Based on observation, interview and record review, the facility did not provide Advanced Beneficiary Notice (ABN, a document informing residents Medicare will no longer pay for services and allows residents to make informed decisions on whether to continue certain services, which may incur out of pocket costs) to one (Resident 22) of three residents, when Resident 22 was discharged from Medicare Part A (temporary insurance which covers hospital and skilled nursing services) to long term care.This failure could have resulted in Resident 22 not given a chance to make informed decisions regarding his care or for his right to appeal.During a concurrent interview and record review on 8/6/2025 at 9:15 AM, with Social Worker (SW), Resident 22's Notice of Medicare Non-Coverage (NOMNOC, a document informing residents Medicare will no longer cover certain services and outlines appeals rights) was reviewed. Resident 22's NOMNOC indicated the notice was issued and signed by Resident 22's family member on 4/4/25. SW stated Resident 22 stayed in the facility under custodial care (long term care). SW stated the Skilled Nursing Facility Beneficiary Notice of Non-Coverage (SNFABN) was not used and one was not completed for Resident 22. SW further stated, I was reading about it and [the SNFABN] is required for long term residents.Review of the Guidance of Appendix PP, revised on 7/23/25, from Centers of Medicare and Medicaid Services (CMS) indicated, Inform each resident of services available in the facility and the charges for those services not covered under Medicare/Medicaid or by the facility's per diem rate. As soon as reasonably possible when a change in coverage occurs; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise plan of care for Resident 32, one of 12 sampled residents, after 10 incidents of falls, to prevent further falls. This failure could result in resident's harm .Review of Resident 32's Facesheet, dated 8/5/24, indicated, Resident 32 was admitted on [DATE] with diagnoses including: Peripheral Vascular Disease (a condition that blood vessels are narrowed causing less blood flow to the limbs), Pain left leg , Cognitive Communication Deficit, Generalized Anxiety Disorder. During a concurrent observation and interview on 8/4/25 at 10:50 AM, in Resident 32's room, Resident 32 was observed in bed and had a caregiver(CG) from a private agency. CG stated she has been with patient for four years now, since last year doing 12 hour shift, was 24 hours before. CG stated Resident 32 was total care, could get agitated and confused, was able to stand up with small steps during transfer to wheelchair but cannot walk. CG stated Resident 32 had fallen but not on her shift and stated She gets scared when CG leaves for the day.Review of facility document, Fall Risk Assessment on admission. dated 8/21/23, indicated a score of 12 indicates high risk for fall.Review of facility document, Post Fall Assessment, dated 7/2/25, indicated a score of 24, high risk for falls with history of 3 or more falls.Review of facility document, Baseline and Comprehensive Care Plan for Falls, started 12/8/23. Resident then had 10 times unwitnessed fall, the latest was 8/6/25. Resident has a private caregiver during the day, has floor mats on both sides. Care plan did not indicate patient's representative's input on the goal and care of this resident.Review of MDS Section C, Cognitive Patterns, dated 6/5/25, not completed. No BIMS Summary Score.Review of Progress Notes by [NAME] ,Can MD (Geriatric Medicine), dated 7/30/25, indicated, Cognitive impairment diagnosis: No formal diagnosis of cognitive impairment but clearly has moderate to advanced dementia, likely AD. During an interview on 8/5/25 at 2:40 PM, with Occupational Therapist (OT), OT stated, Resident 32 had been falling and resident was on rehab for caregiver training to provide safest care. OT stated nurses did the fall risk assessment and approaches .During an interview on 8/6/25 at 10:05 AM, with Licensed Vocational Nurse (LVN), LVN stated she knew Resident 32, and worked for 4 years at facility. OT stated she was aware of resident's frequent falls at night, We check [Resident 32] frequently and when she's humming that means she is awake. OT stated Resident 32's family member was aware of the falls, [Resident 32] had 24/7 caregiver before and always had floor pads. During an interview on 8/6/25 at 10:30 AM, with Director of Nursing (DON), DON stated, It's a day to day basis, we cannot plan the day for her. She is falling even when caregiver is there. She has a private caregiver, she has floor pads. Nurses updates the care plan interventions and MDS to complete.During an interview on 8/6/25 at 11:00 AM, with Certified Nursing Assistant (CNA), CNA stated Resident 32 fell on her shift one time, patient was dreaming she wanted to go to school and was late already. CNA stated Resident 32 was getting anxious and needed to be calmed down. Review of facility Policy and Procedure, Fall Prevention Program-SNF., dated 4/24. Purpose: To prevent accidents and injuries by providing an environment that is free from hazards over which the facility has control. Policy: All resident's environment shall remain as free of hazards as is possible, and residents shall receive adequate supervision and assistive devices to prevent accidents. Procedure: Fall Prevention :b. If a resident triggers a risk for falls, the IDT shall further assess the fall risk factors and shall, if indicated, further update the care plan to minimize the risk of falls utilizing the Falling Star program criteria if appropriate.

