Based on observation, interview, and record review, the facility failed to provide one of four sampled residents (Resident 17), routine housekeeping and maintenance services to maintain a clean, sanitized wheelchair/recliner for resident's daily use. This failure resulted in an undignified and unclean wheelchair for Resident 17's use. Findings: A review of Resident 17's admission Record, printed 3/20/24, indicated resident was admitted to the facility in 2008 with diagnoses of dementia (memory loss) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 17's Minimum Data Set (MDS, an assessment tool used to provide nursing care) indicated resident has severely impaired cognition and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity), with all activities of daily living (ADLs), including chair/bed-to-chair transfer. A review of Resident 17's Care Plan on Risk for Pain and Limitation in Physical Mobility, revised date 9/24/21, indicated resident was non-ambulatory and had limited mobility on lower extremities due to contractures. Care Plan indicated resident was dependent on transfers and demonstrated poor sitting balance and poor sitting posture. Resident used a recliner/wheelchair with thigh belt to facilitate proper sitting position and maintain posture. During a concurrent observation and interview on 3/18/24, at 9:30 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 17's room, Resident 17 was noted seated in a wheelchair with its padded footrest and armrests visibly soiled and stained with dried food and liquid stains in multiple scattered areas. CNA 1 stated resident's wheelchair was unclean and housekeeping should clean the wheelchairs routinely. During an interview on 3/19/24, at 10:34 a.m., with Housekeeping 2 (Hskg 2), Hskg 2 stated she was assigned to Resident 17's room yesterday. Hskg 2 stated resident's wheelchair was supposed to be cleaned and disinfected before each resident use. During an interview on 3/21/24, at 11:00 a.m., with the Director of Nursing (DON), DON stated wheelchairs and all other resident equipment needed to be cleaned and sanitized before and after use to prevent cross-contamination or any other infection-related issues. DON stated cleaning of the wheelchair is a shared responsibility between the nursing and housekeeping departments. A review of the facility's policy and procedure (P&P) titled, Cleaning of Non-Critical, Reusable Equipment Used by Persons Served (Skilled Nursing Facility [SNF]), undated, indicated, It is the policy .to implement and maintain processes to ensure all non-critical, reusable equipment used by residents are routinely cleaned, disinfected, or discarded after use in accordance with existing infection prevention and control policies and procedures .Cleaning is the physical removal of foreign material .Disinfection is the inactivation of disease producing organisms .Cleaning is a shared responsibility between the nursing and housekeeping departments. All reusable equipment are cleaned immediately if visibly soiled .Wheelchairs - between use by each resident and before putting into storage - clean with hospital-approved disinfectant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Set Assessment (MDS a standardized resident assessment tool) was accurate for one of 22 sample residents (Resident 46). For Resident 46, the facility failed to accurately code a fall with major injury (rib fracture) on Resident 46's MDS. Failure to accurately capture fall data may impact care planning and fall interventions for Resident 46. Findings: Review of Resident 46's face sheet, printed on 03/20/2024, indicated he was admitted to the facility on [DATE] with multiple diagnoses including: brain condition causing seizure (seizure= brain disorder that causes changes in behavior, movements, feelings and levels of consciousness), dementia (loss of cognitive function related to thinking, remembering and reasoning), schizophrenia (mental illness manifested by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). Review of Resident 46's record titled, Post Event Assessment Form, dated 10/09/2023, indicated Resident 46 was .found on the floor on 10/8/23. Alert and verbally responsive.(complained of) left ribs and back pain. Review of Resident 46's record titled, ED to hospital admission (ED= Emergency Department), dated 10/13/2023, indicated Resident 46 .was found down after likely fall. Imaging notable for . rib fractures . Review of Resident 46's MDS, dated [DATE], indicated section J health condition was coded incorrectly. Section J1900, asked for number of falls since admission/entry or reentry or prior assessment. Section J1900 was coded by facility staff as one fall with no injury. During an interview on 03/19/24, at 9:58 AM, the MDS coordinator stated Resident 46's December 2023 MDS fall with no injury data was coded incorrectly; it should have been coded as fall with major injury. Review of the facility's policy titled, Resident Assessment lnstrument (RAI): Minimum Data Set, dated October 2023, indicated .Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) in emergency kits (e-kit, a box with emergency medications) were stored appropriately when: 1. two e-kits containing controlled substances were found in locked boxes that were not permanently affixed to the refrigerator in Med room [ROOM NUMBER] and Med room [ROOM NUMBER] 2. an e-kit containing controlled substances was found unsecured on a shelf in Med room [ROOM NUMBER] 3. an e-kit containing controlled substances was found unsecured in the refrigerator in Med room [ROOM NUMBER]. These failures had the potential for diversion and unauthorized access of controlled medications. Findings: 1. During a concurrent observation and interview on 3/21/24, at 10:00 a.m., with Licensed Vocational Nurse 1 (LVN 1), a black lock box was found in a refrigerator in Med room [ROOM NUMBER]. LVN 1 removed the black box from the refrigerator, placed the box on a counter and unlocked it. Inside the box was an e-kit containing two vials of lorazepam (a controlled medication to reduce anxiety). LVN 1 stated e-kits containing controlled medications requiring refrigeration were typically stored in the black lock box in the refrigerator. During a concurrent observation and interview on 3/21/24, at 10:20 a.m., with Registered Nurse 1 (RN 1), a black box was found in a refrigerator in Med room [ROOM NUMBER]. RN 1 removed the black box from the refrigerator, placed the box on a counter and unlocked it. Inside the box was an e-kit containing two vials of lorazepam. RN 1 stated e-kits containing controlled medications requiring refrigeration were normally stored in the black lock box and kept in the refrigerator. During an interview on 3/21/24, at 10:31 a.m., with the Director of Nursing (DON), the DON stated e-kits containing controlled medications could be stored in the black boxes in the refrigerators. During a record review of facility policy and procedure (P&P) titled, Controlled Medication Storage, dated 11/2017, the P&P indicated controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. 2. During an observation on 3/20/24, at 11:28 a.m., an e-kit containing controlled medications was found on a shelf in Med room [ROOM NUMBER]. The e-kit was not locked and could be opened after breaking a thin plastic tie. The e-kit had a list of medications contained in the box and indicated the following: a. acetaminophen-codeine (a controlled medication containing opioids for pain relief) 300-30 mg (milligram, unit of measurement), 4 tablets b. clonazepam (a controlled medication to reduce anxiety) 0.5 mg, 8 tablets c. diphenoxylate/atropine (a controlled medication containing opioids to reduce diarrhea) 2.5-0.025mg, 4 tablets d. lorazepam 0.5 mg, 8 tablets e. phenobarbital (a controlled medication for sedation) vial, 2 vials f. temazepam (a controlled medication to difficulty sleeping) 7.5 mg, 8 tablets g. tramadol (an opioid for pain relief) 50 mg, 8 tablets h. zolpidem (a controlled medication to treat difficulty sleeping) 5 mg, 4 tablets. During a concurrent observation and interview on 3/21/24, at 10:19 a.m., with Licensed Vocational Nurse 2 (LVN 2), an e-kit containing controlled medications was found on a shelf in Med room [ROOM NUMBER]. LVN 2 stated the e-kit should not be on the shelf and needed to be in a locked container. LVN 2 stated the e-kit should be kept in a locked drawer in the med cart. LVN 2 attempted to lock the e-kit in a locked drawer but was unable to do so. LVN 2 stated there was not enough room to store the e-kit in the drawer. During an interview on 3/21/24, at 10:31 a.m., with the DON, the DON stated the e-kit containing controlled medications was expected to be locked in the med cart. The DON stated the unsecured e-kit had the potential for drug diversion. During a record review of facility P&P titled, Controlled Medication Storage, dated 11/2017, the P&P indicated medications included in the DEA classification as controlled substances are subject to .storage .in the nursing care center in accordance with federal, state and other applicable laws and regulations. 3. During a concurrent observation and interview on 3/21/24, at 10:00 a.m., with LVN 1, an e-kit containing lorazepam was found on the door of the refrigerator in Med room [ROOM NUMBER]. A black lock box containing another e-kit with controlled medications was in the same refrigerator. LVN 1 stated the e-kit found on the refrigerator door needed to be secured in a locked container. During a record review of facility policy and procedure (P&P) titled, Controlled Medication Storage, dated 11/2017, the P&P indicated controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards of food and safety when: 1. Freezer and refrigerator: - Inside Freezer 1, a large, half full, opened bag of frozen potato wedges was without a used-by date. - Inside the three-door paneled refrigerator, three cups of individually scooped protein pudding had no label and used-by date. 2. Equipment: - Ice machine scoop holder was unclean. - An unclean bread knife was stored in the knife rack. - Single-door freezer 3 had ice build-up on the top shelf, directly below the freezer fan. - Dietary staff did not sanitize the thermometer in between use. 3. Food Service Worker 1's (FSW 1) hair was not completely secured to the hairnet. 