23 at 0937 hours, an observation was conducted with CNA 1. CNA 1 was passing new water pitcher to the residents, from one room to another room. CNA 1 was observed going to Room B and taking Resident 495's old water pitcher and replacing it with a new water pitcher. Resident 495 requested CNA 1 to clean up her bedside table. CNA 1 removed soiled tissues from the bedside table to the trash can and picked up a wet, soiled, small, white hand towel. CNA 1 then stepped out of Room B and grabbed the soiled linen barrel from the hallway closed to Room B and placed the soiled wet cloth. Then, CNA 1 grabbed another new water pitcher and delivered it to Resident 496's bedside table without performing hand hygiene. On 4/4/23 at 0942 hours, an interview was conducted with CNA 1. CNA 1 confirmed the above findings and stated she did not perform hand hygiene when she should have had. Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the licensed nurse performed hand hygiene between changing of gloves during the medication administration observation. * The facility failed to ensure CNA 3 used the proper PPE in an enhanced standard/barrier precaution room when assisting Resident 295. * The facility failed to ensure CNA 5 performed hand hygiene when assisting the residents with meals. * The facility failed to ensure the staff performed proper hand hygiene when providing care. These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents. Findings: 1. Review of the facility's P&P titled Glove Use with effective date 8/2017, under the general information section, showed the employees shall perform hand hygiene after removal of gloves. On 4/4/23 at 0755 hours, a medication administration observation was conducted with LVN 4. During the observation, LVN 4 was observed preparing medications of Resident 294. LVN 4 put on gloves then took out the medical equipment from the medication cart, and started cleaning the medical equipmnet with disinfecting wipes. LVN 4 changed her gloves without washing her hands, proceeded to take Resident 294's vital signs (measurements of the body's most basic functions). LVN 4 removed gloves and did not wash her hands. On 4/4/23 at 1501 hours, an interview was conducted with LVN 4. LVN 4 verified and acknowledged the above findings. LVN 4 further stated hand hygiene was important between changing of gloves for infection control purposes. 2. Review of the facility's P&P titled Enhanced Standard/Barrier Precautions with the effective date of 7/22/22, showed it is the facility's policy to implement enhanced standard/barrier precautions fort he prevention of transmission of multidrug-resistant organisms (organisms that are resistant to multiple antibiotics or antifungals (medicines that kills or stop the growth of fungi)). Further review of the facility's policy under implementation of enhanced barrier precautions showed to wear gowns and gloves while performing the following tasks associated with the greatest risk for multidrug-resistant organism contamination of healthcare personnel hands, clothes, and the environment: any care activity involving contact with environmental surfaces likely contaminated by the resident. Review of Resident 295's medical record was initiated on 4/4/23. Resident 295 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the Order Summary Report showed an order dated 4/3/23, for enhanced barrier precautions for high contact care activities related to medical device care: foley catheter (a soft, plastic or rubber tube that is inserted into the bladder to drain urine); to perform hand hygiene and apply personal protective equipment (PPE) gloves, gown and/or goggles/face shield if at risk for splash/spray; to remove PPE and perform hand hygiene prior to exiting the room; every shift to prevent transmission of multidrug-resistant organisms; and remains in place or until resolution of wound or discontinuation of medical device. Review of the MAR for April 2023 showed an order dated 4/3/23, for enhanced barrier precautions for high contact care activities related to medical device care: foley catheter; to perform hand hygiene and apply personal protective equipment (PPE) gloves, gown and/or goggles/face shield if at risk for splash/spray; to remove PPE and perform hand hygiene prior to exiting the room; every shift to prevent transmission of multidrug-resistant organisms; and remains in place or until resolution of wound or discontinuation of medical device. On 4/4/23 at 0801 hours, medication administration observation for Room A was conducted. Room A was observed with a stop sign posted which read Enhanced Barrier Precautions at the entry of Room A. CNA 3 was observed entering Room A and proceeded to Bed B without wearing a gown. On 4/4/23 at 0805 hours, an interview was conducted with CNA 3. When asked about the Enhanced Barrier Precautions signage posted outside Room A, CNA 3 stated the precaution signage was for the resident in Bed B. CNA 3 stated the resident in Bed B was not on contact isolation and the precaution signage was for when staff performing care to the resident. CNA 3 further stated he asked for assistance from another staff to pull the resident in Bed B up in bed, and did not wear a gown. On 4/5/23 at 1534 hours, an interview was conducted with the IP. The IP was informed of the above findings. The IP stated hand hygiene should be performed between changing of gloves and proper PPE should be worn when in contact with the resident on enhanced barrier precautions. The IP further stated assisting to pull up the resident in bed was considered high contact care activity because the staff was touching the resident's linens. 