Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were properly stored for 1 (Resident #31) of 6 residents observed for medication administration. Findings included: A facility policy titled, Storage of Medication, dated 01/2024, indicated, The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. An admission Record revealed the facility admitted Resident #31 on 09/29/2017. According to the admission Record, the resident had a medical history that included diagnoses of essential hypertension and hemiplegia and hemiparesis following cerebral infarction. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. During medication administration observation on 01/28/2025 at 8:35 AM, Licensed Vocational Nurse (LVN) #2 left medication that belonged to Resident #31 in a medication cup on top of an unattended medication cart when she left the unit to find another nurse. On 01/28/2025 at 8:46 AM, LVN #2 stated Resident #31 medications were left in a cup unsecured on top of the medication cart and confirmed she walked away, and the medication cart was out of her sight. On 01/29/2025 at 10:04 AM, the Director of Staff Development stated medications should be secured and under the supervision of a licensed personnel. On 01/29/2025 at 1:48 PM, the Director of Nursing (DON) stated the nurses must not leave medications unattended. Per the DON, nurses must ensure medications were locked and secured when they stepped away from the medication cart. On 01/30/2025 at 9:22 AM, the Executive Director stated the expectation was for nurses not to leave medication unsecured.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene and wore gloves during eye drop administration for 1 (Resident #35) of 6 residents observed for medication administration. Findings included: A facility policy titled, Infection Prevention & Control Program, revised 01/2024, indicated, Treat all human blood, bodily fluids and other potentially infectious materials as if they are infections. SP [standard precautions] include but are not limited to hand hygiene; use of gloves, gowns, masks, eye protection or face shields when contact with any blood or moist body fluids (secretions and excretions) is likely, room placement; injection and medication safety practices, respiratory hygiene/cough etiquette; environmental cleaning and disinfection; and safe management of textiles and laundry. A policy titled, Medication Administration Eye Drops, dated 01/2023, indicated, Policy To administer ophthalmic solution into eye in a safe and accurate manner. The policy specified, 8. With a gloved finger, gently pull down lower eyelid to form pouch, while instructing resident to look up. An admission Record revealed the facility admitted Resident #35 on 11/17/2023. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease with late onset, unspecified visual loss, and bilateral, severe primary open-angle glaucoma. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2025, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Resident #35's care plan included a focus area initiated 11/18/2023, that indicated the resident had impaired visual function related to glaucoma and visual loss. Interventions directed staff to administer medication as ordered. Resident #35's Order Summary Report which contained active orders as of 01/28/2025, revealed an order dated 11/18/2023, for timolol maleate ophthalmic solution 0.5 %, instill one drop in both eyes one time a day for glaucoma. During medication administration observation on 01/28/2025 at 8:27 AM, Licensed Vocational Nurse (LVN) #2 instilled one drop of timolol maleate ophthalmic solution in each of Resident #35's eyes. On 01/28/2025 at 8:29 AM, LVN #2 stated she did not wash or sanitize her hands and did not wear gloves when she administered eye drops to Resident #35. LVN #2 stated gloves should be worn during eye drop administration to help prevent infections. On 01/29/2025 at 10:04 AM, the Director of Staff Development stated nurses were expected to follow the facility infection control policy, to include handwashing and glove use during administration of eye drops. On 01/29/2025 at 1:48 PM, the Director of Nursing (DON) stated nurses were expected to complete hand hygiene prior to and after care. The DON stated nurses must wear gloves during eye drop administration due to the potential contact with mucous membrane. On 01/30/2025 at 9:22 AM, the Executive Director stated the expectation was for the facility nurses to wear gloves and wash their hands when it was required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure prompt efforts were made to resolve a grievance for one of two residents (Resident 1). For Resident 1 the facility did not acknowledge the receipt of or actively work toward a resolution of Resident 1's complaint/grievance. This failure had the potential to adversely affect Resident 1's health, safety, welfare, and rights. Review of Resident 1's face sheet (a single page document containing essential information, e.g. contact details) indicated she was admitted to the facility on [DATE] and had a diagnosis of fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/20/23 indicated Resident 1 was cognitively intact. Review of Resident 1's care plan (document summarizing a person's health conditions, specific care needs and current treatments), dated 5/1/2020, indicated she preferred to use messages distributed by electronic means (email, messages distributed by electronic means from one computer user to one or more recipients via a network) to communicate her concerns and grievances to interdisciplinary team members (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), to specific departments and to Cc: Executive Director and Social Service. Further review of the care plan indicated the intervention was to respond to resident emails with resolutions of her concerns and grievances. During an interview on 7/20/23 at 10:27 a.m., with the social service director (SSD), SSD stated it was her responsibility to respond to resident concerns and grievances. SSD further stated Resident 1 had repeated complaints about staff entering her room. During a concurrent interview and record review on 7/20/23 at 11:24 a.m., with the SSD, an email sent by Resident 1 to IDT members, dated 7/10/23 at 1:59 p.m. was reviewed. The email indicated, at 12:05 p.m. today, a black female unknown to me, wearing civilian clothes, not wearing any identification badge, suddenly appeared at my bedside, and began asking me questions about what kind of insurance I had and if I wanted to buy some kind of insurance. The SSD stated she did not read the email clearly and she got busy the next day. SSD further stated she should have followed up and she missed it. Review of the social service director job description, last updated 5/2021, indicated reviews Skilled Nursing .complaints and grievances; makes necessary oral/written reports to the Administrator. Review of the facility policy dated 2/2020 Resident Grievance Policy indicated . will acknowledge receipt of the grievance within two business days and will research the issue and respond to the resident within five business days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS, a comprehensive assessment tool) when one of 15 sampled residents (Resident 35) experienced declines in multiple areas of health status. Failure to comprehensively assess the resident had the potential to compromise the facility's ability to develop and implement resident-centered care plan interventions. Findings: During observations on 2/21/23 at 11:13 a.m., 2/22/23 at 1:30 p.m. and 2/23/23 at 8:46 a.m., Resident 35 was lying in bed. She appeared weak, did not move much while in bed, and was minimally verbal. During a lunch observation on 2/24/23 at 1:08 p.m., Resident 35 was lying in bed with her caregiver at bedside. The caregiver was attempting to feed Resident 35, but the resident would only accept liquids and small bites of mashed banana. When the caregiver tried to offer other foods from the lunch tray, Resident 35 said, No. Review of Resident 35's medical record indicated she was admitted on [DATE] and had the diagnoses of dementia (mental disorder caused by brain disease or injury), spinal stenosis (narrowing of the spinal canal) osteoporosis (condition that causes bones to become brittle and fragile) and scoliosis (abnormal curvature of the spine). The medical record also indicated Resident 35 had the diagnosis of Coronavirus Disease 2019 (COVID-19, a contagious viral infection that can cause severe respiratory symptoms) starting on 11/28/22. Review of Resident 35's Change in Condition Evaluation, dated 12/7/22, indicated she had a deep tissue injury (DTI, a type of pressure ulcer [damage to the skin an underlying tissues due to prolonged pressure]) on her mid-back. Review of Resident 35's Change in Condition Evaluation, dated 12/29/22, indicated she had a functional decline. The evaluation indicated Resident 35 was not taking food, fluids or medications. She also had general weakness, difficulty swallowing, decreased mobility (ability to move), and was not verbally responsive. Review of Resident 35's Weights and Vitals Summary indicated she lost 17 pounds from 12/2/22 to 2/14/23. During an interview with the director of nursing (DON) on 2/24/23 at 10:29 a.m., she confirmed Resident 35 had declined in multiple areas of health status. The DON stated these declines began shortly after she contracted COVID-19 in November of 2022. Further review of Resident 35's medical record indicated the facility did not complete a significant change in status MDS to address the above declines in the resident's health status. During an interview with the Minimum Data Set Coordinator (MDSC) on 2/24/23 at 10:44 a.m., she reviewed Resident 35's medical record and confirmed the facility did not complete a significant change in status MDS. The MDSC confirmed Resident 35 declined in multiple areas of health status and acknowledged a significant change in status MDS should have been completed. Review of the Centers for Medicare & Medicaid Services 2019 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI manual, MDS instructions) indicated, The SCSA [significant change in status assessment] is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. The RAI manual indicated a significant change is a major decline in a resident's status that would not normally resolve