4. Environment: - Kitchen entrance sink had a leaky faucet. - The pantry entrance was dark and had inadequate lighting. - Kitchen work areas had six overhead light fixtures that were not in good working condition. These failures had the potential to result in contamination of food and food borne illness for 60 out of 60 facility resident census who received food from the kitchen. Findings: 1. During a concurrent kitchen observation and interview on 3/18/24, at 9:40 a.m., with Food Services Manager (FSM), the following were found: - Inside the freezer 1 was a large, half bag of frozen potato wedges. The bag had an opened date of 3/12/24 but did not have a used-by date. FSM stated opened bags of food items should be labeled with used-by dates for safe storage. - Inside the three-door paneled refrigerator where three cups of individually scooped protein pudding were stored did not have a label and used-by date. FSM stated the cups should have been labeled with the name of the food item being stored, placed date, and the used-by date. A review of the facility's policy and procedure (P&P) titled, Labeling and Dating for Safe Storage of Food, revised date 3/6/2020, indicated, Participants will learn that labeling and dating are critical in order to promote food safety .Use Use-By dates on all food once opened and stored under refrigeration .When food is taken out of an original container write the name of the food being stored on the container, the placed date, and the Use-by date . 2. During an observation on 3/18/24, at 9:30 a.m., the wall-mounted ice machine scoop holder located outside by the kitchen was found with about a tablespoonful of water with multiple black sediments settled at the bottom of the scoop holder. During a concurrent follow-up observation and interview on 3/19/24, at 10:15 a.m., with FSM, the ice machine scoop holder was checked. FSM stated the scoop holder had black sediments and appeared like there was mold growth at the bottom of the scoop holder. FSM stated it was the responsibility of the dietary staff to ensure the scoop and scoop holder were cleaned and washed daily. During a concurrent kitchen observation and interview on 3/18/24, at 9:50 a.m., with FSM, an unclean bread knife was found stored inside the wall-mounted knife rack. The bread knife had visible and tactile dried matter stuck to the surface of the knife. FSM stated equipment should be washed well, air dried, and stored clean after each use to decrease the risk of bacterial growth and cross-contamination. A review of the facility's P&P titled, Sanitation and Infection Control, subtitled, Cleaning Small Appliances/Equipment, dated 2018, indicated, Equipment will be cleaned and sanitized to prevent food borne illness .Knives will be cleaned and sanitized after each use . During a concurrent kitchen observation and interview on 3/18/24, at 10:00 a.m., with FSM and Registered Dietitian and Nutritionist (RDN), the single-door freezer 3 was checked. FSM confirmed there was ice build-up on the plastic bag of frozen food placed on the top shelf directly below the freezer fan. RDN stated it looked like moisture that leaked from fan perhaps from the constant opening and closing of the freezer door. RDN stated it was not typical and not normal to have an ice build-up inside the freezer below the freezer fan and should be looked upon by Maintenance and/or vendor. During a concurrent observation and interview on 3/19/24, at 11:12 a.m., with FSM and [NAME] 1, [NAME] 1 checked the temperature of the cold drinks using the calibrated (the ice-point method done to ensure accurate temperature readings) thermometers. [NAME] 1 poked the thermometer through the plastic cover of the lemonade juice then pulled the thermometer out and re-inserted the thermometer through the plastic cover of the apple juice. The thermometer was not sanitized after switching from one glass of juice to the next. FSM stated [NAME] 1 should have sanitized the thermometer in between use. During an interview on 3/20/24, at 11:02 a.m., FSM stated when using the same thermometer on multiple drinks, thermometers should be sanitized in between use to prevent cross- contamination. A review of the facility's P&P titled, Food Thermometer Use and Calibration, undated, indicated, .Cleaning and Sanitizing .Thermometers are cleaned and sanitized after use .Sanitize the thermometer with the food grade sanitizer .When using the same thermometer on multiple different foods during one meal, wipe the thermometer with an alcohol swab, clean cloth, or paper towel between different food items . 