3. Review of the facility's P&P titled Handwashing/ Hand Hygiene revised date 8/2019 showed all personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-microbial) and water for the following situations: - before and after assisting a resident with meals - before and after direct contact with residents - after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident a. On 4/4/23 at 1247 hours, during the initial dining observation, CNA 5 was observed not performing hand hygiene before and after assisting the residents with meals. For example: - CNA 5 was observed holding a lunch tray and entering Room C without performing hand hygiene. CNA 5 was observed assisting the resident in Bed A with the food items in the tray. CNA 5 was observed exiting the room without performing hand hygiene; - CNA 5 was observed getting another lunch tray from the meal cart and entering Room D without performing hand hygiene. CNA 5 was observed assisting the resident in Bed B with the food items in the tray. CNA 5 was observed exiting the room without performing hand hygiene; and - CNA 5 was observed getting another lunch tray from the meal cart and entering Room E without performing hand hygiene. CNA 5 was observed assisting the resident with the food items in the tray. CNA 5 was observed exiting the room with the resident's lunch tray, without performing hand hygiene. CNA 5 was observed taking the meal ticket card from the tray, spoke to the charge nurse and walked away. On 4/4/23 at 1453 hours, an interview was conducted with CNA 5. CNA 5 verified the above findings. CNA 5 verified she delivered lunch trays and assisted the residents with their lunch trays. CNA 5 stated she assisted the residents such as opening the straws, placing the straws into the beverage cups, and opening the plate domes. When asked if she performed hand hygiene before and after assisting the residents with their lunch trays, CNA 5 stated she could not remember washing her hands or using the alcohol-based hand rub but that was not the practice in the facility. CNA 5 stated the facility practice was to use the alcohol-based hand rub or wash hands in between residents. On 3/1/23 at 1545 hours, an interview was conducted with the IP. The IP stated the staff were supposed to perform hand hygiene by washing hands or using alcohol hand rub before and assisting residents with their meal trays.

Based on observation and interview, the facility failed to ensure the freezer compartment inside the residents' refrigerator was free of ice buildup. This had the potential for the refrigerators not being maintained in safe operating condition. Findings: On 4/4/23 at 0753 hours, an inspection of the residents' refrigerator was conducted with the DSS. The surrounding of the freezer compartment of the residents' refrigerator was observed with a build-up of ice. The DSS verified the above findings. The DSS stated the dietary staff was responsible to check the temperature of the refrigerator and make sure the food items inside the refrigerator were not expired. The DSS stated the maintenance department was responsible to check the build-up of ice inside the resident's refrigerator. On 4/6/23 at 0735 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the dietary staff was responsible to check the resident's refrigerator daily and to inform the maintenance department if the refrigerator needed to be fixed such as if there was a build-up of ice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the regular inspection of all the bed frames, mattresses, and side rails were performed as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Bed Safety revised March 2017 showed the facility strives to reduce hazards such as resident entrapment associated with side rails, mattresses and/ or bedrails. In an effort to reduce injuries associated with bedside rails, the DON Services/Environmental Supervisor/ designee and the community IDT shall: - Inspect all bed frames, bedside rails and mattresses according to the regular preventive safety schedule to identify potential areas of possible entrapment; - Ensure that no gap between the mattress, bedframe or side rails exceeds FDA regulations; and - Ensure that replacement mattresses and bedside rail are suitable with dimensions of the bed and in accordance with specified manufacturer instructions. According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's document titled Annual Facility Beds Preventive Maintenance Checklist - Electric Drive Model for June 2022 showed, N/A (not applicable) for the column for side rails. The document showed for side rails, to inspect for proper up, down and storage operation, inspect the locking latch for proper operation and to lubricate the mechanism if needed. Review