without intervention, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 60) had hearing aids on while awake for optimal hearing abilities. This failure had the potential to result in ineffective and insufficient communication between Resident 60 and caregivers, and could have negatively affected the resident's psychosocial well-being. Findings: During a concurrent observation and interview, on 2/21/23, at 11:45 a.m., in Resident 60's room, Resident 60 was observed lying in the bed awake without his hearing aids on. The hearing aids were on the nightstand behind his bed. The surveyor asked Resident 60 the same question three times and the resident was not able to answer. He pointed to his ears, stated he could not hear and that he needed the hearing aids. During an interview on 2/21/23, at 12:00 p.m., with registered nurse A (RN A), he stated usually Resident 60's wife came before lunch time, and she put the hearing aids on. During an observation on 2/22/23, at 11:40 a.m., in Resident 60's room, Resident 60 was observed again lying in his bed awake without the hearing aids on. A review of Resident 60's Face Sheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history) indicated the resident was admitted to the facility on [DATE], with the diagnoses of osteomyelitis (an infection of the bone) of lumbar spine and need for assistance with personal care. A review of Resident 60's Minimum Data Set (MDS, a resident clinical assessment), dated 1/16/23, indicated the resident's Brief Interview for Mental Status (BIMS, a brief cognitive screening tool) score was 13, which indicated Resident 60 was cognitively intact. It also indicated Resident 60 had moderate hearing difficulty and required extensive assistance (weight-bearing support) with activities of daily living (ADLs), except eating. A review of Resident 60's care plan (CP, provides direction on the type of nursing care the resident may need), initiated on 1/11/23, indicated, Ensure hearing aid(s) (left and right) is in place and functioning. During a concurrent interview and record review on 2/22/23, at 12:11 p.m., with the social services manager (SSM), the SSM reviewed Resident 60's physician orders and confirmed there was no order for Resident 60's hearing aids applying and removal schedule. The SSM further stated there should have been an order. During an interview on 2/22/23, at 12:38 p.m., with the director of staff development (DSD), he stated residents with hearing aid should always have a schedule order that indicated when to put on and when to remove the hearing aids. During an interview on 2/22/23, at 12:45 p.m., with the director of nursing (DON), she stated the licensed nurse was responsible to put on and remove the hearing aids. The DON stated the staff who received the hearing aids should have put in an applying/removal schedule order. During a concurrent observation and interview on 2/22/23, at 1:37 p.m., in Resident 60's room with his wife, Resident 60 was observed eating lunch, the resident's wife had to repeat herself several times when talking to him because he did not have his hearing aids on. His wife stated she did not usually put the hearing aids on, she was hoping the facility staff could put them on every morning after breakfast, then put them away to charge at bedtime. She further stated the resident was upset because he could not hear well without the hearing aids. A review of the facility's policy and procedure, titled, Policy of Hearing Aid, undated, indicated, 1. Nursing will ask physician order in administering hearing aid. 2. Nursing will be the responsible in keeping the hearing aid. CNA (Certified Nursing Assistant) will collect the hearing aid at bedtime and give to LN (Licensed Nurse) for safekeeping, nursing AM shift (7 a.m. to 3 p.m.) will administer hearing aid after ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure necessary services were provided to promote healing of a pressure ulcer (damage to the skin and underlying tissues due to prolonged pressure) for one of two sampled residents (Resident 35) when: 1. There were 8 days for which there was no documentation that Resident 35's pressure ulcer was treated; and 2. Resident 35's pressure ulcer assessment was incomplete. These failures had the potential to result in worsening of Resident 35's pressure ulcer. Findings: Review of Resident 35's medical record indicated she was admitted on [DATE] and had the diagnoses of dementia (mental disorder caused by brain disease or injury), spinal stenosis (narrowing of the spinal canal) osteoporosis (condition that causes bones to become brittle and fragile) and scoliosis (abnormal curvature of the spine). Review of Resident 35's 6/2022 treatment administration record (TAR) indicated she had a stage 3 pressure ulcer (full-thickness tissue loss) on her mid-back. The TAR indicated Resident 35 received daily pressure ulcer treatments from 6/10/22 to 6/14/22. There was no documentation that Resident 35 received any pressure ulcer treatments from 6/15/22 to 6/22/22. Further review of the TAR indicated Resident 35 started receiving daily pressure ulcer treatments again on 6/23/22. Review of Resident 35's Skin Only Evaluation, dated 6/14/22, indicated Resident 35's mid-back stage 3 pressure ulcer was still not healed. According to the evaluation, the pressure ulcer was 1.5 by 1.5 centimeters (cm, unit of measurement) in size and had a depth of 0.2 cm. The evaluation also indicated the wound had slough (substance consisting of blood cells, bacteria, dead tissue and other material) and serosanguineous (pink watery fluid) drainage. Review of Resident 35's Skin Only Evaluation, dated 6/23/22, indicated her mid-back pressure ulcer improved (despite the absence of treatment documentation from 6/15/22 to 6/22/22). The evaluation no longer indicated the presence of slough or drainage, and the wound had granulating tissue (healing surface of a wound). However, the section of the Skin Only Evaluation designated for wound measurements was left blank. During an interview and concurrent record review with licensed vocational nurse I (LVN I) on 2/24/23 at 8:23 a.m., she reviewed Resident 35's's medical record and confirmed there was no documentation that her pressure ulcer was treated from 6/15/22 to 6/22/22. LVN I acknowledged that Resident 35's pressure ulcer was still not healed during that time frame. LVN I also reviewed Resident 35's Skin Only Evaluation, dated 6/23/22, and confirmed it was incomplete because the section for wound measurements was left blank. During an interview and concurrent record review with the director of nursing (DON) on 2/24/23 at 10:29 a.m., she Reviewed Resident 35's medical record and confirmed there was no documentation of pressure ulcer treatments from 6/15/22 to 6/22/22. She stated that after the treatment order ended on 6/14/22, the nurse did not put a new treatment order into the computer system. The DON also reviewed Resident 35's Skin Only Evaluation, dated 6/23/22, and confirmed it was incomplete because the section for wound measurements was left blank. Review of the facility's policy titled Skin Integrity & Management, revised 8/2022 indicated, The skilled nursing facility (SNF) must ensure that .a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.The policy further indicated pressure ulcers will be monitored at least weekly, and assessments should include size and depth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 4's medical record indicated she was admitted on [DATE] and had the diagnoses of dementia, bipolar disorder, and history of falling. Review of Resident 4's fall risk care plan, dated 1/16/19, indicated to encourage Resident 4 to use her call light for assistance and to ensure she was wearing appropriate footwear when walking with her walker. Review of Resident 4's Change in Condition Evaluation, dated 2/11/23, indicated she had a fall. There were no interventions documented on the Change in Condition Evaluation to prevent Resident 4 from falling again. Review of Resident 4's actual fall care plan, dated 2/12/23, indicated to encourage Resident 4 to use her call light for assistance and to make sure she wears non-skid shoes when walking (interventions that were already on Resident 4's 1/16/19 fall risk care plan). Review of Resident 4's Post Event Review, dated 2/13/23, indicated she had a fall on 2/12/23 (incorrectly dated, as the fall occurred on 2/11/23). There were no interventions documented on the Post Event Review to prevent Resident 4 from falling again. During an interview and concurrent record review with the DON on 2/24/23 at 10:00 a.m., she stated when a resident falls, the interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) should develop and implement new interventions to prevent future falls. The DON reviewed Resident 4's medical record and confirmed that after the fall on 2/11/23, the IDT did not develop and implement any new interventions to prevent Resident 4 from falling again. Review of the facility's policy titled Fall Prevention and Management Program, revised 12/2022, indicated, The nursing function in a fall prevention program includes, but is not limited to .Being able to identify causative factors should a fall occur, and then accelerate the care plan with new interventions to prevent future falls. Based on observation, interview, and record review, the facility failed to follow their fall management program for two of four residents (Residents 56 and 4) when: 1. Fall interventions were not implemented for Resident 56; and 2. No new interventions were developed and implemented after Resident 4 fell. These failures had the potential to result in further falls and/or injury to the residents. Findings: 1. Review of Resident 56's record indicated she was admitted to the facility with diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 56's IDT Post Event Review, dated 12/22/22, indicated she had a fall on 12/22/22. Review of Resident 56's fall care plan indicated an intervention, initiated on 12/29/22, The resident uses silent alarm. Check for placement and functioning Q [every] shift. Review of Resident 56's IDT Post Event Review, dated 1/9/23 indicated she had a fall on 1/9/23. Review of Resident 56's fall care plan indicated an intervention, initiated on 1/10/23, Floor mat on both side[s] of the bed. During an observation on 2/23/23 at 8:49 a.m., Resident 56 did