Based on interview and record review, the facility failed to ensure controlled medications (narcotics that have high abuse potential) were fully accounted for when a random controlled medication use audit for two out of four sampled residents (Residents 4, 24) did not reconcile. The residents' medications were signed out of the Controlled Drugs Records (CDR, inventory record of controlled drugs) but not documented on the Electronic Medication Administration Record (eMAR, record of medications administered to a resident) to indicate they were administered to the residents. This failure resulted in inaccurate accountability of controlled medications and had the potential for abuse and narcotic diversion (unlawful distribution or use) of controlled medications.Findings: During the survey, the CDRs for four random residents receiving as-needed (PRN) controlled medications were selected for review. On 8/5/25 at 1:40 p.m., a concurrent interview and record review with the Director of Nursing (DON), the DON stated any time a PRN controlled medication was requested from the resident, the Licensed Nurse will administer the controlled medication after reviewing the medication orders, checking the time of administration, and documenting on the CDR and on the eMAR. A. A review of Resident 4's physician orders indicated an order for Oxycodone (a potent narcotic for pain) 5 milligrams (mg, unit of measurement), take 0.5 tablet to 1 tablet (2.5 mg to 5 mg total) by mouth every 6 hours as needed for moderate pain, start date 7/7/25. On 8/5/25 at 2: 25 p.m., a review of Resident 4's CDR for Oxycodone 5 mg and July 2025 medication administration record eMAR with a Licensed Nurse 1 (LVN1) indicated the nursing staff signed 1 tablet out of the CDR, but did not document the administration on the eMAR on two occasions: on 7/27/25 at 9 p.m. and 7/30/25 at 8:22 p.m. After reviewing the resident's clinical records including the eMAR and the nursing progress notes, LVN1 verified no documentation of administration was present, stating No, I don't see it. When asked about the process for controlled medication administration, LVN1 stated the nurse Put it on the eMAR first, then go to the resident (to administer), then sign out of narcotic (CDR) book. After medication is given, then click (document) on eMAR. B. A review of Resident 24's clinical record indicated she had a physician's order for Tramadol (Brand name: Ultram, a strong painkiller to treat pain) 25 mg, give 1 tablet by mouth every 4 hours as needed for moderate pain, start date 7/17/25. On 8/5/25 at 2:08 p.m., a review of resident 24's CDR for Tramadol 25 mg and the July 2025 MAR with LN1 indicated the nursing staff signed 1 tablet out of the CDR but did not document the administration on the eMAR on three occasions: on 7/20/25 at 6 a.m., 7/23/25 at 2:38 p.m. and 9:00 p.m. In addition to the above medication order, Resident 24 also had a medication order for Tramadol 50 mg, give 1 tablet by mouth every 4 hours as needed for severe pain, start date 7/16/25. A review of resident 24's CDR for Tramadol 50 mg and the July 2025 MAR with LN1 indicated the nursing staff signed 1 tablet out of the CDR but did not document the administration on the MAR: on 7/20/25 at 12:30 p.m. LVN1 verified the findings and stated the medication administration should have been documented on the MAR During a concurrent interview and record review on 8/5/25 at 2:35 p.m. with LVN1 and DON, LVN1 reported the findings to the DON and stated after reviewing Resident 4 and Resident 24's clinical records, controlled medications were not documented on the MAR for two residents. The DON stated the CDR is a count sheet and verified the MAR should have also been signed when the controlled medications were given. Review of the facility's policy and procedure titled Medication Administration, reviewed/revised on 4/2024, indicated The licensed nurse shall chart the date and time of each administered medication.If the medication is given on a per need (PRN) basis, the time shall be noted on the eMAR.

Based on interview and record review, the facility failed to ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was implemented when: 1. The Infection Preventionist (IP, a licensed nurse that has specialized training in infection prevention) did not communicate or provide notification to the primary medical doctor when the residents' presenting symptoms did not meet criteria for antibiotic use based on McGeer criteria (Standardized criteria to help consistently identify and classify infections treated with antibiotics) for 2 out of 6 residents (Residents 22 and 17).2. The IP did not track the antibiotic use for 1 out of 6 residents (Resident 26).This failure resulted in antibiotics being prescribed without the qualified indication (use) or monitoring and had the potential for adverse outcomes and the development of antibiotic- resistant organisms. Findings:During an interview on 8/7/25 at 9:31 AM with the Infection Preventionist (IP), the IP stated when antibiotic medication is administered, he utilizes the McGeer Criteria for qualification of antibiotic use based on the resident's presenting symptoms, communicates the determination with the physician, and updates a tracking spreadsheet for monitoring all residents receiving antibiotics. The IP further stated if the antibiotic use qualifications are not met based on McGeer Criteria he would communicate with physician and would ask for what to do next. During a concurrent interview and record review on 8/7/25 at 10:05 AM with the IP, Resident 26's Physician's Orders were reviewed. Resident 26's Physician's Orders indicated, Methenamine (an antibiotic used to treat or prevent urinary tract infection [UTI]) 1 gram (a unit of measurement) 1 tablet by mouth twice daily UTI prevention, was dated 7/15/25. The IP stated he did communicate antibiotic order with the physician, but did not add Resident 26 to the tracking spreadsheet for antibiotic use monitoring. The IP stated, It should have been included because it is an antibiotic. During a concurrent interview and record review on 8/7/25 at 10:07 AM with the IP, facility document titled, Safety Meeting - Infection Control was reviewed. Safety Meeting - Infection Control, dated 7/30/25, indicated Resident 17 had an antibiotic order for Cephalexin (Brand name: Keflex, an antibiotic used to treat infections) 500 milligrams (mg, unit of measurement) 1 tablet by mouth twice daily for seven days for UTI. The IP stated Resident 17 did not have any presenting UTI symptoms and therefore did not meet McGeer criteria for antibiotic use. The IP was unable to provide documentation of physician notification for further guidance. The IP stated Resident 17 completed a full dose of antibiotic therapy. During a concurrent interview and record review on 8/7/25 at 10:13 AM, with the IP, facility document Safety Meeting - Infection Control was reviewed. Safety Meeting - Infection Control, dated 7/30/25, indicated Resident 22 had physician orders on 6/16/25 for Azithromycin (an antibiotic to treat infections) 500mg 1 tablet by mouth daily for 5 days and Ceftriaxone (an injectable antibiotic for infections) 1 gram solution for injection intramuscularly daily for three days for pneumonia. The IP stated Resident 22 did not have any presenting respiratory symptoms, but was weak, lethargic, and had a change in level of consciousness. The IP stated Resident 22 did not meet McGeer criteria for use of the two antibiotics. After reviewing his notes, the IP stated he had no documentation of physician notification about this. He confirmed Resident 22 completed all antibiotic therapies. During a phone interview on 8/7/25 at 11:11 a.m., with the consultant pharmacist (CP, a contracted pharmacist that provides consultation for medication program), the CP stated she meets with the IP quarterly to review infection control and vaccination status for all residents. The CP further stated, If not met McGeer criteria, the nurse would notify the doctor, and she (the physician) will decide whether the resident will continue the antibiotic. Review of the facility policy and procedure titled, Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes reviewed/revised on 8/2022, indicated The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent wit the appropriate use of antibiotics.At the conclusion of the review, the provider will be notified of the review findings.