3. During a concurrent observation and interview on 3/18/24, at 9:37 a.m., with FSM, FSW 1's hair to the forehead and back of the neck were not completely covered by the hairnet. FSM called the attention of the FSW 1 and gestured to go and fix her hair so that all the hair is fully secured inside the hairnet. FSM stated hairnets prevent staff's hair from getting in contact with the food, drinks, or trays, etc. during meal preparation and service. A review of the facility's P&P titled, Sanitation and Infection Control, subtitled, Personal Hygiene, dated 2018, indicated, .A hair net and/or head covering which completely cover all hair should be worn during meal preparation and service . 4. During a concurrent observation, interview, and record review on 3/18/24, at 9:37 a.m., inside the kitchen, with the Food Services Manager (FSM), entrance sink right faucet handle did not close tightly when turned off. FSM stated food service workers were trained to report kitchen issues to the Environmental Services Director (EVSD) by using the Environmental Maintenance Log Binder located outside by the kitchen next to the Ice Machine. Review of the Environmental Log Binder did not indicate any reported leaky faucet. During a concurrent observation and interview on 3/19/24, at 10:15 a.m., a second observation of the entrance sink continued to reveal a leaking faucet, this time less leaky than the initial observation. FSM stated EVSD was aware and looking for other options to completely fix the leaky faucet. During an interview on 3/21/24, at 10:00 a.m., with the EVSD, EVSD stated food service workers usually gave verbal report instead of using Environmental Maintenance Log Binder located next to the Ice Machine. EVSD stated food service workers informed him about kitchen equipment issues as needed. EVSD stated the entrance sink faucet will be changed to a new fixture to prevent water leak. During a concurrent kitchen pantry observation and interview on 3/18/24, at 9:47 a.m., with FSM, the entrance area to the pantry was dark and had poor lighting. FSM stated it was difficult for the dietary staff to clearly see the food items stored in the shelves due to inadequate lighting and will remind Maintenance to change the ceiling light. During a concurrent kitchen observation and interview on 3/20/24, at 11:02 a.m., with FSM and [NAME] 1, the kitchen work areas had six overhead light fixtures that were not in good working condition. [NAME] 1 stated dietary staff workers did not even noticed that some of the light fixtures were not working. [NAME] 1 stated food service workers report to EVSD verbally when something was needed to be fixed in the kitchen even though they were aware of the EVS Maintenance Log Binder located next to the ice machine outside by the kitchen. During a follow-up interview on 3/21/24, at 10:00 a.m., with the EVSD, EVSD stated the kitchen pantry light will be changed to a brighter bulb and non-working light fixtures throughout the kitchen work area will be fixed to provide adequate lighting in the kitchen.

Based on observation, interview, and record review, the facility failed to ensure that one of two garbage dumpster bins located outside the facility grounds had lids that tightly closed. This failure had the potential to attract pests to the facility and lead to pest-related disease for 60 residents out of a facility census of 60. Findings: During a concurrent observation and interview on 3/19/24, at 10:15 a.m., with the Food Services Manager (FSM), outside the facility parking lot were three large dumpster bins. FSM stated the bin with blue lids was for recycling and the other two bins with black lids were for all the facility trash which included nursing and dietary. One trash bin had a lid that was significantly bent to the back, cracked to the right side, and had a three-inch gap to the front of the two parallel lids that even when the lids were closed revealed multiple gaps between the lids and bin. Flies were observed circling around the area between the dumpster bins and the back door exit. FSM stated this will be reported to the Environmental Services Director (EVSD). During an interview on 3/19/24, at 11:10 a.m., the EVSD stated one of the two trash bins cannot close tightly due to the bent and cracked lids. EVSD stated the lids needed to be changed to get the bins tightly sealed when closed to prevent pest-related issues. According to the 2017 Federal Food Code, receptacles for refuse used with materials that contained food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids or covers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide adequate supervision to prevent a physical altercation for two of two sampled residents (Resident 1 and Resident 2) when assigned staff members did not closely monitor the residents who were dining during dinnertime in the large dining room. This failure resulted in an unwitnessed altercation between Resident 1 and Resident 2 wherein Resident 2 hit Resident 1 with his right-hand ?st. This created a red discoloration underneath Resident 1 ' s left eye and had the potential to cause Resident 1 emotional and/or psychological distress, as well as place all the other residents eating in the large dining room at safety risk. Findings: A review of Resident 1's admission Record, dated August 16, 2033, indicated Resident 1 was admitted to the facility in January 2022, with diagnoses of vascular dementia (brain damage caused by multiple strokes) and schizophrenia (a disorder that a?ects a person ' s ability to think, feel, and behave clearly). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 3/16/23, indicated Resident 1 had a score of 8 on the Brief Interview for Mental Status exam. (BIMS, a scoring system used to determine the resident's cognition status regarding attention, orientation, and ability to register and recall information. The scale is from zero to 15, with a score of eight to 12 an indication of moderate impairment). The MDS indicated Resident 1 was independent and needed supervision (oversight, encouragement, or cueing), with set-up help only during eating, toilet use, and personal hygiene. The MDS indicated Resident 1 used a walker for ambulation. A review of Resident 2's Face Sheet, dated August 16,2023, indicated Resident 2 was admitted to the facility in 2020 with diagnoses of dementia (memory loss) and schizophrenia. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 13, an indica??on of intact cognition. The MDS indicated Resident 2 was independent, but required supervision with set-up help only, during eating and personal hygiene. The MDS indicated Resident 2 was ambulatory with no mobility devices needed. During a review of the facility video (without audio) on 8/16/23, at 11:30 a.m., with the Administrator (ADM), video from the big dining room, dated 4/23/23, was reviewed. The video showed both Resident 1 and Resident 2 were eating dinner in the same table while other residents were seated in their assigned tables. No staff members were seen close to the residents. Resident 1 ' s mouth, appeared to be opening and closing, talking while facing Resident 2, then suddenly spat on Resident 2 ' s food plate. Resident 2 got up from his chair and threw a punch twice to Resident 1 ' s face. Resident 1 tried to stand but lost his balance and landed on the floor. Resident 1 attempted to get up and tried to grab Resident 2 ' s chair. Resident 2 grabbed on the same chair when two staff (CNA 1 and CNA 2) came into the picture and appeared to be talking to the two residents. A review of Resident 1's Post Event Assessment Form Part 2 - IDT (Interdisciplinary Team) Notes, dated 5/9/23, indicated Resident 1 had been interviewed by the Behavioral Specialist 1 (BS 1) on 4/25/23, at 10 a.m. The IDT Notes indicated Resident 1 was noted with red discoloration under his left eye and stated Resident 2 had hit him on Sunday, April 23, 2023, in the dining room. Further review of the IDT Notes indicated Resident 2 was also interviewed and stated Resident 1 spat on Resident 2 ' s food and bumped his leg with a chair. Resident 2 stated he hit Resident 1 on his face. The IDT Notes also indicated on Sunday, April 23, staff were assisting the residents with dinner when they heard yelling and observed the two residents pulling on the same chair. Code Green, (facility ' s emergency code for an altercation) was called, and the residents were separated. During a telephone interview on 8/16/23, at 12:20 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 denied seeing or hearing anything unusual between Resident 1 and Resident 2, during dinnertime at the large dining room, on April 23, 202. CNA 1 stated she was busy passing dinner trays to the other residents at that time. During a telephone interview on 8/17/23, at 9:08 a.m., with CNA 2, CNA 2 denied seeing or hearing anything unusual between Resident 1 and Resident 2, during dinnertime at the large dining room, on April 23, 2023. CNA 2 stated she was busy preparing coffee at the back of the food cart. CNA 2 further stated she remembered seeing a chair on the floor and had asked Resident 2 what happened but Resident 2 stated, Nothing. CNA 2 stated she remembered seeing Resident 1 sitting quietly in a chair in front of Resident 1 and Resident 2 ' s shared table. CNA 2 also stated both Resident 1 and Resident 2 showed no signs of injury nor any signs of being upset. During a telephone interview on 8/17/23, at 9:14 a.m., with CNA 3, CNA 3 also denied seeing or hearing anything unusual between Resident 1 and Resident 2, during dinnertime at the large dining room, on April 23, 