not have a fall mat on one side of her bed. One fall mat was folded and placed behind the head of her bed. During an observation on 2/23/23 at 1:13 p.m., Resident 56 did not have a fall mat on one side of her bed. One fall mat was folded on floor at foot of her bed. During an observation on 2/24/23 at 8:20 a.m., Resident 56 did not have a fall mat on one side of her bed. During an observation on 2/24/23 at 10:52 a.m., Resident 56 did not have a fall mat on one side of her bed. The fall mat was folded on floor at foot of her bed. During a concurrent observation and interview on 2/24/23 at 11:28 a.m., the director of nursing (DON) confirmed Resident 56 did not have a fall mat on one side of her bed and stated it was supposed to be there while she was in bed. The DON also confirmed there was no silent alarm on Resident 56's bed. During an interview on 2/24/23 at 1:34 p.m., the director of medical records (DMR) stated she was not able to find any documentation that indicated staff checked the placement and function of Resident 56's silent alarm. Review of the facility's policy, Falls Prevention and Management Program, last revised 12/2022, indicated the nursing function in a fall prevention program includes providing timely intervention to minimize risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive policy for enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) services, when there was no policy that indicated a consistent method that a licensed nurse should use for bolus feeding (the administration of a limited volume of enteral formula over brief periods of time). This failure had the potential to result in inconsistency of care and complications related to the G-tube and cause harm to the resident. Findings: A review of Resident 22's face sheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history), indicated the resident was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dysphagia (swallowing difficulties). A review of Resident 22's hospital Discharge summary, dated [DATE], indicated Resident 22 was admitted to the hospital on [DATE] for aspiration pneumonia (inflammation [swelling] and infection of the lungs or large airways that occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed). A review of Resident 22's physician orders indicated, Diet: NPO (nothing by mouth), Enteral Feed: three times a day Enteral Feed Via Bolus Jevity [a nutritional formula] 1.5 @ 3 cans /day via PEG tube (G-tube) to provide 711/1067 kcal [kilocalorie, a unit of energy], 45 g pro[tein], 540 ml (milliliter, unit of measurement) free water. Give 1 can @ 8 AM 1 can @ 2 PM 1 can @ 6 PM. Enteral Feed: three times a day Flush with 30 ml H2O (water) before and after bolus feeding. During a concurrent interview and record review on 2/24/23, at 9:23 a.m., with registered nurse H (RN H), she was asked if the surveyor could observe her administering bolus feeding to Resident 22 when it was due. RN H informed the surveyor that she was a temporary agency staff, and this was her first time working in the facility. She stated she did not know Resident 22 was on bolus feeding. After reviewing Resident 22's electronic medication administration records (EMAR) and treatment administration records (TAR), RN H informed the surveyor that the tube feeding order was in the TAR, so she was not sure if she should administer it. RN H had to verify with the facility's treatment nurse, because usually the treatment nurse would take care of the orders in TAR. During an interview on 2/24/23, at 9:57 a.m., with RN H, she stated she would be the one to administer the bolus feeding, and she would do it right now for the 8:00 a.m. feeding. During the bolus feeding observation on 2/24/23, at 10:00 a.m., in Resident 22's room, RN H was observed. After checking stomach residual, RN H poured Jevity formula into cups, withdrew it into a 60 mL syringe, attached the syringe to the resident's G-tube, and administered the formula by pushing the syringe plunger to empty the contents into the G-tube without flushing the G-tube before the bolus feeding. RN H administered three syringes for a total of 180 mL of formula by pushing the plunger, then flushed the G-tube with 30 mL warm water by pushing the plunger. During an interview on 2/24/23, at 10:15 a.m., with RN H, when asked what the facility's standards of practice for G-tube bolus feeding method was, she stated she did not receive this training from the facility, but if the order said administer by gravity, she would do so. Since Resident 22's bolus feeding order did not say administer by gravity, she used the push method. RN H confirmed she should have flushed the resident's G-tube with 30 mL of water before administering the bolus feeding. During an interview on 2/24/23, at 10:55 a.m., with the director of nursing (DON), she stated she was not able to find a policy that indicated the method for administering formula via G-tube, but the facility's standards of practice for bolus feeding should be by gravity. The DON confirmed RN H should not have used the push method to administer bolus feeding. The DON further stated RN H should have flushed the G-tube with 30 mL water before the feeding. A review of American society for Parenteral and Enteral Nutrition (ASPEN) Consensus Recommendation, titled, ASPEN Safe Practices for Enteral Nutrition Therapy, dated January 2017, indicated, 1. Develop policy and procedure documents for evidence-based practices to standardize the approach to and the administration of EN in all patient populations. 2. Maintain competency as defined within the organization to maximize safety of the patient for all caregivers involved in the administration of EN. [ .] 4. Initiate and update protocols periodically based on best evidence, including national guidelines and recommendations to meet the needs of the specific patient populations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for when: 1. A random controlled medication use audit for two out of three residents (Residents 20 and 39) showed that medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications), but were not documented as given to the residents on the medication administration record (MAR); and 2. Expired and discontinued controlled drugs were not removed from the medication cart. These failures had the potential to result in loss, misuse, and/or diversion of controlled medications. Findings: 1. The Controlled Drug Records (CDRs) for three (3) random residents receiving PRN (meaning as needed) controlled medications were requested for review during the survey. During a concurrent interview and record review with the director of nursing (DON) on [DATE] at 1:56 p.m., she stated any time a controlled medication was needed for a resident, the nurse would remove the medication from the medication cart, sign it out on the CDR (or the count sheet) to indicate it was removed, and document the administration on the MAR. a. Resident 20 had a physician's order, dated [DATE], for tramadol (a controlled medication for pain) oral tablet 50 milligrams (mg, unit of measurement), to give 25 mg by mouth every 8 hours as needed for pain. On [DATE] at 1:56 p.m., a review of Resident 20's CDR for tramadol 50 mg and the [DATE], [DATE], and February 2023 MAR with the DON indicated nursing staff signed out one (1) tablet on [DATE] at 3:00 p.m., [DATE] at 9:00 a.m., and on [DATE] at 12:30 p.m., but did not document on the MARs to show they were administered to the resident. The DON verified three missing documentations on the MAR to account for the tramadol tablets. b. Resident 39 had a physician's order, dated [DATE], for oxycodone (a potent controlled medication for moderate to severe pain) 5 mg, 1 tablet by mouth every 6 hours as needed for pain. During a concurrent interview and record review with the DON on [DATE] at 2:06 p.m., a review of Resident 39's CDR for oxycodone and the February 2023 MAR reflected the nursing staff signed out of the CDR but did not document the respective administration on the MAR on [DATE] at 2:58 p.m. The DON verified this finding and acknowledged one (1) oxycodone tablet was not accounted for. During a review of facility's policy and procedure titled Administering Medication, dated [DATE], it indicated, The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 2. During an inspection of the fourth floor medication cart with licensed vocational nurse D (LVN D) on [DATE], at 12:24 p.m., three expired and discontinued medications were identified in the locked compartment of the medication cart, as follows: a. A bubble pack of containing 4 tablets and another bubble pack containing 4 half-tablets of lorazepam (a controlled medication for anxiety) 1 mg for a resident who was discharged on [DATE] (2 weeks ago). b. A bubble pack containing 55 tablets of oxycodone 5 mg tablet, that had an expiration date of 10/2022 (four months ago). During an interview on [DATE] at 12:24 p.m., with LVN D, she stated she did not know how long the controlled medications were in the cart as it was her first day working in the facility. During an interview with the DON on [DATE] at 3:10 p.m., she stated the night shift nurse was supposed to give expired and discontinued controlled medications to her right way. The DON verified the above bubble packs should have been removed from the medication cart to prevent loss or medication errors. During a review of the facility's policy and procedure titled Discontinued Medications, dated 10/2007, it indicated, If a prescriber discontinues a medication, the medication container is removed from the medication cart immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Residents 27) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors). Resident 27 received Abilify (an antipsychotic medication) when there were no specific target behaviors (behaviors intended to be reduced or eliminated by the medication) monitored. There was also no indication that Resident 27's behaviors presented a danger to herself or others, or caused significant distress to the resident. This failure put the resident at risk for experiencing adverse effects from unnecessary psychotropic medications such as dry mouth, blurred vision, urinary retention, constipation, heat intolerance, and tachycardia (abnormally rapid heart rate). Findings: A review of Resident 27's medical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (intense and