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, when a carton of orange juice and 4 cartons of apple juice and a paper cup wrapped in plastic, inside the refrigerator in the pantry, has no expiration date, has no use by date, cup has no label. This failure has the potential to put residents at risk for foodborne illnesses.During a concurrent observation and interview on 8/4/25 at 10:30 AM, with Registered Dietitian (RD), in the refrigerator in the pantry, found one orange juice carton, and four apple juice cartons, with no expiration date and no use by date, and one paper cup wrapped in plastic no label. RD stated, every food stored in the refrigerator should have expiration dates or use by dates and should be labeled. Review of facility Policy and Procedure: Food and Supply Storage, dated 1/24, indicated, Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain safety an wholesomeness of the food for human consumption. Procedures : . Most, but not all, products contain an expiration date.Foods past the use by , sell by, best by date should be discarded. Cover, label and date unused portions and open packages.Review of the Guidance of Appendix PP, revised on 7/23/25, from Centers of Medicare and Medicaid Services (CMS) indicated, When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and coverage, labeling and dating all stored foods in the refrigerator or freezer as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure there was a clean comfortable homelike environment when these two issues were found: 1. Two window screens had gaps. 2. Washbasins in four different rooms were found stored on the bathroom floor. Failure to ensure window screens were properly maintained had the potential to allow flying pests into residents' living spaces. Failure to store Resident's washbasins in a sanitary manner had the potential for residents to be exposed to dirty personal care equipment or infectious agents. Findings: Washbasins During observation on 5/20/24 at 9:43 AM, a washbasin was found stored on the bathroom floor in room [ROOM NUMBER]. During observation on 5/20/24 at 10:27 AM, a washbasin was found stored on the bathroom floor in room [ROOM NUMBER]. During observation on 5/21/24 at 10:37 AM , a washbasin was found stored on the bathroom floor in room [ROOM NUMBER]. During observation on 5/21/24 at 10:38 AM , a washbasin was found stored on the bathroom floor in room [ROOM NUMBER]. During an interview on 5/23/24 at 9:44 AM, the Staff Development (SD) Nurse stated staff were trained to use these washbasins sometimes to clean the patient's body including their private areas. The SD Nurse was shown three pictures of washbasins stored on the floor in three different bathrooms. The SD Nurse stated No they should not be storing .(these washbasins) like that. I'll in-service to correct that. The facility was asked to provide their policy regarding storage of washbasins on 5/23/24. On 5/24/24, the facility provided a policy titled Cleaning and Disinfecting Non-Critical Resident-Care Items, revised on June 2011. Review of the policy found no mention of washbasins and no information about proper storage of wash basins after use. Window Screens During observation on 5/22/24 at 12:00 PM, room [ROOM NUMBER] and 10's window screens were noted to have gaps between the window opening and the outer frame of the window screens. These observations were confirmed with LVN 2. Review of the facility's policy titled SCHEDULED MAINTENANCE, not dated, indicated .The Director of Plant Operations will also conduct a grounds inspection (externally) once a week and identify any areas of concern such as: dead foliage, weeds, pot holes in pavement, trees/lawn issues, etc. (see attached external grounds checklist) . The attached external grounds checklist indicated .Window/Screens . should be checked during these weekly inspections.

Based on interview and record review the facility failed to transmit one of 12 sample residents' MDS (Resident 22) in a timely manner and failed to complete and transmit one of 12 sample residents' MDS (Resident 26). Failure to transmit required assessments violated the facility's contractual agreement with the State and CMS. Additionally, the facility failed to provide a policy governing the tracking and timely transmission of MDSs. Findings: During a concurrent interview and record review on 5/23/24 at 11:08 AM, the MDS Nurse was invited to review MDS for Resident 22 and Resident 26. The MDS Nurse acknowledged Resident 22's MDS was transmitted late and Resident 26's MDS was incomplete. The facility was asked to provide their policy regarding timely completion and transmission of MDS. The document submitted by the facility appears to be pages out of a Resident Assessment (RAI) manual published by CMS, dated October 2023. The document did not contain critical elements of a policy (such as General Information, Purpose, Policy, Procedure) and did not address how the facility should have a system in place to track when MDS are due and when they should be submitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to accurately code Resident 10's Minimum Data Set (MDS) assessment, one of 12 sample residents. Failure to accurately code Resident 10's assessment regarding restraints did not ensure health care providers could make safe and individualized health care decisions/recommendations based on Resident 10's MDS. Additionally, the facility failed to provide a policy regarding accurately coding a resident's MDS assessment. Findings: Review of Resident 10's MDS assessments dated 11/14/23 and 2/14/24 indicated the MDS nurse coded him as having a restraint. On 5/22/24 at 12:00 PM during an observation and concurrent interview, Resident 10 stated he was never restrained. Observation indicated there no signs of restraints in his room and Resident 10's wheelchair had no restraints nor were there any restraints on his bed. During an interview on 5/22/24 at 10:29 AM, the MDS Nurse stated I don't know why .(the MDS dated [DATE] and 2/14/24 were) coded as a restraint. I'll do a correction and re-submit. The facility was asked to provide their policy regarding accurate coding of MDS data. The document sent by the facility was not a policy but what appears to be pages out of a Resident Assessment (RAI) manual published by CMS, dated October 2023. The document did not contain critical elements of a policy (such as General Information, Purpose, Policy, Procedure) and did not address how the MDS nurse should gather and verify data (either through observation, record reviews or staff/resident interviews) prior to coding a resident's MDS.

Based on observation, interviews, and record review the facility failed to develop an individualized care plan for one of 12 sample residents (Resident 11). The facility failed to address Resident 11's behavior of refusing footrests for her wheelchair. Failure to develop an individualized care plan did not ensure the facility was providing care tailored to Resident 11's personal needs. Findings: During observation on 5/21/24 at 1:30 PM, Resident 11 was seen in her wheelchair. The bottom half of her left leg and foot was bent under the seat of her wheelchair. Resident 11 was seen dragging her left leg under her wheelchair as she wheeled herself down the hallway. During an interview on 5/21/24 at 1:31 PM, LVN 2 stated Resident 11 has a history of refusing footrests for her wheelchair. A follow up interview with Resident 11 indicated she does not want a footrest as she believes that the footrest would tip her wheelchair. LVN 2 was asked to search Resident 11's medical record for evidence that this behavior was care planned. LVN 2 stated the behavior was not care planned. Review of the facility's policy titled CARE PLANNING/ INTERDISCIPLINARY TEAM CARE PLANNING CONFERENCE, effective 3/24, indicated To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions. All residents will have a comprehensive care plan to meet their individual needs that is . periodically reviewed and revised after subsequent assessments.