of the facility's document titled Bed Side Rails for March 2023 showed Resident 30's side rails were installed by the Maintenance Director on 3/4/23. Review of the facility's documents and medical records showed the residents beds in the facility were not properly inspected for possible entrapment. For example: On 4/4/23 at 0957 hours, an observation and concurrent interview was conducted with Resident 30. Resident 30 was observed in bed with bilateral ¼ (quarter) side rails elevated. Resident 30 stated he used the side rails to reposition himself. Medical record review for Resident 30 was initiated on 4/4/23. Resident 30 was readmitted to the facility on [DATE]. Review of Resident 30's MDS 2/20/23, showed Resident 30 had a moderate cognitive impairment. Resident 30 required one-person assist for bed mobility and two-person assist for transfer. Review of Resident 30's Order Summary Report showed a physician's order dated 3/3/23, for bilateral ¼ side rails to promote bed mobility and transfer and as an enabler with diagnosis of bilateral AKA (above the knee amputation). Review of Resident 30's Bedrail Use and Entrapment Risk Evaluation dated 2/21/23, showed Resident 30 needed to use the bed rails due to weakness, balance deficit, and bilateral AKA. On 4/5/23 at 0936 hours, and 4/6/23 at 1453 hours, Resident 30 was observed in bed with bilateral ¼ side rails elevated. On 4/6/23 at 0818 hours, an interview and medical record review for Resident 30 was conducted with the DON. The DON verified the above findings. The DON stated Resident 30 was the only resident in the facility with the side rails. When asked about the entrapment assessment, the DON stated the facility used the form titled Bedrail Use and Entrapment Risk Evaluation, and Resident 30 was assessed for entrapment risk. When asked if Resident 30 was assessed in the seven areas/zones of the bed where there was a potential for entrapment are, the DON stated she was not familiar with the different zones of the bed for possible entrapment. When asked about the bed inspection, the DON stated the beds were being inspected on rounds, and the defects would be reported to the maintenance department. When asked if the gaps between the mattress, bedframe or side rails were inspected during the bed inspection, the DON stated the gaps were not inspected because the facility only used bilateral ¼ side rails. On 4/6/23 at 1524 hours, an interview and facility document review for Resident 30 was conducted with the Maintenance Director. The Maintenance verified the above findings. When asked about the bed inspection process, the Maintenance Director stated he checked the beds annually and as need. The Maintenance Director stated he checked the remote control, power cord, and up and down function of the bed during bed inspection. The Maintenance Director stated he installed Resident 30's side rails. When asked if Resident 30's bed was inspected in the seven areas/zones of the bed where there was a potential for entrapment are, the Maintenance Director answered no and stated he was not familiar with the different zones of the bed for possible areas of entrapment. The Maintenance Director stated he was not informed that he had to inspect the bed for possible entrapment.

4. Review of the facility's document titled Diet Spreadsheet for Tuesday Week 2 for soft and bit sized for lunch showed to served chicken (chopped) with gravy, mashed potatoes, green beans (chopped), bread sticks (puree), diced pears, milk, and choice of beverage. On 4/4/23 at 1219 hours, an observation and concurrent interview was conducted with CNA 2. During lunch meal observation, Resident 11's meal card showed soft and bit size diet textures, thin liquids, and regular diet. Resident 11's meal tray observed with chopped chicken with gravy, mashed potato no gravy, chopped green beans with no gravy, empty small dish of gravy, and 8 ounces of house nutrition 2.0; and the puree bread was missing. CNA 2 verified there was no puree bread on Resident 11's lunch tray and stated the nurses checked the meal card to make sure the residents got all items listed in their lunch tray. On 4/4/23 at 1221 hours, an interview with LVN 2 was conducted. LVN 2 stated Resident 11's lunch tray and meal card were checked by another nurse and verified the puree bread was missing. On 4/4/23 at 1223 hours, an interview with the DSS was conducted. The DSS verified the above findings and stated the dietary aid checked the diet and placed items on the resident's tray accordingly. The DSS further stated the nurses would check the tray card and meal trays again, and if items were missing, the nurses would request the missing item from the kitchen staff. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. * The soup was served to the residents without following recipe and nutritional analysis. * The wrong scoop size was used to serve green beans for the residents on the soft-and-bite size diet. * The regular bread was used instead of garlic bread during the pureed bread preparation for the residents on the soft-and-bite size diet. * The pureed bread was not served to Resident 11 during lunch as per the menu. These failures had the potential for residents not receiving adequate nutrition, and appropriate servings. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 4/4/23, showed 54 of 54 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Menu dated 11/17 showed the residents receive food in the amount, type, consistency, and frequency to maintain normal body weight and acceptable nutritional values. Menus meet basic nutritional needs by providing meals based on individual nutritional assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue. Menus are reviewed and revised as needed by a qualified dietitian or other qualified nutrition professional. Review of the facility's document titled Soft and Bite Size Texture (undated) showed five residents were on soft-and-bite size diet, with no restrictions to green beans, and bread. 1. Review of the facility's document titled Diet Spreadsheet for Wednesday Week 2 for lunch showed to served farmers pot roast, brown gravy, mashed potatoes, fresh green beans, cheesecake, milk and a choice of beverage. The spreadsheet did not include soup. On 4/5/23 at 1149 hours, a pot of soup was observed during the trayline observation. The soup was not included in the menu. The RD and DSS verified the findings. The RD and DSS stated the soup was something extra they served to the residents who were in the dining room. On 4/5/23 at 1459 hours, an interview and concurrent facility document review was conducted with the RD. The RD verified the above findings. The RD stated the soup was served to the residents who were in the dining room during lunch. When asked if the residents were aware what soup they would be served during lunch, the RD stated the residents did not know what type of soup, but they were aware they would be served soup in the dining room. The RD stated she was not made aware of what kind of soup the kitchen would serve, but it would depend on what the cook would prepare. When asked if a recipe or if there was a nutritional analysis done for the soups that were served during lunch, the RD stated there was none because it was just something extra and as an incentive for the residents to come to the dining room. On 4/5/23 at 1526 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS verified the above findings. When asked who decided on what soup to be served to the residents during lunch, the DSS stated the cook decided what to make depending on what they had in the kitchen. When asked if there were any recipes followed by the cook when they prepared the soup served to the residents during lunch, the DSS stated there were no recipes for the soup because this was just extra soup. 2. Review of the facility's document titled Diet Spreadsheet for Wednesday Week 2 for lunch, showed four-ounce (#8 scoop) green beans will be served for the soft-and-bite size diet. On 4/5/23 at 1149 hours, during the tray line observation, [NAME] 1 was observed using #10 scoop (three ounces) to serve green beans. The DSS verified the findings. The DSS verified the serving size was not what was stated on the spreadsheet for soft-and-bite-size diet. When asked about the portion size for green beans for soft-and-bite-size diet, the DSS stated it should have been #8 scoop. 3. Review of the facility's document titled Diet Spreadsheet for Thursday Week 2 for lunch showed to serve garlic bread under regular diet and bread (pureed/ moist) for soft-and-bite size diet. On 4/6/23 at 1154 hours, an observation of the puree preparation and concurrent interview with [NAME] 2 was conducted. [NAME] 2 stated he was preparing a pureed bread for the soft-and-bite size diet. A bowl containing breadcrumbs was observed in the food preparation area. [NAME] 2 stated he prepared the breadcrumbs from regular bread. When asked if a garlic bread should be prepared, [NAME] 2 stated he did not use garlic bread because the spreadsheet only showed pureed bread and not garlic bread. [NAME] 2 proceeded to prepare the pureed bread. On 4/6/23 at 1205 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS verified the above findings. The DSS acknowledged a pureed bread was served to residents on soft-and-bite size diet because the spreadsheet showed pureed bread. On 4/6/23 at 1208 hours, an interview and concurrent facility document review was conducted with the RD. The RD verified the above findings. The RD stated whatever was served in regular diet, should also be served in the pureed form, unless there was a restriction. The RD stated the cook should have used garlic bread instead of a regular bread.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the food items in the freezer were properly labeled. * The facility failed to ensure the cooking utensils were in good repair. * The facility failed to ensure the cutting boards were in sanitary condition. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/4/23, showed 54 of 54 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022 Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact and utensils shall be clean to sight and touch. On 4/5/23 at 0815 hours, an observation of the ice machine and concurrent interview was conducted with the Maintenance Director. The ice machine had a brownish substance on a white pipe on the inside of the upper front panel of the ice machine. When wiped off with a paper towel, a brownish substance was observed on the paper towel. The Maintenance Director verified the above findings and stated he would have to clean the ice machine today. 