persistent worry and fear), and major depressive disorder (condition that causes persistent feelings of sadness or loss of interest) A review of Resident 27's Minimum Data Set (MDS, an assessment tool), dated 1/5/22, indicated she had a brief interview for mental status (BIMS) score of 8 (a score of 8 to 12 indicates moderate cognitive impairment). The MDS indicated Resident 27 had no hallucinations (perceiving things that are not present), no delusions (false beliefs or judgements despite evidence to the contrary) and did not exhibit behaviors during the assessment period. Review of Resident 27's MDS, dated [DATE], indicated she had no hallucinations, no delusions, and did not exbibit behaviors during the assessment period. Review of Resident 's 27 medical record indicated she had been receiving Abilify in various doses since 1/7/19. Her current physician's order, dated 12/16/20, indicated Abilify 5 milligrams (mg, unit of dose measurement) 1 tablet by mouth at bedtime for unspecified Dementia with behavioral disturbance, visual hallucination. Review of Resident 27's care plan for psychotropic drug use, dated 4/12/19, indicated she was at risk for behavioral disturbances related to her diagnoses of Alzheimer's Disease and dementia manifested by visual hallucinations. The care plan further indicated, Pt [patient] on Abilify med per MD order. During an observation on 2/22/23 at 3:52 p.m., Resident 27 was sitting on her wheelchair with other residents near the facility elevator. She was very quiet and pleasant. During an interview with Licensed Vocational Nurse E (LVN E) on 2/22/23 at 3:52 p.m., she stated Resident 27 had no behaviors. LVN E stated Resident 27 had confusion when she had a urinary tract infection (UTI), but it had been a month since her last UTI. LVN E further stated Resident 27 was nice, very compliant with medications, quiet, did not yell or scream, and did not have any hallucinations. During an interview with LVN J on 2/23/23 at 10:42 a.m., LVN J stated Resident 27 was confused sometimes but a very lovely person, pleasant, and quiet most of the time. LVN J stated Resident 27 was did not have any hallucinations that she was aware of. During an interview with Certified Nurse Assistant F (CNA F) on 2/23/23 at 10:49 a.m., she stated Resident 27 was quiet and always wanted to go to her bed. CNA F stated Resident 27 had no hallucination, only confusion. CNA F explained Resident 27 would look for her son or ask why he was not there. At times she would say she was late for her job. CNA F further stated Resident 27 was very passive, complaint with care most of the time, and had no behaviors. During an interview and concurrent record review with the director of nursing (DON) on 2/23/23 at 1:19 p.m., she stated Resident 27 was usually calm. She reviewed Resident 27's medical record and could not find evidence of visual hallucination episodes, such as what she actually saw, and how it caused a danger to herself/others or caused her significant distress. The DON confirmed staff were not tallying the behaviors. The DON acknowledged that the target behavior of visual hallucinations was not specific enough (such as seeing people who are not there) and did not demonstrate a danger or significant distress to the resident. A review of the behavior monitoring documented on the monthly medication administration records for December 2022 to March 2023 indicated Resident 27 had zero (0) episodes of visual hallucinations. During a telephone interview with Resident 27's Family Member 1 (FM 1) on 2/23/23 at 3:24 p.m., FM 1 stated Resident 27 did not have any hallucinations, just confusion and depression. FM 1 stated Resident was more confused whenever she had a UTI. During an observation and concurrent interview with Resident 27 on 2/24/23 at 11:25 a.m., Resident 27 was sitting on her wheelchair outside of her room. She was pleasant and quiet. When asked if she had been having any hallucinations, Resident 27 stated, Nope. During an interview and concurrent record review with the DON on 2/24/23 at 1:02 p.m., she reviewed Resident 27's medical record and stated she could not find documentation regarding how visual hallucinations caused danger or distress to the resident. A review of the facility's policy and procedure titled Psychotropic Drug, revised 10/13/11, indicated, Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of ten sampled residents (Resident 24) was free from significant medication errors when she received six doses of expired Insulin Lispro (fast-acting insulin, medication to lower blood sugar level). This deficient practice had the potential for the resident to receive ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident. Findings: During an observation on [DATE] at 11:31 a.m., at Resident 24's bedside, licensed vocational nurse B (LVN B) was observed pricking Resident 24's left forefinger to obtain a blood sample to measure her blood sugar (BS) level. The BS reading was 402 milligrams/deciLiter (mg/dL, unit of measurement; normal BS is less than 100 mg/dL) at that time. LVN B stated she would come back with some insulin. During a concurrent observation and interview on [DATE], at 11:40 a.m., LVN B withdrew 11 units of insulin lispro 100 units/1 milliliter (unit of dose measurement) into a syringe from the insulin lispro vial. After drawing up the insulin, she showed the surveyor the insulin vial. The sticker label on the Insulin lispro vial indicated it was opened on [DATE]. The sticker label indicated to discard the insulin lispro 28 days after opening. LVN B carried the syringe into Resident 24's room. As LVN B was about to inject the insulin into Resident 24's abdomen, the surveyor asked LVN B to leave the room before proceeding with the injection. On [DATE] at 11:45 a.m., at the medication cart, LVN B reviewed the lispro vial and verified it was opened on [DATE], and the sticker on the label indicated to discard after 28 days. Using the calendar on her phone, LVN B verified the insulin lispro vial would have expired on [DATE], or 28 days after opening. She stated, It's past expiration date by a few days already. LVN B confirmed the insulin syringe she just prepared was no longer usable as it already expired and went to the medication refrigerator to obtain a new vial of insulin lispro. On [DATE] at 11:55 a.m., LVN B returned and said she could not find another vial and had to get it from the emergency kit. LVN B would have given the expired insulin lispro to Resident 24 had the surveyor not intervened. During an interview and concurrent record review with LVN B on [DATE], at 12:18 p.m., LVN B reviewed Resident 24's medication administration record (MAR) and stated nursing staff administered the expired insulin lispro to Resident 24 six times since [DATE] (after the expiration date). On [DATE], a review of Resident 24's clinical record indicated a physician's order, dated [DATE], for Insulin Lispro, inject as per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings) if 0-200=0 units . 400+ = 11 units Call MD, recheck BS in 30 minutes., subcutaneously before meals for diabetes. A review of Resident 24's February 2023 MAR indicated the insulin lispro was administered 6 times past the expiration date: two times on [DATE], two times on [DATE], and two times on [DATE]. During an interview with the director of nursing (DON) on [DATE] at 12:33 p.m., she stated the nursing staff was supposed to check the expiration date before giving medications. During a review of the facility's policy and procedure titled Administering Medications, revised dated [DATE], indicated The expiration date on the medication label must be checked prior to administering. When opening a multi dose container, the date shall be recorded on the container. According to the Consumermedsafety.org (a nationally recognized medication safety organization), it indicated, OPEN vials can be stored in the fridge or at CONTROLLED room temperature. Regardless of where it is stored, OPEN insulin will only last 28 days before it must be thrown away . Never use insulin if expired. The expiration date will be stamped on the vial or pen. Remember if not in the fridge, the date on the vial or pen does not apply. You must throw away after 28 days since outside the fridge. (https://www.consumermedsafety.org/insulin-safety-center/insulin-basics/storage-of-insulin#; accessed on [DATE]).

Based on interview and record review, the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) for August of 2022. This deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: Review of the CMS PBJ (payroll-based journal) Staffing Data Report, dated 7/1/22 to 9/30/22, indicated the facility had no registered nurse (RN) hours from 8/1/22 to 8/31/22. The report also indicated for the same time period, the facility did not have licensed nursing coverage 24 hours a day. During an interview with the director of nursing (DON) on 2/24/23 at 2:42 p.m., she stated the information on the PBJ Staffing Data Report was not accurate. The DON stated the senior director of risk management (SDRM) called the facility and explained that he submitted the wrong direct care staffing information to CMS for the month of August 2022. During an interview with the administrator (ADM) on 2/27/23 at 10:17 a.m., he explained that the SDRM made an error when submitting direct care staffing information and CMS did not receive the information for August of 2022. The ADM provided a copy of an email from the SDRM explaining what happened. Review of the email from the SDRM to the facility, dated 1/31/23, indicated, I looked at the August [file] that was submitted and it has September dates instead of August dates. So the August and September files were the same and no August dates were submitted. During an interview and concurrent record review with the staffing coordinator (SC) on 2/27/23 at 10:38 a.m., she stated the reports indicating the facility did not have RN hours and licensed nursing staffing for August of 2022 were not accurate. The SC presented the staffing binder, which contained documentation that for August of 2022, the facility had RNs in the facility for at least 16 hours each day, and had licensed nurses in the facility 24 hours a day. Review of CMS's Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual Version 2.6, dated June 2022 indicated, Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate.