Based on interviews and record review the facility failed to ensure an intervention recommended by a physician was communicated in a timely fashion for Resident 1, one of 12 sampled residents. Resident 1 had a fracture of unknown origin, and his physician recommended no Hoyer lift (a transfer device). This recommendation was not communicated in a timely manner to all direct caregivers. Failure to communicate physician's recommendations to direct caregivers had the potential to inflict and/or worsen an injury. Additionally, the facility failed to provide their policy regarding shift-to-shift endorsement. Findings: Review of Resident 1's medical records titled Progress Notes, Dated 5/19/2024 10:27 AM, indicated the physician assessed Resident 1 and charted .(leg) fracture .He is in his bed, I recommended that staff no longer use the Hoyer lift to get him up because that is what probably caused this fracture, . The facility has an endorsement report book that nurses write down what they want to pass onto the next shift regarding residents under their care. Review of the endorsement report book indicated the No Hoyer lift recommendation was not documented until 5/21/24 (almost 48 hours later). CNA 1 was assigned to care for Resident 1. During an interview on 5/22/24 at 10:04 AM, CNA 1 stated Resident 1 was on bedrest. When asked if the nurses said not to use a Hoyer lift on Resident 1, CNA 1 stated They just told me he was on bedrest. On 5/23/24, the facility was asked to provide their policy regarding endorsement to the next shift. Review of the policy sent by the facility found no such policy. The policy sent by the facility was titled FALL PREVENTION PROGRAM-SNF, revised 8/17. A search of the policy provided found no language about reading the physician's notes and passing on recommendations to the next shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure there was monitoring for adverse side effect (harmful effects suspected to be caused by a medicine) or behavioral monitoring for Ambien (same as Zolpidem, a drug used to treat insomnia) for one of 3 sampled residents (Resident 136). This failure could result in Resident 136 receiving unnecessary use of, ineffective, and/or lack of monitoring for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic [a type of psychiatric medication which are available on prescription to treat psychosis]; (ii) Anti-depressant [prescription medicines to treat depression]; (iii) Anti-anxiety [drugs used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress]; and (iv) Hypnotic [a class of drugs that induce or prolong sleep in people with sleep disorders and are intended to improve the overall quality of sleep]) that could negatively affect the resident's highest practicable mental, physical and psychosocial well-being. Findings: Review of Resident 136's document titled, Profile Face Sheet indicated, she was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a common lung disease that blocks airflow and makes it difficult to breathe), generalized muscle weakness (a decrease in muscle strength), and insomnia (inability to sleep). Review of the document titled, MATRIX FOR PROVIDERS (a form used by the facility to list all current residents and to note pertinent care categories), dated 5/20/24 indicated, Resident 136 was on hypnotic. During a concurrent interview and record review on 5/24/24 at 11:17 AM with Licensed Vocational Nurse (LVN) 3, Resident 136's physician's orders (PO) dated 5/19/24 were reviewed. The PO indicated, Ambien 5mg (milligram) tablet [Zolpidem] -Give 2.5 mg by mouth at HS (Latin: [NAME] somni, at bedtime) For Insomnia AT BEDTIME . LVN 3 stated, I don't see any monitoring when asked if there was behavioral monitoring for Ambien. During a concurrent interview and record review on 5/24/24 at 11:55 AM with Infection Preventionist (IP), Resident 136's document titled, Baseline & Comp (comprehensive) Care Plan was reviewed. The care plan indicated, XXXXX (Resident 136's name) has medication concerns related to . Hypnotic . (A) Monitor . adverse side effects of medication . (A) Every shift recording of presence/absence of untoward mood/behaviors . related to psychotropic medications . IP stated, the care plan was initiated on 5/19/24, but there was no evidence of monitoring for adverse side effects or behaviors for Ambien. She stated, monitoring adverse side effects or behaviors was a part of the care plan, but it was not ordered for nurses to do the interventions when asked. She stated, There is no monitoring since 5/19 when asked. During a concurrent interview and record review on 5/24/24 at 12:27 PM with LVN 3, Resident 136's documents were reviewed. LVN 3 stated, I don't see any sleeping hours when asked if there was monitoring sleeping patterns, sleeping hours, or anything regarding sleeping. She stated, I don't see anything. There's none. Review of the facility's policy and procedure (P&P) titled, Psychotherapeutic (a variety of treatments that aim to help a person identify and change troubling emotions, thoughts, and behaviors) Medication Management Program revised in June 2017 and reviewed in April 2024 indicated, . The focus of this policy is to ensure that all residents who receive psychotherapeutic mediations do so only when necessary to improve their wellbeing and that those medications are consistently monitored for effectiveness, the present of adverse consequences . This facility shall monitor all psychotherapeutic medications for effectiveness and adverse consequences .