2023. During an interview on 3/7/24, at 9:59 a.m., with the Director of Nursing (DON), the DON stated the incident between Resident 1 and Resident 2 happened in the large dining room while the staff were getting the dinner trays from the food cart and passing them out to the other residents. The DON stated the food cart usually parked in the middle, next to Resident 1 and Resident 2 ' s dining table, not too far from the dining room entrance, was rectangular in shape, can be opened from two opposite sides, and were tall. The DON stated the food cart door closer to the resident ' s table was kept close to prevent the residents from grabbing trays out of the cart. The DON also stated there were usually two licensed nurses assigned in the large dining room, together with the four CNA ' s who were fluidly in and out of the dining room to assist in passing trays and monitor residents during dining. During an observation and interview on 3/7/24, at 1:20 p.m., inside Resident 2 ' s room, Resident 2 stated Resident 1 was his peer and remained to be his peer up to the time of writing. Resident 2 stated he remembered when Resident 1 spat on his food and so he punched Resident 1 to his face with his right-hand fist. Resident 2 stated he and Resident 1 did not report the incident to anyone until the discoloration to Resident 1 ' s eye appeared a day later. Resident 2 stated he lost his appetite even though he was hungry when Resident 1 spat on his food. During an interview on 3/7/24, at 1:30 p.m., with the ADM, ADM was unable to explain how no staff members assigned in the large dining room, during dinnertime on 4/23/23, were able to witness the incident between Resident 1 and Resident 2. Resident 1 refused to be reinterviewed during the investigation.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received medication according to the physician orders for Quinidine (a medication used to treat fast or irregular heartbeat [arrythmia]). The facility also failed to notify Resident 1 ' s physician of the missed medications in a timely manner. This failure to inform the physician of Resident 1's missed medications prevented the physician from prescribing a change in treatment or monitoring and had contributed to Resident 1 receiving 10 shocks, from the Cardiology Clinic to his defibrillator (a device that provide electric shock to the heart to restore a normal heartbeat) on 5/21/22 and was sent out to acute hospital via 911 for evaluation and further treatment on 5/23/22. Findings: A review of Resident 1's admission Record, printed on 8/16/23, indicated resident was admitted to the facility in January 1999 with diagnoses of dementia (memory loss), schizophrenia (a chronic brain disorder that affects a person ' s ability to think, feel, and behave), and cardiac arrythmia. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide resident care), dated 4/14/22, indicated Resident 1 required supervision with minimal assist on activities of daily living, was rarely/never able to make himself understood, and rarely/never able to understand others. A review of Resident 1 ' s Care Plan titled Potential for Alteration in Cardiac Function related to diagnosis of Ventricular Tachycardia, revised 6/2/22, indicated Resident 1, .had a cardiac defibrillator surgically implanted .He maintains his appointment with cardiologist . The care plan also indicated Resident 1 was connected to a monitoring machine every week for defibrillator check which reading is directly submitted or relayed to his cardiologist. Some of the care plan interventions indicated, .Administer med as ordered. Maintain Cardiology Appointment. Maintain weekly defibrillator check. Monitor for change in heart rhythm and refer accordingly . A review of Resident 1's Order Summary Report, dated 5/23/22, indicated an order with a start date of 1/24/2020, Quinidine Gluconate 324 milligram (mg) tab give 324 mg orally five times a day related to cardiac dysrhythmia (irregular heartbeat). During an interview on 8/16/23, at 12:28 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was not able to give Resident 1 his Quinidine once on night shift due to medication unavailability. LVN 1 stated it indicated on the Medication Administration Record (MAR) that the medication had been ordered from the pharmacy on 5/21/22 but had not been received by the facility. LVN 1 stated best practice was to inform the Director of Nursing (DON), Assistant DON, or Administrator (ADM) when facility is unable to receive significant medications ordered and followed up from the pharmacy. LVN 1 also stated he should have informed the physician regarding resident ' s missed doses. During a concurrent interview and record review on 8/16/23, at 1 p.m., with the Director of Nursing (DON), Resident 1 ' s May 2022 Medication Administration Record (MAR) was reviewed. The DON confirmed Resident 1 did not receive Quinidine on the