3. During an observation on 2/21/23, at 9:42 a.m., in Resident 24's room, LVN B was observed taking Resident 24's blood pressure (BP). LVN B did not disinfect the BP apparatus (a cuff that is wrapped around the arm to measure BP) before and after using it. During an interview with LVN B on 2/21/23, at 10:18 a.m., she confirmed she did not disinfect the BP apparatus before and after using it on Resident 24. LVN B stated she was supposed to disinfect it with a disinfectant wipe before and after using it on the resident. During an interview on 2/22/23, at 12:33 p.m., with the DON, she stated the nurse was supposed to disinfect the BP apparatus before and after using it to prevent spreading of infections among residents. A review of the facility's policy and procedure titled Cleaning and Disinfecting of Equipment, revised 5/25/10, indicated, Reusable items are cleaned and disinfected or sterilized between residents. 2. During a bolus tube feeding observation, on 2/24/23, at 10:00 a.m., in Resident 22's room, RN H washed her hands, put on a pair of gloves, checked Resident 22's gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) placement, checked stomach residual, and used the bed control to elevate the head of the resident's bed. Then, RN H removed the gloves and put on a pair of new gloves without performing hand hygiene. During an interview on 2/24/23, at 10:55 a.m., with RN H, she stated she should have washed her hands between changing the gloves. During an interview on 2/24/23, at 1:38 p.m., with the director of nursing (DON), she stated RN H should have washed her hands or utilized the hand sanitizer between changing the gloves. A review of the facility's policy and procedure titled, Hand Washing/Hand Hygiene, retrieved 2/2023, indicated, All employees shall follow hand washing/hand hygiene procedures [ .] use an ABHR [Alcohol-Based Hand Rub], or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations, even if gloves are used: [ .] c. before putting on gloves; [ .] n. immediately after glove removal. Based on observation, interview and record review, the facility failed to implement infection prevention and control practices when: 1. Certified nurse assistant G (CNA G) did not wear a facemask while providing care to Resident 32; 2. Registered nurse H (RN H) did not perform hand hygiene (hand washing or use of alcohol-based hand rub [ABHR]) when changing gloves; and 3. Licensed vocational nurse B (LVN B) did not disinfect medical equipment before and after using it on Resident 24 These failures had the potential to result in transmission and spread of infection in the facility. Findings: 1. During an observation on 2/27/23 at 8:15 a.m., CNA G was in Resident 32's room setting up her breakfast tray. CNA G's facemask was hanging down from her right ear and was not covering her mouth and nose. While unmasked, CNA G was standing right next to Resident 32 and speaking to her while setting up the breakfast tray. Resident 32 was also not wearing a facemask. During an interview with CNA G on 2/27/23 at 8:20 a.m., she confirmed she did not wear her facemask while setting up Resident 32's breakfast tray. CNA G confirmed staff were supposed wear a facemask while providing care to the residents. During an interview with the director of staff development (DSD) on 2/27/23 at 9:48 a.m., he confirmed all staff must wear a facemask while inside the facility, especially when providing care to the residents. Review of the facility's Suspected or Confirmed COVID-19 [Coronavirus Disease 2019, a contagious viral infection that can cause severe respiratory symptoms] Policy, revised 5/2021 indicated, Implement universal use of facemask for HCP [health care personnel] while in the facility.

During an observation on 2/23/23, at 3:18 p.m., Resident 27 had quarter bed rails elevated. During an observation on 2/23/23, at 3:25 p.m., Resident 363 had quarter bed rails elevated. During a concurrent interview and record review on 2/24/23, at 3:16 p.m., with the DON, she was unable to show the bed rail consents for Residents 27 and 363. The DON stated both residents should have had informed consents for the use of bed rails. A review of the facility's policy and procedure, titled, Bed Safety, updated 3/28/17, indicated, [ .] 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. [ .] 9. Before using side rails for any reason, the staff shall inform the resident and representative about the benefits and potential hazards associated with side rails. Based on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident or resident representative and obtain informed consent prior to the use of bed rails for seven of 27 residents (Residents 18, 23, 27, 37, 45, 55, and 363). This failure had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Findings: During the initial tour of the facility conducted on 2/21/23, at 9:30 a.m., Residents 18, 23, 37, 45, and 55, all had quarter bed rails elevated. During a concurrent interview and record review on 2/23/23, at 3:38 p.m., with the director of nursing (DON), when asked to show bed rail consents that indicated the facility reviewed the risks and benefits of bed rails with Residents 18, 23, 37, 45 and 55 or their legal representatives, the DON was unable to show the consents for those five residents. She stated the facility recently started to obtain bed rail consents in January of 2023. The DON explained bed rail consents were usually obtained during care plan conferences, and those five residents' care plan conferences were not due, so there were no bed rail consents for those residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility had a medication error rate of 17.86%, when five medication errors out of 28 opportunities occurred during medication administrations for three of six residents (Residents 11, 24, and 49). These deficient practices resulted in medications not being given in accordance with the prescriber's orders and/or manufacturer's specifications, which could have resulted in the residents not receiving the full therapeutic effects of the medications. Findings: 1. During a medication pass observation on [DATE], at 9:06 a.m., with Registered Nurse A (RN A), he administered six medications to Resident 49, including one tablet of aspirin enteric coated (a pain reliever with a coating that creates a delayed release of the medication, also used to prevent stroke) 81 milligrams (mg, unit of dose measurement). A review of Resident 49's clinical record indicated a physician's order, dated [DATE], for aspirin low dose tablet chewable 81 mg, give 1 tablet by mouth one time a day for stroke prevention. During a concurrent interview and record review on [DATE], at 2:16 p.m., with RN A, he verified the order indicated to give aspirin chewable tablet, but he administered the enteric coated tablet. He confirmed they were not the same. 2. During a medication administration observation on [DATE] at 9:56 a.m., Licensed Vocational Nurse B (LVN B) was observed administering seven oral medications to Resident 24. LVN B stated there was an order for a lidocaine patch due at this time, but she could not locate it in the medication cart. A review of Resident 24's clinical record indicated she had a physician's order, dated [DATE], for Methyl Salicylate-Lido[[NAME]]-Menthol External Patch 4-4-5% [a topical pain medication] apply to tailbone topically one time a day for pain remove after 8 hours X [for] 14 days. Review of Resident 24's medication administration record (MAR) indicated this medication was scheduled to be given at 9:00 a.m. During a concurrent interview and record review on [DATE], at 2:22 p.m., with LVN B, she stated she could not find the patch for Resident 24, she already re-ordered it from the pharmacy, and documented she did not have the medication. A review of Resident 24's February 2023 MAR showed on [DATE], 9 Other/See Progress Notes and had the nurse's initials. Review of the nursing progress notes, dated [DATE] at 10:05 a.m., indicated, Methyl Salicylate lido Menthol External Patch 4-4-5% Not given. Waiting for patches from pharmacy. 