Based on observation, interview and record review, the facility failed to ensure that all medications were properly labeled in one out of one sampled medication carts when Resident 132's Prednisone (a medication used to decrease swelling in the body) label was not consistent with the physician order written in the electronic medical record (EMR). This failure has the potential to result in a medication error that could over dose a resident or under dose them. Findings: During a concurrent observation and interview on 05/21/24 at 9:30 AM with Licensed Vocational Nurse (LVN) 4, outside of Resident 132's room, LVN 4 was observed dispensing (taking out medication from its package) two tablets of Prednisone 1 milligram (mg) and one tablet of Prednisone 5mg. LVN 4 stated that they are administering a total of 7mg of Prednisone to Resident 132. A review of Resident 132's medication order for Prednisone, dated to start 05/28/24, indicated that Resident 132 should receive 7 mg (5mg+ 1mg + 1mg = 7mg Total) By Mouth Once daily ( For Month of May give 7mg and starting June 1st 6mg daily) During a concurrent interview and record review on 05/21/24 at 11:50 AM with LVN 4, Resident 132's Prednisone medication labels, dated 05/18/24, were reviewed. The Prednisone 5mg tablet label indicated that Resident 132 should get 1 TAB [tablet] WITH 5MG (6MG) BY MOUTH ONCE DAILY. The Prednisone 1mg tablet label indicated that Resident 132 should get 1 TAB WITH 1MG (6MG) BY MOUTH ONCE DAILY. LVN 4 stated that the label did not match what was written in the EMR. LVN 4 stated that if the physician's medication order is different from the label on the medication, the medication should also have a sticker indicating a dosage change. LVN 4 verified that Resident 132's Prednisone did not have a sticker indicating a dosage change and stated, it should have that sticker. During an interview on 05/21/24 at 12:11 PM with the Director of Nursing (DON), the DON stated that medication labels should typically match the physician's written medication order. In instances that an order is changed but the medication can still be used, the DON stated that the LVN should place a dosage changed sticked on the medication label. The DON further stated that her expectation is that the licensed nurses always defer to the EMR for the most accurate written order. During an interview on 05/22/24 at 11:58 AM with Pharmacist 1, Pharmacist 1 stated that if a medication's ordered directions are changed but the facility would like to use the existing medication, she expects that a change of direction sticker be placed on the medication label to ensure that nurses follow the new order in the EMR. Pharmacist 1 further stated it is possible for a medication error to occur if a medication's label and the order in the EMR are not consistent and there is no sticker indicating a change in the direction of administration.

Based on interview and record review, the facility failed to transmit their Payroll Based Journal (PBJ) data to Center for Medicare Services (CMS) in a timely manner. Failure to transmit staffing data did not ensure the facility was fulfilling their contract agreement with the State and CMS. Additionally, the facility provided an incomplete PBJ data transmission policy which lacked certain key policy elements. Findings: Review of CMS data base indicated the facility failed to transmit their Payroll Based Journal (PBJ, direct caregiver staffing data) data to Center for Medicare Services (CMS). During an interview on 5/20/24 at 3:42 PM, the Minimum Data Set Nurse (MDS Nurse) stated she was responsible for transmitting PBJ data to CMS. The MDS Nurse stated she did not have access to the CMS website, and she had to call IT (Information Technology) at CMS to get access. It was 48 hours before she was granted access. By that time, the deadline for PBJ data submission had passed. On 5/23/24 at 11:50 AM, the Director of Nursing was asked to provide a copy of their policy regarding PBJ data submission. The undated document provided by the facility was titled PBJ Reporting Export & conversion Process Guide. Review of the document indicated it was a process guide and was missing key elements of a standard policy such as: 1.Clearly states the policy's objectives and the expected behavior or actions. 2.Responsibilities: Outlines the roles and duties of individuals or departments involved. 3.Purpose.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when there was a garlic oil container beyond its use-by date in the refrigerator. This failure had the potential to put residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 5/20/24 at 11:05 AM with Director of Dining Services (DoDS), and Executive Chef (EC) in the kitchen, there was one peeled garlic oil container in the refrigerator with a use-by date of 5/15/24. DoDS stated, the garlic oil was expired when asked. He acknowledged that it should have been tossed out. EC also acknowledged it was expired. EC stated, Yes when asked if it should have been tossed out. Review of the facility's policy and procedure P&P titled, PRODUCTION, PURCHASING, STORAGE revised in January 2024, indicated, . All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Foods past the use by, sellby, best-by, or enjoy by date should be discarded . Date and rotate items; first in, first out . Discard food past the use-by or expiration date . Review of the Guidance of Appendix PP, revised on 2/3/23, from Centers for Medicare and Medicaid Services (CMS) indicated, the facility should follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Appendix PP also indicated, unsafe food handling practices represent a potential source of pathogen (any organism, such as viruses or bacteria, that causes disease) exposure for residents. Review of U.S. Food and Drug Administration (FDA)'s 2022 Food Code indicated, . The Food Code states the person in charge of a food establishment is accountable for developing, carrying out, and enforcing procedures aimed at preventing food-borne illness .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to effectively assess or develop therapeutic interventions to one of one sampled resident (Resident 14). The failure resulted in Resident 14 experiencing severe weight loss. Findings: Weight loss in nursing home residents is linked to poor outcomes, including higher rates of hospitalization and death (American Journal of Nursing, 2008). Suggested parameters for evaluating significance of unplanned and undesired weight loss are: Interval: 1 month: significant loss is 5%, severe weight loss if greater than 5%. Interval 3 months: significant weight loss is 7.5%, severe loss if greater than 7.5%. Interval 6 months, significant weight loss 10%, severe weight loss if greater than 10%. (Centers for Medicaid/Medicare, CMS, Appendix PP 2017). Resident 14 was admitted on [DATE], with diagnoses including congestive heart failure (CHF, when the heart muscles do not pump as strong as it should). admission weight was documented on 11/4/21, as 137.2 lbs. admission diet order dated 11/3/21, indicated, .Pre cut meat for diet, no milk . During observation on 12/28/21, at 12:35 PM, Resident 14 was eating the facility served lunch that consist of a french dip sandwich, potato [NAME] soup, steamed green beans, cream puff and sweet potato fries. Resident 14 took a spoonful of the [NAME] soup, and took few of the steamed green beans. During an interview on 12/28/21, at 1 PM, Resident 14 stated, I told them I don't like greasy and fatty food. This is greasy and fatty. I have lost over 10 lbs. Resident 14 stated she will continue to eat her lunch, and does not want anything from the alternative menu. During an interview on 12/28/21, at 1:05 PM, Licensed Vocational Nurse (LVN) 1 stated, Her (Resident 14) appetite vary. During a review of facility document titled Vital Stats for period 11/3/21 thru 12/30/21 for Resident 14 indicated: 11/25/21 weight 139 pounds, 12/2/21 weight 132.2 pounds. Resident 14 lost 4.8 lbs (3.45%) in one week. 12/9/21 weight 127.2 pounds. Resident 14 lost 5.4 lbs (5.22%) in one week. 12/16/21 weight 125.8 pounds, 12/23/21 weight 120.6 pounds. Resident 14 lost 5.2 lbs (4.13%) in one week. 12/28/21 weight 114.8 pounds, an additional weight loss of 5.8 pounds. Resident 14 had a total weight loss of 22.4 lbs (16.33%) since admission (11/3 - 12/28/21). During a review of the Resident 14's clinical records the nursing progress notes indicated the following: 12/2/21, there was no mention