2. Review of the facility's P&P titled Sanitation and Infection Control, Food Storage (Label/ Dates) revised date 3/2010 showed all cooked foods, pre-packaged open contains, protein-based salads, and desserts are labeled, dated, and securely covered. On 4/4/23 at 0753 hours, during the initial tour of kitchen with the DSS, an observation of the pantry area showed two containers of whole thyme and chicken seasoning were opened and not dated. The DSS verified these were not dated and stated these should have been labeled with the opened date. 3. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. On 4/5/23 at 0810 hours, five white rubber spatulas were observed to be chipped. The RD verified the findings. 4. According to the USDA Food Code 2022, 4-501.12, Cutting Surfaces, surfaces such as cutting blocks that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. On 4/5/23 at 0810 hours, several cutting boards were observed to be heavily marred with knife marks. The RD verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the requested medical records for one of two sampled residents (Resident 1). This had the potential for delay in obtaining necessary services for the resident after discharge from the facility. Findings: Review of the facility's Policy and Pocedure titled Resident/Personal Representative Access to Protected Health Information dated 6/2016 showed if the resident and/or their personal representative requested a copy of the discharged resident's medical record, it should be sent within 15 calendar days of the request. Closed medical record for Resident 1 was initiated on 2/6/23. Resident 1 was admitted to the facility on [DATE], and discharged on 10/17/22. On 2/6/23 at 1115 hours, an interview was conducted with the Medical Records Director. The Medical Records Director stated the email wasthe way they kept track of the medical records requests. Review of the Request for Access to Protected Health Information form dated 12/16/22, showed Requestor 1 had requested a copy of Resident 1's medical record. Review of the email correspondence between the Medical Records Assistant and Requestor 1 dated 1/10/23, showed only some of the requested records had been sent to Requestor 1. On 3/15/23 at 1617 hours, an interview was conducted with the Administrator. The Administrator stated he looked at the attachments listed in the email and could not confirm all medical records requested had been provided to Requestor 1. There was no documented evidence all requested documents were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the door to the room of one of 13 final sampled residents (Resident 245) remained closed while the treatment was being provided. This had the potential for the resident's dignity not being maintained. Findings: On 12/17/19 at 1512 hours, observation of Resident 245's wound treatment to her buttocks area was conducted with LVN 2. LVN 2 was observed closing Resident 245's door. Resident 245 was positioned on her bed with her buttocks area uncovered. Resident 245's privacy curtain was not pulled. LVN 2 was observed leaving Resident 245's door open while retrieving supplies from her treatment cart, located outside Resident 245's door. LVN 2 was then observed reentering Resident 245's room and leaving Resident 245's door open. Facility staff were observed standing in the hallway outside Resident 245's room looking into Resident 245's room while Resident 245's door was open. When asked about Resident 245's door being left open during Resident 245's buttocks wound treatment, LVN 2 acknowledged Resident 245's door was left open during the resident's wound treatment. On 12/19/19 at 0848 hours, an interview was conducted with Resident 245. When asked about the door being left open during wound treatment of her buttocks, Resident 245 stated leaving her door open during the wound treatment bothered her due to the loss of dignity. Medical record review for Resident 245 was initiated on 12/17/19. Resident 245 was admitted to the facility on [DATE]. Review of Resident 245's H&P Note dated 12/9/19, showed Resident 245 was alert and oriented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, the facility failed to obtain the PRN (as needed) pain medication for one nonsampled resident (Resident 18) and ensure the supply was available for the resident. This failure had the potential for medication errors and for PRN drugs not being available when needed by the resident. Findings: Medical record review of Resident 18 was initiated on 12/18/19. Resident 18 was admitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 11/27/19, to administer hydromorphone hcl 2 mg (Dilaudid, a controlled pain medication) give 10 mg by mouth every six hours as needed for moderate to very severe pain (4-10). Review of Drug Control Receipt/Record/Disposition Form for the hydromorphone hcl 2 mg take five tablets (10 mg) showed the last dose was was signed out on 12/11/19. Review