following dates: 5/21/22, at 10 a.m. and 2 p.m., 5/22/22, at 6 a.m., 10 a.m., and 2 p.m., and on 5 /23/22, at 6 a.m. The DON stated the MAR had no checkmarks on the said dates, instead was coded a 9, which meant the medication ran out and was ordered from the pharmacy. The DON stated the risk of Resident 1 not receiving his Quinidine put the resident ' s heart at risk of not functioning properly. The DON further stated licensed nurses are expected to notify the physician anytime medication doses were missed. A review of Resident 1 ' s Progress Notes, printed 8/16/23, dated 5/23/22, at 1 p.m., documentation by Assistant Director of Nursing (ADON) indicated, Resident was noted to have missed several Quinidine doses .MD was notified regarding the missed doses and ordered to give the medication once it arrives. Cardiology clinic was also notified, and Physician Assistant (PA) stated that resident received a total of 10 shocks to his defibrillator since May 21, 2022. The Progress Notes further indicated PA ordered resident sent out to acute hospital via 911 for evaluation and further treatment. During a telephone interview on 3/6/24, at 1:40 p.m., with the Physician, the Physician stated the facility notified him on a Monday, via phone call that Resident 1 had not received the Quinidine over the weekend (including the Monday he was called) and missed a total of six doses. The Physician stated the medication was an antiarrhythmic and if missed longer could result in arrythmia. A review of Resident 1's acute care hospital Discharge Summary, printed on 5/27/22, indicated Resident 1 went to the emergency department on 5/23/22 due to the 10 shocks delivered to resident ' s defibrillator over the weekend and reported missed Quinidine doses and was admitted to the hospital for treatment of resident ' s ventricular fibrillation (a life-threatening heart rhythm that results in a rapid, inadequate heartbeat). The Discharge Summary indicated Resident 1 was discharged from the hospital on 5/27/22 after treatment with ventricular fibrillation and defibrillator battery replacement. A review of the facility's policy and procedure titled, Medication Error and Reporting, undated, indicated, .Medication errors are defined as any failure to give medications as prescribed, or to give any medication without a prescription .When a medication error is discovered: Notify: the Administrator, Director of Nursing or designee, immediately .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from medication error when Quinidine (a medication used to treat fast or irregular heartbeat [arrythmia]) was not administered as ordered by the physician. This failure contributed to Resident 1 receiving 10 shocks, from the Cardiology Clinic to his defibrillator (a device that provide electric shock to the heart to restore a normal heartbeat) on 5/21/22 and sent out to acute hospital via 911 for evaluation and further treatment on 5/23/22. Findings: A review of Resident 1's admission Record, printed on 8/16/23, indicated resident was admitted to the facility in January 1999 with diagnoses of dementia (memory loss), schizophrenia (a chronic brain disorder that affects a person ' s ability to think, feel, and behave), and cardiac arrythmia. A review of Resident 1's Order Summary Report, dated 5/23/22, indicated an order with a start date of 1/24/2020, Quinidine Gluconate 324 milligram (mg) tab give 324 mg orally five times a day related to cardiac dysrhythmia (irregular heartbeat). During a concurrent interview and record review on 8/16/23, at 1 p.m., with the Director of Nursing (DON), Resident 1 ' s May 2022 Medication Administration Record (MAR) was reviewed. The DON confirmed Resident 1 did not receive Quinidine on the following dates: 5/21/22, at 10 a.m. and 2 p.m., 5/22/22, at 6 a.m., 10 a.m., and 2 p.m., and on 5 /23/22, at 6 a.m. The DON stated the MAR had no checkmarks on the said dates, instead was coded a 9, which meant the medication ran out and was ordered from the pharmacy. The DON stated the risk of Resident 1 not receiving his Quinidine put the resident ' s heart at risk of not functioning properly. The DON further stated licensed nurses are expected to notify the physician anytime medication doses were missed. A review of Resident 1 ' s Progress Notes, printed 8/16/23, dated 5/23/22, at 1 p.m., documentation by Assistant Director of Nursing (ADON) indicated, Resident was noted to have missed several Quinidine doses .MD was notified regarding the missed doses and ordered to give the medication once it arrives. Cardiology clinic was also notified, and Physician Assistant (PA) stated that resident received a total of 10 shocks to his defibrillator since May 21, 2022. The Progress Notes further indicated PA ordered resident sent out to acute hospital via 911 for evaluation and further treatment. A review of the facility's policy and procedure titled, Medication Error and Reporting, undated, indicated, To establish standards and processes that promote accuracy in the dispensing, administration and monitoring of medications and in the identification and elimination of causes of errors .Medication errors are defined as any failure to give medications as prescribed, or to give any medication without a prescription .When a medication error is discovered: Notify: The Administrator, Director of Nursing or designee, immediately .