of current weight loss, 12/9/21, there was no mention of current weight loss and 12/23/21, there was no mention of current weight loss. During a review of Resident 14's clinical order dated 11/20/21, the physician order indicated, Regular diet with pre-cut meats, no milk, thin liquids. A review of physician progress notes dated 12/6/21 and 12/15/21, has no mention of Resident 14's weight loss. During a review of Resident 14's meal intakes from 12/1 - 12/28/21, indicated breakfast 20% - 80%, lunch 20% -70% and dinner 30% - 85%,100% X 7. During an interview on 12/30/21, 10 AM, LVN 3 stated, Weights are taken weekly, and as per doctors order. The Restorative Nurse Assistant (RNA, ) or the Certified Nurse Assistant (CNA, caregiver) take the residents weight, the licensed nurses are notified if there is a weight loss,and the physician (medical doctor) is notified. The Registered Dietitian (RD, a professional nutritionist, creates nutrition plans to improve the health and physical conditions of residents). RD follow up on residents weight loss, makes recommendations, like supplements and snacks. Residents are monitored. These are all documented in the nurses notes and the RD notes. During an interview on 12/20/21, at 10:55 AM, the RD stated, For assessments, I do the initial assessment on their admission, the quarterly assessment, and as needed for weight changes. Reviewed with RD Resident 14's weight record. RD acknowledged there was no evidence of completed assessments when Resident 14 was experiencing weight losses on 11/25 to 12/2/21, 12/3 to 12/9/21, and on 12/16 to 12/23/21. RD stated, I was not able to document. During an interview on 12/30/21, at 11:05 AM, the Director of Nursing (DON) stated, Assessment is done to newly admitted resident, diet is reviewed, they are assisted to fill out menus, and weights are monitored. The DON acknowledged Resident 14's weight loss and stated, The RD completes assessment and follows up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled according to federal regulations and facility policy and procedure when: 1. There was no direction change refer to chart label on the Omeprazole (a medication used to treat frequent heartburn and stomach ulcers) medication blister pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles) for Resident 4. 2. Suppository medications for two discharged residents were not removed from the active medication storage cabinet. These deficient practices had the potential to cause harm to residents through infection and medication errors. Findings: 1. During a medication pass observation with Licensed Vocational Nurse (LVN) 3, on [DATE], at 4:14 PM, LVN 3 was preparing medications to administer to Resident 4. LVN 3 took one capsule from a medication blister pack with a label indicating, .Omeprazole 20 mg (milligrams) . take 1 cap (capsule) by mouth every day before breakfast as needed for GERD (gastroesophageal reflux disease - also known as acid reflux) . LVN 3 read the label and stated, oh, she's supposed to take two capsules before breakfast and before dinner . the E-MAR (electronic medication administration record) is the bible of medication administration that we follow . During a concurrent interview, LVN 3 acknowledged the medication label was incorrect and stated there should be a sticker label indicating, directions changed refer to chart attached to the medication label. Review of Resident 4's clinical record, the electronic Medication Administration Record and Physician's Orders for [DATE] indicated, . order date [DATE] . start date [DATE] . Omeprazole 20 mg capsule, delayed release [generic] - 2 caps (40 mg) by mouth twice daily for GERD. During an interview with the Director of Nursing (DON) on [DATE], at 11:48 AM, the DON stated the nurse should verify the medication label against the physician's order and notify the pharmacy for any change in dosage and/or frequency. The DON added, a sticker label should be attached to the medication label to alert the nurses of the changes. Review of the facility's policy titled, Medications and Medication Labels, dated 12/12, indicated, .Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws. Procedures . 3. Improperly or inaccurately labeled medications are refused and returned to the dispensing pharmacy . 6. a. If the prescriber's directions for use change or the label is inaccurate, the nurse may place a direction change, change of order-check chart or similar label on the container indicating there is a change in directions for use, taking care not to cover important label information. b. when such a direction change label appears o the container, the medication nurse checks the resident's medication administration record (MAR) or the prescriber's order for current information . Review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 05/16, indicated, .Medication Preparation: . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label . 2. During a medication storage inspection on [DATE], at 12:56 PM, the following suppositories for two expired residents were stored in the active medication storage cabinet: a. Two clear plastic bag, each containing six Acetaminophen (medication used to treat mild to moderate pain and to reduce fever) suppository (a dosage form used to deliver medications by insertion into a body orifice) 650 mg (milligrams) for Resident 2. b. One box containing twelve Bisacodyl (used on a short-term basis to treat constipation and also to empty the bowels before surgery and certain medical procedures) suppository 10 mg. The prescription number and resident's name on the medication label was marked with a black colored marker but remains visible and readable. LVN 1 read the medication label and verified it belongs to a resident who already expired. During a concurrent interview, LVN 1 acknowledged the findings and stated the Acetaminophen and Bisacodyl suppository belongs to the two residents who already expired. LVN 1 stated it should not be stored in the active medication storage cabinet and should have been discarded right after the resident expired. During an interview with the Director of Nursing (DON) on [DATE], at 11:48 AM, the DON stated unused, expired, and discontinued medications including discharged residents are disposed in a medical waste container in the medication room and should not be kept in the active medication storage cabinet. The DON stated there is a separate area to store medications for disposal or destruction in the medication storage room. Review of the facility's policy titled, Disposal of Medications, dated 12/12, indicated, Policy 1. Discontinued medications and/or medications left in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition . 3. Methods of disposition are consistent with applicable state and federal requirements, local ordinances, and standards of practice . Review of the facility's policy titled, Storage of Medications, dated 09/10, indicated, . Procedures . 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal (Refer to Section 5.4 Disposal of Medications) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide residents with the written summary of the Baseline Care Plan (BCP, Baseline Care Plan is developed and implemented for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standard of quality care and must be developed within 48 hours of a resident's admission) for seven (7) residents out of 12 sampled residents, Residents 4, 16, 18, 6, 13, 14, 75. Failure to provide written summary of the BCP to the residents had the potential to compromise person-centered care to each resident, and to safeguard against adverse events that are most likely to occur right after admission. Findings: 1. Review of Resident 4 record on 12/29/21 at 11: 00 AM, indicated he was admitted on [DATE] with diagnosis of orthostatic syncope, secondary diagnosis of chronic upper gastrointestinal bleed. A review of BCP Summary dated 12/20/21, did not indicate acknowledgment of patient or family representative. 2. Review of the Resident 16 record indicated he was admitted on [DATE] with diagnosis of aspiration pneumonia. A review of BCP Summary dated 02/02/2021, did not indicate acknowledgement of patient or family representative. 