3. During an observation on [DATE] at 11:31 a.m., at Resident 24's bedside, LVN B was observed pricking Resident 24's left forefinger to obtain a blood sample to measure her blood sugar (BS) level. The BS reading was 402 milligrams/deciLiter (mg/dL, unit of measurement; normal BS is less than 100 mg/dL) at that time. LVN B stated she would come back with some insulin. During a concurrent observation and interview on [DATE], at 11:40 a.m., LVN B withdrew 11 units of insulin lispro 100 units/1 milliliter (unit of dose measurement) into a syringe from the insulin lispro vial. After drawing up the insulin, she showed the surveyor the insulin vial. The sticker label on the Insulin lispro vial indicated it was opened on [DATE]. The sticker label indicated to discard the insulin lispro 28 days after opening. LVN B carried the syringe into Resident 24's room. As LVN B was about to inject the insulin into Resident 24's abdomen, the surveyor asked LVN B to leave the room before proceeding with the injection. On [DATE] at 11:45 a.m., at the medication cart, LVN B reviewed the lispro vial and verified it was opened on [DATE], and the sticker on the label indicated to discard after 28 days. Using the calendar on her phone, LVN B verified the insulin lispro vial would have expired on [DATE], or 28 days after opening. She stated, It's past expiration date by a few days already. LVN B confirmed the insulin syringe she just prepared was no longer usable as it already expired and went to the medication refrigerator to obtain a new vial of insulin lispro. On [DATE] at 11:55 a.m., LVN B returned and said she could not find another vial and had to get it from the emergency kit. LVN B would have given the expired insulin lispro to Resident 24 had the surveyor not intervened. On [DATE], a review of Resident 24's clinical record indicated a physician's order, dated [DATE], for Insulin Lispro, inject as per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings) if 0-200=0 units . 400+ = 11 units Call MD, recheck BS in 30 minutes., subcutaneously before meals for diabetes. During an interview with the director of nursing (DON) on [DATE] at 12:33 p.m., she stated the nursing staff was supposed to check the expiration date before giving medications. 4a. During a medication administration observation on [DATE], at 9:53 a.m., LVN C was observed administering 4 medications to Resident 11 including a patch of Aspercreme with Lidoderm 4% (topical medication for pain relief). LVN C applied the Aspercreme patch to Resident 11's lower back, then signed, and dated the patch. A review of resident 11's clinical record indicated she had a physician's order, dated [DATE], for Lidoderm (Lidocaine) Patch, Apply to left shoulder topically one time a day for left shoulder pain. Apply Lidocaine Patch 4 % and remove per schedule. During a concurrent interview and record review on [DATE], at 12:14 p.m., with LVN C, she verified Resident 11's physician's order indicated to apply the Lidoderm Patch to the left shoulder, not the lower back. 4b. During a medication administration observation with LVN C on [DATE], at 9:27 a.m., LVN C was observed preparing 4 medications for Resident 11. She removed the polyethylene glycol 3350 powder (Brand name Miralax, a laxative to treat constipation) from the medication cart. Then, using the 30-milliliter (mL, or 1 ounce [oz]) graduated medicine cup, she measured one full (about 30 mL) and about one-half cup of the Miralax powder and placed it into the 8-oz cup. Then she mixed the Miralax powder with about 8 oz of water and brought the prepared medications to the resident's bedside. During a concurrent interview and record review on [DATE], at 9:52 a.m., with LVN C, she stated the Miralax order was for 17 grams (unit of mass). LVN C was asked how she prepared the Miralax. Using the Miralax powder, LVN C demonstrated and stated she used the 1-oz medicine cup to measure one cup of 15 mL and another cup of 2 mL (17 ml total) but remembered she used more than that. She stated she did not use the Miralax bottle cap because it was not the right one. A review of the manufacturer's directions on the Miralax powder bottle, with LVN C, indicated the bottle cap was a measuring cup designed to contain 17 grams of powder when filled to the top rim. The demonstrated amount of 15 mL and 2 mL powder contents exceeded the amount needed to measure 17 grams using the bottle cap. LVN C verified 17 mL of powder was not the same as 17 grams, and she gave more than the ordered amount of 17 grams. A review of Resident 11's clinical record indicated she had a physician's order, dated [DATE], for Glycolax Powder (Polyethylene glycol 3350 powder), give 17 grams (g) by mouth one time a day for bowel regimen. Mix in 8 oz of liquid. Hold for loose bowel. A review of the facility's policy and procedure titled Administering Medications, revised [DATE], indicated, Medication must be administered in accordance with the orders, including any required time frame and The expiration date on the medication label must be checked prior to administering. When opening a multi dose container, the date shall be recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired medications were removed, and medications were labeled and stored according to manufacturer's instructions for one out of one medication room and two out of two medication carts. These deficient practices had the potential for residents to receive medications with reduced potency and had the potential to result in medication errors. Findings: 1. During an inspection of the third floor medication cart on 2/21/23, at 10:26 a.m., with Registered Nurse A (RN A), a bottle containing loratadine (medication for allergies) 10 milligram (mg, unit of dose measurement) tablets was identified with the expiration date of 1/2023. RN A verified the medication was expired. The medication cart inspection with RN A also identified a bottle of latanoprost 0.005% eye drops (medication used to treat glaucoma) unopened but kept in the medication cart. The pharmacy label on the eye drop indicated to refrigerate until opened. RN A verified this finding and stated he did not know who put the latanoprost eye drops in the medication cart. According to Lexi-comp (www.[NAME].com, a nationally recognized drug information resource), store unopened bottle of latanoprost solution in the refrigerator and once opened, the container may be stored at room temperature for 6 weeks (https://online.[NAME].com/lco/action/doc/retrieve/docid/pated, assessed on 3/3/23). 2. An inspection of the fourth floor medication cart, side 1, was conducted with LVN D on 2/21/23, at 12:24 p.m., as follows: a. An unopened bottle of latanoprost ophthalmic solution 0.005% eye drops, delivered on 2/18/23, not stored in the refrigerator. LVN D verified the medication was not opened and not stored in refrigerator. b. Two expired Combivent Respimat (used to treat breathing problems) 20 microgram (mcg) /100 mcg inhalers were identified. One was opened on 6/26/22, and the other was opened on 9/4/22. A review of manufacturer's label on the Combivent inhaler with LVN D indicated opened inhalers were good for 90 days. This indicated the inhalers expired on 9/26/22 and 12/4/22, respectively. LVN D verified this finding and stated the medications expired a long time ago. c. An oral inhalation of fluticasone furoate/vilanterol ellipta (medication for breathing problems) Inhalation Powder 200 mcg/25 mcg was identified without an open date. A review of the manufacturer's label indicated to discard 42 days after opening. LVN D verified this finding. A review of the facility's policy and procedure titled Storage of Medication, dated 9/2010, indicated, Medication for oral inhalation is stored in the dispensed containers following manufacturer guidelines for position and priming. d. A controlled medication E-kit (an emergency kit which contains medications for use in emergency situations) was identified with expiration date of 1/2023. Inside the E-kit were Ambien (medication for insomnia) tablets that expired on 1/2023. RN D verified the E-kit was expired. A review of the facility's policy and procedure titled EMERGENCY PHARMACY SERVICE AND EMERGENCY KITS (E-KITS), dated 9/2010, indicated, The nursing staff, consultant pharmacist and provider pharmacy designee checks the emergency kits regularly for expiration dating of the content. 3. During an inspection of the medication room on the fourth floor, on 2/22/23, at 11:57 a.m., with the DON, three expired medications were observed. These included 13 tablets of loperamide (medication for diarrhea) 2 mg, expired on 9/2021; 23 tablets of ferrous gluconate (medication to treat or prevent iron deficiency anemia) 324 mg, expired on 6/2022; and one bottle of fiber (a type of carbohydrate that the body can't digest) capsules, expired on 12/2022. The DON verified the medications were expired and should have been moved to the expired section of the medication room cabinet. A review of the facility's policy and procedure titled Storage of Medication, dated 9/2010, indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stocks, disposed of according to procedures for medication disposal . and reordered from pharmacy . if a current order exists.