of 24 - Hour Nursing Report Census dated 12/12/19, showed the unidentified author spoke with staff from the pain specialist physician's office - still waiting for physician' s authorization for Dilaudid 10 mg. Review of the facility's P&P titled Medication Orders effective date 10/12 under Refill Requests for C (controlled) III-C V and Partial Fill Requests for C II showed if one or more refills ( C III- Vs) or a partial fill quantity (C IIs) remains and medications are not automatically refilled by the pharmacy, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy 5 days in advance of need to assure an adequate supply is on hand. On 12/18/19 at 1347 hours, Medication Cart 1 was inspected with LVN 4. The cart contained the controlled medications for Resident 18. A bubble pack of hydromorphone 2 mg for Resident 18 was observed with no remaining tablets in the bubble pack. However, Review of Drug Control Receipt/Record/Disposition form for Resident 18 showed the last tablets in the bubble pack were removed on 12/11/19. On 12/19/19 at 0719 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. The MDS Coordinator was asked what the process was to order for refill the PRN Dilaudid. The MDS Coordinator stated the nurse contacted the pharmacy, they needed the C II form and needed the physician to sign it. The pharmacy usually contacted the physician for authorization or the facility nurse called the physician. The MDS Coordinator stated they had been waiting for the physician's authorization for the Dilaudid. The MDS Coordinator stated the nurse should have called three days before the medication ran out. The MDS Coordinator was asked if there were any notes showing the nurses called the pharmacy or attempted to get authorization from the physician to refill the medication. The MDS Coordinator was unable to provide the documentation. The MDS Coordinator stated they called the pharmacy today (12/19/19) a few minutes ago and the physician faxed the authorization to the wrong pharmacist. The MDS Coordinator stated they did not document when they called the pharmacist for the refill but if the order needed the physician's authorization they had a C II form and faxed it to the physician or pharmacist. The MDS Coordinator was unable to provide the documentation. The MDS Coordinator verified the finding. On 12/19/19 at 0936 hours, a concurrent interview and medical record review was conducted with the DON. The DON was asked when the nurse should have requested the refill of the PRN pain medication. The DON stated the nurse should have called two days before the medication ran out. The nurse should have called the physician for the refill and call the pharmacy for preprinted C II form. The pharmacist could fax the form to the facility and the physician. The physician faxes the form back directly to pharmacist or pharmacy. The nurse should document this action in the nurses notes. When asked for documentation if the nurse followed up with the physician or the pharmacist regarding the refill of the PRN Dilaudid, the DON was unable provide the documentation. On 12/19/19 at 1330 hours, a concurrent interview and medical record review was conducted with the DON and LVN 4. LVN 4 was asked if there was any documentation showing the facility informed the physician before Resident 18's medication ran out on 12/11/19. The DON stated she was unable to provide documentation. The DON and LVN 4 were asked if there was any follow up regarding the hydromorphone after notifying the physician on 12/12/19. The DON stated she was unable to provide the documentation. The DON verified the findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary practices for food storage were maintained. * The facility failed to ensure proper labeling and dating of food items in the residents' refrigerator. This failure had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings: Review of the facility's P&P titled Use and Storage of Food Brought to Resident dated November 2017 showed labeling, dating, and monitoring refrigerated food, including, leftovers, so it is used by its use-by date, or frozen, or discarded in accordance with acceptable standards of safe food storage guidelines. On 12/18/19 at 1435 hours, a concurrent inspection of the residents' refrigerator and interview was conducted with the DSS. The following food items were observed in the freezer section of the residents' refrigerator: - An opened bag of mixed berries was not labeled with a date or a resident's name; - A pint of ice cream labeled with 28B was not labeled with a date and a resident's name; - A pint of ice cream labeled with #2 with a resident's name was not labeled with a date - A small Styrofoam cup was not labeled with a date and a resident's name. During the interview with the DSS, the DSS verified the above findings. The DSS was asked to describe how the residents' food items in the freezer section of the refrigerator should be labeled. The DSS stated the residents' food items in the freezer section of the refrigerator should be labeled with the resident's name and date. The DSS stated she did not expect there were residents' food items in the freezer section of the refrigerator.