3. During a review of Resident18 record on 12/29/21 at 9:00 AM, indicated she was admitted on [DATE] with diagnosis of mechanical fall ( an external mechanical force or object caused to fall) unoperable left humerus (the arm bone between the shoulder and elbow) fracture, and cancer of the pancreas. A review of BCP Summary dated 11/15/21 did not indicate acknowledgment of patient or family representative. During an interview on 12/29/21 at 9:00 AM Resident 18, stated . I cannot recall seeing a paper about my care. During an interview on 12/30/2021 at 11:30 AM with ADM and DON stated . we do not do that. During an interview on 12/29/21 at 11:00 with MDSC, stated . practice of letting resident and or responsible party sign and acknowledge the BCP started only last week. Review of the facility Policy and Procedure (P&P) titled Care Planning/Interdisci Team Care Planning Conference dated 4/02 indicated Procedure, 5. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. If resident and/or resident representative is not willing to participate in care planning process the facility will document why in EHR. 7. IDT (Interdisciplinary Team) meetings may take place face-to-face in a conference room or in the resident's room. May involve teleconference or written communications with family and Physicians. Resident and or resident representative will be encouraged to review and sign care plans. Findings: Resident 75 was admitted on [DATE], with diagnoses including urinary tract infection, fracture (break in a bone) of the neck, and congestive heart failure (CHF, when the heart muscle does not pump as strong as it should). During a review of the clinical record on 12/30/21, indicated there was no evidence of documentation a BCP was completed for Resident 75. Resident 14 was admitted on [DATE], with diagnoses including fracture of the right femur (thigh bone), osteoporosis (fragile bones), and CHF. During a review of the clinical record on 12/30/21, indicated there was no evidence of documentation a BCP was completed for Resident 14. Resident 13 was admitted on [DATE], with diagnoses including fracture of the femur (thigh bone), dysphagia (difficulty of swallowing), and hypertension (abnormally high blood pressure). During a review of the clinical record on 12/30/21, indicated there was no evidence of documentation a BCP was completed for Resident 13. Resident 6 was admitted on [DATE], with diagnoses including compression fracture of the vertebra (back bone, spine), osteoporosis, and parkinson's disease ( damage in the brain that affects movement, often including tremors). During a review of the clinical record on 12/30/21, indicated there was no evidence of documentation a BCP was completed for Resident 6. During an interview on 12/20/21, at 3 PM, Director of Nursing stated, Each department fill out their sections in the baseline care plan form, and the Assessment Nurse (MDS) scans it to the residents medical record. During a review of the facility document titled Care Planning/Interdisciplinary Team Care Planning Conference dated 6/17, indicated .7. Interdisciplinary Team (IDT) meetings may take place face-to-face in a conference room or in the resident's room. May involve teleconference or written communications with family and Physicians. Residnet and/or resident representative will be encouraged to review and sign care plans .

Based on observation, interview, and record review, the facility failed to provide care and treatment according to standards of clinical practice for two of 12 sampled residents (Resident 4 and Resident 21) when: 1. The Omeprazole (a medication used to treat frequent heartburn and stomach ulcers) was not administered according to current physician's order for Resident 4. This failure resulted in a medication error. 2. The facility's procedure on management of indwelling catheter and closed drainage system was not implemented for Resident 21. This failure had the potential to cause cross contamination of infection that may jeopardize the health and safety of Resident 21. Findings: 1. During a medication pass observation with Licensed Vocational Nurse (LVN) 3, on 12/29/21, at 4:14 PM, LVN 3 was preparing medications to administer to Resident 4. LVN 3 took one capsule from a medication blister pack with a label indicating, .Omeprazole 20 mg (milligrams) . take 1 cap (capsule) by mouth every day before breakfast as needed for GERD (gastroesophageal reflux disease - also known as acid reflux) . and returned the blister pack in the second drawer of the medication cart. During a concurrent interview and record with LVN 3 on 12/29/21 at 4:16 PM, the electronic Medication Administration Record and Physician's Orders for 12/29/21 indicated, . order date 12/20/21 . start date 12/20/21 . Omeprazole 20 mg capsule, delayed release [generic] - 2 caps (40 mg) by mouth twice daily for GERD. LVN 3 stated, oh, she's supposed to take 2 capsules before breakfast and before dinner . the electronic medication administration record (EMAR) is the bible of medication administration that we follow . LVN 3 acknowledged she forgot to verify the medication label with the EMAR and physician orders. During an interview with the Director of Nursing (DON) on 12/30/21, at 11:48 AM, the DON stated the nurse should always verify the medication label with the physician's order and MAR for current and accurate orders. Review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 05/16, indicated, .Medication Preparation: . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label . Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber . 2. During an observation on 12/28/21, at 3:25 PM, in resident's room, Resident 21 was lying in bed in a lowest position. An uncovered transparent urinary drainage bag (collecting bag) dated 12/22 was attached on the right side of the foot of the bed while the bottom part of the bag with the drain valve was touching the floor. The collecting tube attached to the urinary drainage bag was kinked resulting in urine collected in the tubing. During a concurrent interview, Certified Nursing Assistant (CNA) 1 acknowledged the findings and stated the bag should have a protective cover and should not touch the floor and that the tubing should not be twisted. During an interview with the DON on 12/30/21, at 2:10 PM, the DON stated the facility does not have a policy specific for care and management of residents with indwelling catheters (a soft hollow tube inserted in the bladder to drain urine into a bag outside the body). The DON stated, we use Lippincott Nursing Manual as our policy. Review of the Lippincott Nursing Manual procedure guidelines for Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage System, [2012] 10th ed., indicated, .Maintaining a closed drainage system . 2. Maintain unobstructed urine flow. a. Keep the drainage bag in a dependent position, below the level of the bladder. b. Urine should not be allowed to collect in the tubing because a free flow of urine must be maintained to prevent infection. - (rationale: b. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of drainage to collect int eh loops of tubing.) c. Keep the bag off the floor. - (rationale: c. Prevents bacterial contamination) . 3. Empty the bag at regular intervals, making sure that the drainage valve/spout is not contaminated . c. Avoid letting the drainage bag touch the floor. d. Change the drainage bag if contamination occurs . According to the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter Associated Urinary Tract Infections (2009), retrieved from https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html, dated February 2017, indicated, .III. Proper Techniques for Urinary Catheter Maintenance . III.B. Maintain unobstructed urine flow. III.B.1. Keep the catheter and collecting tube free from kinking. III.B.2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Based on observation and interview, the facility failed to ensure the garbage are contained and a dumpster are covered. This facility's failure has the potential to attract pest to the area. Findings: During an observation and concurrent interview on 12/29/21, at 2:36 PM, the Environmental Manager acknowledged two garbage containers, and one dumspter were uncovered. There was a plastic bag of garbage lying on the ground. by one of the open garbage container. Environmental Manager stated that he has to remind the housekeepers. During an interview on 12/29/21, the Director of Nursing stated, We do not have a policy for garbage disposal or pest control. During an interview on 12/20/21, at 3:45 PM, the Administrator stated, We do not have a policy for garbage disposal. We have look at the maintenance , the environmental and the infection control. We cannot find a policy for garbage.