Based on observation, interview, and record review, the facility failed to ensure the dietary staff followed their recipe when the senior lead cook (SLC) prepared yellow squash and red pepper vegetables for lunch. This failure had the potential to compromise the nutritional value and palatability of the food for 58 residents who received food services from the facility. Findings: During an interview on 2/21/22 at 10:43 a.m., Resident 363 stated, Food is not so good. He further stated hot food was served cold, and the food was not tasty. During an interview with Resident 10 on 2/21/23 at 11:00 a.m., Resident 10 stated, Food has no taste. During an interview with Resident 46 on 2/21/23 at 11:30 a.m., Resident 46 stated, Food is not tasty, cold, stale, and awful. Resident 46 further stated, Vegetables are not cooked well, not soft enough to eat, shrimp is tough. She further stated she could not even cut shrimp with a dinner knife. During an interview with Resident 34 on 2/21/23 at 11:45 a.m., Resident 34 stated, Food does not taste good. Review of the facility lunch menu on 2/22/23 indicated Cuban black bean and rice soup, chicken bacon ranch salad sandwich, mashed potatoes, sautéed yellow squash and red peppers, corn muffin, and vanilla pudding. A test tray (a test meal to evaluate the quality of food during a normal meal service and identify any areas for improvement) of regular and pureed diet (soft, pudding like consistency, modified textured diet for people who cannot chew and swallow solid foods) was conducted on 2/22/23 at 1:00 p.m., in the presence of the registered dietitian (RD) and director of dining services (DDS). The regular and pureed consistency sauteed yellow squash and red peppers tasted bland with no flavor. During an interview with DDS on 2/23/23 at 3:02 p.m., the DDS acknowledged the yellow squash and red peppers served on 2/22/23 for lunch were bland with no flavor. He further stated both vegetables tasted bland and should have added flavoring. During an interview with the SLC, in the presence of the DDS, on 2/27/23 at 10:59 a.m., the SLC acknowledged he prepared yellow squash and red peppers for lunch on 2/22/23. He explained how he prepared these vegetables on 2/22/23. He placed fresh cut pieces of yellow squash and red peppers in a baking dish, put the baking dish in the streamer for 10 minutes, and the temperature reached 210 degrees Fahrenheit (F, scale of measuring temperature). He took them out of the streamer and placed them in the holding oven until ready to serve. He transferred the streamed vegetables to the stream table before tray line started for lunch. Review of the facility's recipe titled, MenuWorks Recipe Book Report, HC Sauteed Yellow Squash and Red Pepper (5664.3) from Webtrition 2, dated 10/10/2022, indicated, Heat the oil in large skillet. Add squash and peppers. Sauté until tender, stirring constantly until squash and peppers tender yet firm and internal temperature reaches 140 F. (Do not overcook). Portion ½ cup vegetables in each serving dish. Hold warm for service. During a concurrent interview and record review with the DDS, on 2/27/23 at 11:08 a.m., the DDS acknowledged the SLC did not follow the facility's recipe when cooking yellow squash and red peppers on 2/22/23. He further stated the SLC should have followed the recipe to conserve flavor, taste, and nutritional value of both vegetables. Review of the facility's policy and procedure titled Daily Production Workbook, dated 1/2022, indicated, Webtrition-Menu Works is the compass food production system and the source of approved standardized recipes. Menu Works all production report or summary as guidance in providing recipes to the production staff. Review of the facility's policy and procedure titled Food-Nutrition, dated 1/2023, indicated, Food will be prepared by methods that conserve nutritive value, flavor and appearance and in a form designed to meet individual needs.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There was expired food in the kitchen; 2. Prepared food trays in the walk-in refrigerator were uncovered and undated; 3. Wet and dry containers were stored together; 4. The Dish washer (DW) used expired sanitizer test strips to test sanitizer solution; and 5. [NAME] K (CK) failed to perform hand hygiene between tasks. These failures had the potential to result in food borne illness for 58 residents who received food from the kitchen. Findings: 1. During initial kitchen observation and concurrent interview with the assistant director of dining services (ADDS), on 2/21/23 at 9:05 a.m., there was sweet ground white chocolate powder on the dry food storage shelf, with an open date of 8/27/22 and an expiration date of 1/31/23. There was a container of black pepper corns on the spice shelf with an open date of 12/27/21 and an expiration date of 12/27/22. There was a plastic container of croutons on the kitchen counter with an open date of 2/8/23 and an expiration date of 2/20/23. The ADDS confirmed these food items were expired. She stated staff should have removed them and replaced them with new ones. Review of the facility's policy and procedure titled, Food and Supply Storage, dated 1/22 indicated, Discard food past the use-by or expiration date. 2. During a concurrent kitchen observation and interview with the ADDS, on 2/21/23 at 9:15 a.m., there were two undated and uncovered steel trays of apple crisp, and one undated and uncovered steel tray of tapioca pudding in the walk-in refrigerator. There were six tortillas in plastic wrap with no open date and no expiration date on a food storage rack. The ADDS acknowledged the uncovered and undated food items. She stated staff should have covered them and labeled them with the prepared date, open date, and expiration date. Review of the facility's policy and procedure titled, Food and Supply Storage, dated 1/22 indicated, Cover, label and date unused portions and open packages. Products are good through the close of business on the date noted on the label. 3. During a concurrent kitchen observation and interview with the ADDS, on 2/21/23 at 9:25 a.m., there were three plastic food containers with water droplets on the inside and outside. These wet food containers were stored on a dish rack next to several other food containers that were dry. The ADDS confirmed this observation and stated staff should not have stored wet and dry containers together. Review of the facility's policy and procedure titled, Storage of pots, dishes, flatware, utensils, dated 1/23, indicated, Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet. 4. During a concurrent kitchen observation and interview with the ADDS, on 2/21/23 at 10:00 a.m., the DW used sanitizer test strips to test the sanitizing solution for the three-compartment sink. The container of sanitizer test strips had an expiration date of 8/15/22. The ADDS acknowledged the DW used expired sanitizer test strips and stated the DW should not have use them. 5. During tray line (process of placing food and drink items on meal trays) observation with the director of dining services (DDS), registered dietitian (RD), and ADDS on 2/22/23 at 11:45 a.m., CK was plating food for lunch. While wearing a pair of gloves, CK took a plate from the plate warmer, used a scoop to put yellow squash on the plate, and used a scoop to put mashed potatoes on the plate. Using the same pair of gloves, CK then handled uncovered ready-to-eat bread and chicken salad sandwiches. The DDS confirmed this observation, went to the tray line area, and provided CK with tongs to handle the ready-to-eat bread and chicken salad sandwiches. The DDS made CK remove her gloves and wash her hands before returning to the tray line area. During an interview with the DDS on 2/22/23 at 11:50 a.m., the DDS acknowledged that CK did not perform hand hygiene between tasks. He stated CK should not have touched the uncovered ready-to-eat bread and sandwiches with potentially contaminated gloves. Review of the facility's policy and procedure titled, Food handling guidelines, dated 1/22 indicated, Minimize hand contact with ready-to-use food by the use of utensils, disposable gloves or individual wax papers. Gloves are changed between tasks. Hands are washed after gloves are removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interivew and record review, the facility failed to properly store and label drug and biological's in accordance with facility policy and current standards when: 1. A bottle of Milk of Magnesia (used for constipation) was with altered pharmacy label. 2. An eye antibiotic passed its length of therapy was found in the medication cart. 3. A vial of Humalog (used to regulate insulin in the blood) was expired. 4. Licensed vocational nurse I (LVN I) left Brimonidine 0.2% (used to relieve redness in the eyes caused by minor eye irritations.) on top of the cart unattended. These failures can potentially compromise Residents' health and safety. Findings: 1. A bottle of Milk of Magnesia (used for constipation) was found with altered pharmacy label. During a medication cart audit with licensed vocational nurse G (LVN G) on [DATE] at 10:03 a.m., a bottle of Milk of Magnesia was found with altered pharmacy label. During an interview with the director of nursing (DON) on [DATE] at 7:53 a.m., the DON stated staff should not alter pharmacy label. A review of the facility's policy, Medication and Medication Label, dated 5/16, indicated medication labels are not altered, modified, or marked in any way by nursing personnel. 2. An eye antibiotic passed its length of therapy was found in the medication cart. During a medication cart audit with licensed vocational nurse G (LVN G) on [DATE] at 10:03 a.m., a Gentamicin 3mg/ml ordered on [DATE] for five days was found in the cart. LVN G confirmed medication was discontinued and should be taken out of the medication cart. During an interview with the DON on [DATE] at 7:53 a.m., the DON confirmed medication should be taken out of the medication cart when it's been discontinued. 3. A vial of Humalog (used to regulate insulin in the blood) was expired. During a medication cart audit with registered nurse (RN H) on [DATE] at 10:16 a.m., a vial of Humalog insulin with an opened date of [DATE] was found in the medication cart. RN H confirmed that Humalog insulin was stored passed 28 days. During an interview with the DON on [DATE] at 7:54 a.m., the DON stated insulin should only be kept inside the medication cart no longer than 28 days. A review of manufacturer's guideline for Humalog insulin indicated, throw away open vials 28 days after first use. 4. Licensed vocational nurse I (LVN I) left Brimonidine 0.2% (used to relieve redness in the eyes caused by minor eye irritations.) on top of the cart unattended. During an observation with LVN I on [DATE] at 4:16 p.m., LVN I left Brimonidine 0.2% on top of the cart unattended. LVN I confirmed she should not leave medication on top of the cart unattended. During an interview with the DON on [DATE] at 7:50 a.m., the DON stated medication should not be left of top of the cart unattended. A review of the facility's policy, Administering Medication, indicated no medication are left on top of the cart.