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure an environment free of hazards for one of two (Resident 1) sampled residents when spray bottles of cleaning solution on a cleaning cart were not locked in the cart. This failure resulted in Resident 1 orally ingesting the cleaning solution and had the potential to result in chemical burns to Resident 1 ' s mouth, throat, stomach and skin. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted on [DATE] for Huntington ' s Disease (a disease causing progressive loss of motor and cognitive function) and dementia (a disease causing progressive loss of cognitive function). A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool to guide resident care), dated 8/24/22, indicated Resident 1 was cognitively impaired, was not able to make safe decisions and could not verbally communicate. The MDS indicated Resident 1 was ambulatory and did not have impairments to both upper extremities. During a concurrent interview and video recording review, on 11/29/22, at 10:32 a.m., with the Administrator (ADM) and Director of Nursing (DON), two video recordings, dated 11/28/22, less than one minute in length were reviewed. Both videos showed, at 5:23 a.m., Resident 1, Environmental Service worker (EVS 1) and a cleaning cart were in a facility hallway. Resident 1 and EVS 1 were on opposing sides of the cleaning cart; on Resident 1 ' s side of the cleaning cart two spray bottles of cleaning solution hung off the top of the cart. The video showed EVS 1 faced away from the cleaning cart and Resident 1. Resident 1 faced the cleaning cart and began to unscrew one of the spray bottles. The video showed, at 5:24 a.m., Resident 1 removed the top of the spray bottle, placed the bottle to his mouth and began to tip the bottle up. At this moment, EVS 1 turned around and saw Resident 1 with the bottle to his mouth. EVS 1 quickly took the bottle away from Resident 1 as the bottle was being tipped up. The cleaning solution was observed in the bottle flowing towards Resident 1 ' s mouth, and the bottle was taken away just as the solution appeared to exit the bottle. The video showed cleaning solution splashing out of the bottle and over the face of Resident 1; EVS 1 took possession of both spray bottles and placed them into a compartment in the cleaning cart, while Resident 1 remained standing in the same position. DON stated Resident 1 may have ingested some cleaning solution before EVS 1 could take away the bottle. ADM stated the bottle of cleaning solution Resident 1 picked up was later identified as AF79. A review of Material Safety Data Sheet (MSDS) for AF79, dated 3/26/2004, indicated AF79 can cause burns to mouth, throat and stomach if ingested. The MSDS further indicates skin contact can also cause burns. During a phone interview on 12/2/22, at 10:05 a.m., with EVS 1, EVS 1 stated on 11/28/22, at approximately 5:20 a.m., she performed her normal cleaning routine which included changing the trash bags. EVS 1 stated she observed Resident 1 near her cleaning cart. EVS 1 stated she turned around, away from Resident 1, to change a trash bag in a trash container. She then turned back around and observed Resident 1 trying to drink out of a bottle of cleaning solution left unattended on the cleaning cart. EVS 1 stated the two bottles of cleaning solutions should have been locked away in the cleaning cart when she was changing the trash bag. During an interview on 11/29/22, at 10:55 a.m., with Behavioral Specialist (BS 1), BS 1 stated on 11/28/22, at around 5:25 a.m., EVS 1 informed him that Resident 1 had attempted to drink out of a bottle with cleaning solution. BS 1 stated he observed Resident 1 spit a foamy, white spit on the floor and cough, and he notified Licensed Vocational Nurse (LVN 1). BS 1 stated EVS 1 should have kept the two bottles of cleaning solutions away from Resident 1 by locking it in a compartment in the cleaning cart. During an interview on 11/29/22, at 12:20 p.m., with Facilities Manager (FM), FM stated housekeeping staff were required to keep all cleaning solutions locked in the cart if not in use. FM stated all housekeeping staff should lock away cleaning solutions when not in use to prevent accidents. A review of facility policy and procedure (P&P) titled, Hazardous Materials and Waste Management Plan, undated, indicated, chemicals for general cleaning if not in use, will be locked in housekeeping carts or storage area.