Based on interview, and record review, the facility failed to ensure a follow up was made in a timely manner for a missing denture for one of two sampled residents (6). Resident 6' s upper denture was missing and Resident 6's insurance denied to replace. These failures caused a delay in Resident 6 receiving the necessary dental services and could negatively affect Resident 6's physical comfort and psychosocial well-being. Findings: Review of Resident 6's clinical record indicated she was admitted to the facility with a diagnoses including hemiplegia (affecting one side of the body) following cerebral infarction (stroke). Review of Resident 6' Progress Notes dated 8/6/19, indicated Resident 6's upper denture was not taken by a family member (FM) and would be evaluated by a dentist for possible replacement. Resident 6 was also seen by the dentist on 8/23/19, and recommendation was to have a full set of dentures (upper and lower). Review of the facility's theft and lost binder indicated Resident 6's full upper dentures was missing on 8/6/19. It also noted, on 10/22/19, Resident 6 was denied by the insurance for full set of dentures. Another referral to Resident 6's insurance was made on 10/23/19. Review of Resident 6's insurance notice of action dated 10/18/19 indicated the replacement was denied due to Resident 6's no longer in the facility. During an interview with Resident 6's FM on 11/12. /19 at 11:45 a.m. The FM stated he had concerns about what happened to Resident 6's upper dentures. The FM stated he received a letter of denial from Resident 6's insurance sometime in October 2019. During an interview with licensed vocational nurse E (LVN E) on 11/13/19 at 7:48 a.m. LVN E confirmed Resident 6' s upper denture was missing since August 2019. During an interview with the DSS on 11/13/19 at 7:58 a.m., the DSS confirmed Resident 6's upper denture was missing on 8/6/19. The DSS stated the dentist recommended replacement of upper and lower dentures, and a referral was submitted to Resident 6's insurance. The DSS stated the facility could only pay for the upper denture.The DSS acknowledged the insurance denial notice did not have the right information as Resident 6 was an active resident in their facility .The DSS stated the dentist had to resubmit another referral to the insurance after the denial. During an interview with the director of nursing (DON) on 11/13/19 at 8:20 a.m., the DON stated the facility should replace Resident 6' s full set of dentures regardless of the insurance,

3.During a medication pass observation with licensed vocational nurse E (LVN E) on 11/14/19 at 9:10 a.m., LVN E used the same gloved hand to administer eyedrop, nose spray, and inhaler for Resident 66. During an interview with LVN E on 11/14/19 at 9:18 a.m., LVN E confirmed she did not perform hand hygiene in between administering eye drop, nose spray and inhaler medication for Resident 66. A review of the facility's policy Administering Medication, dated 10/13/11, indicated staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications. Based on observation, interview, and record review, the facility failed to ensure staff implemented the infection control practices when: 1. Treatment nurse C (TXN C) did not perform hand hygeine while providing wound treatment; 2. Certified nursing assistant D (CNA D) disposed dining ware of a resident in the isolation room; 3. Licensed vocational nurse E (LVN E) failed to perform hand hygeine between different medication routes. These failures had the potential to put vulnerable residents at risk for infection. Findings: 1. During a wound treatment observation with TXN C on 11/14/19 at 12:00 p.m., TXN C performed wound treatment on Resident 24's right lateral foot. TXN C confirmed she wore at least two layers of gloves on each hand while treating Resident 24's wound, removing each layer as she cleaned and dressed the wound. During an interview with the director of staff development (DSD) on 11/15/19 9:17 a.m., he stated using multiple layers of gloves and removing layer by layer during wound treatment should not be done. Licensed nurse need to apply hand hygiene every time they wear or remove gloves. During an interview with the director of nursing (DON) on 1:52 p.m., she stated using multiple layers of gloves and removing them layer by layer is a big no no. Staff should not do that. Review of the facility's policy and procedures, Pressure Ulcer Treatment, indicated put clean gloves on after washing and drying hands completely before and after removing wound dressing, opening wound treatment equipment, cleansing the wound. 2. During an observation on 11/13/19 at 9:01 a.m., CNA D carried a breakfast tray out of Resident 152's room. CNA D was not wearing any PPE. CNA D then opened the dining room/ kitchen door and discarded the used disposable dining ware on to the kitchen trash with her bare hands. CNA D then opened the dining room/kitchen door and opened the utility room door to wash her hands. During a concurrent interview with CNA D, she stated the tray was from Resident 152's room. Resident 152 was on isolation precautions. She confirmed she disposed the disposable dining ware in the kitchen with her ungloved hands. During an interview with the DSD on 11/14/19 at 12:59 a.m., he stated Resident 152 was on isolation precautions. Staff need to wear disposable personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) - such as gloves, gown, mask when entering Resident 152's room. PPE and other items used by the resident need to be discarded in the biohazard bin inside the resident's bathroom. The DSD further stated CNA D broke the infection control chain when she went outside Resident 152's room and disposed Resident 152's used dining ware in the kitchen; She should have not done that. CNA D should have thrown the dining ware in the biohazard bins inside Resident 152's room.

Based on observation, interview, and record review, the facility failed to ensure a cook utilized standardized recipes for puree (smooth texture) food preparation to ensure nutritive value. This failure resulted in the residents prescribed puree diet being placed at an increased risk for nutritional impairment. Findings: During a concurrent observation and interview with lead cook (LC) on11/14/19 at 9:53 a.m., LC was adding water inside a container with biscuits inside. LC stated she used water when pureeing biscuits. During a review of recipe with the dietary manager (DM) on 11/14/19 at 10:15 a.m., puree recipe for buttermilk biscuits indicated, blend biscuits with milk in Robocop, blender or food processor until smooth. During an interview with registered dietician A (RD A) on 11/14/19 at 10:22 a.m., RD A confirmed changes in nutrients of the biscuits could occur when diluted with water instead of milk.

5. During an observation and interview with dietary staff J (DS J) on 11/12/19 at 12:02 p.m., he measured the temperature of the meat loaf prior to starting tray line: DS J stated the meatloaf temperature was 140F and recorded it on the temperature log. During an interview with registered dietitian A (RD A) on 11/14/19 at 10:57 a.m., she stated the meat loaf served for lunch on 11/12/19 was made of ground beef. During an interview with RD B on 11/14/19 at 1:18 p.m., she stated the holding temperature for meat loaf or ground beef was 140 F According to CDC and federal guidelines, indicated monitoring the food's internal temperature is important and will help ensure microorganisms can no longer survive and food is safe for consumption, ground beef should be held for service at 155 F. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions when: 1. Bin used to store flour was unlabeled; 2. Scoop utensil was lying on top of the thickener bin; 3. Ice machine spout was dirty; 4. Staff crossed yellow line (division between kitchen and dining area) during trayline without hairnets; 5. Beef meat loaf was held for service at 140 F (F, fahrenheit, unit of temperature). This failure had the potential for occurrence of food-borne illnesses. Findings: 1. During an observation on 11/12/19 at 8:21 a.m., with the dietary manager (DM), a bin with dry food powder was observed under the kitchen sink. During an interview with the registered dietitian A (RD A) on 11/15/19 at 3:18 p.m., RD A stated the flour should have a label. 2. During an observation on 11/12/19 at 8:23 a.m., there was a scoop lying on top of thickener container. The DM stated it was ok for the scoop to be stored on top of the container. During an interview with RD A on 11/15/19 at 3:18 p.m., the RD A stated the scoop should be stored in a different container. Acccording to the FDA 2017 Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage shall be stored with their handles above the top of the food. 3. During an observation with the building maintenance director (BMD) on 11/15/19 at 1:40 p.m., unit 2's (2nd floor) ice machine had whitish, brownish discoloration in the plastic chute (where the ice comes out). The BDM stated it was a calcium build up. According to Food Code 2017 as specified in paragraph 4-602.11 indicated water vending equipment, ice makers should be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganism. 4. During a trayline observation of the fourth floor, together with the dining services manager (DSM) on 11/12/19 at 12:15 p.m, licensed vocational nurse E (LVN E) looked at trays crossing the yellow line without a hair net. An activity staff (AS) went inside the kitchen through a closed door without a hair net. Certified nursing assistant F (CNA F) looked in the refrigerator and was holding a tray and crossed the yellow line without a hair net. During a concurrent interview with the DSM, she acknowledged facility staff should wear a hair net when crossing the yellow line.