Based on observation, interview, and record review, the facility failed to implement and maintain its infection control program when: 1. Cleaning and disinfection of the glucometer (a device used to measure blood sugar level) was not performed after use for Resident 18 who was on fingerstick blood sugar monitoring. 2. Resident 21's urinary drainage bag was left uncovered and touching the floor. 3. For Resident 13, the canister and the suction drainage tubing for urine collection was unlabeled and undated and the suction drainage tubing for urine collection was not cleaned after use. Failure to implement infection prevention practices may result in cross contamination of infection that may jeopardize the health and safety of the residents. Findings: 1. During a medication pass observation with Licensed Vocational Nurse (LVN) 3, on 12/29/21, at 4:35 PM, LVN 3 took out a glucometer from the third right drawer of the South medication cart and performed a fingerstick procedure (making a small prick into the fingertip to collect a blood sample on a strip that is inserted in the glucometer to obtain a reading of the blood sugar level) for Resident 18. LVN 3 did not clean and disinfect the glucometer before it was returned on the third right drawer of the South medication cart. During a concurrent interview, LVN 3 stated she used the Sani-Cloth (a brand of disinfectant wipes) wipes (with the purple top cover) to clean the glucometer. LVN 3 stated, I don't clean it after use, only before I use it. LVN 3 acknowledged she did not clean and disinfect the glucometer before and after use for Resident 18. During an interview with the Director of Nursing (DON) on 12/30/21, at 11:50 AM, the DON stated all glucometers should be cleaned and disinfected after each patient use. The Sani-Cloth is an approved disinfectant to use for Assure Platinum glucometers. Review of the Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System, revised 12/17, indicated, .The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens . blood glucose meters need to be leaned and disinfected after each use . 2. During an observation on 12/28/21, at 3:25 PM, in resident's room, Resident 21 was lying in bed in a lowest position. An uncovered transparent urinary drainage bag (collecting bag) dated 12/22 was attached on the right side of the foot of the bed while the bottom part of the bag with the drain valve was touching the floor. The collecting tube attached to the urinary drainage bag was kinked resulting in urine collected in the tubing. During a concurrent interview, Certified Nursing Assistant (CNA) 1 acknowledged the findings and stated the bag should have a protective cover and should not touch the floor and that the tubing should not be twisted. During an interview with the DON on 12/30/21, at 2:10 PM, the DON stated the facility does not have a policy specific for care and management of residents with indwelling catheters (a soft hollow tube inserted in the bladder to drain urine into a bag outside the body). The DON stated, we use Lippincott Nursing Manual as our policy. Review of the Lippincott Nursing Manual procedure guidelines for Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage System, [2012] 10th ed., indicated, .Maintaining a closed drainage system . 2. Maintain unobstructed urine flow. a. Keep the drainage bag in a dependent position, below the level of the bladder . c. Keep the bag off the floor - c. Prevents bacterial contamination . 3. Empty the bag at regular intervals, making sure that the drainage valve/spout is not contaminated . c. Avoid letting the drainage bag touch the floor. d. Change the drainage bag if contamination occurs . 3. Resident 13 was admitted with diagnoses including osteoporosis (fragile bones). Minimum Data Set (MDS, a standardized tool) dated 11/7/21 Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function) score of 13 indicates little to no cognitive impairment. Under functional status Resident 13 requires staff assistance in performance of activity of daily living including toileting and personal hygiene. During observation on 12/28/21, at 11:10 AM, a suction equipment was on an overbed table. The canister and tubing was unlabeled, undated. On concurrent interview, Resident 13 stated, That is my external catheter. A nurse can help you more about it. During an interview on 12/28/21, at 12:32 PM, LVN 2 acknowledged the canister and the tubing were unlabeled, undated, and uncovered. LVN 2 stated, We change the canister and tubing weekly, it has to be dated or else we won't know when to change them. It can cause an infection. During an interview on 12/29/21, at 3:35 PM, LVN 4 stated, The purewick is like a sanitary pad applied in the perineal area to catch the urine. It is connected to the collecting tubing, and the urine was suctioned to the canister. For the aftercare, we bring the canister to the bathroom and dump the urine in the toilet. We rinse the canister just like a bedpan, and set it up again. We do not rinse the urine drainage tubing. The canister and the tubing are change weekly. During a review of the untitled facility document dated 3/3/21, indicated The purewick collection system is for management of urinary incontinence. The external urinary collection device is utilized as an alternative to an indwelling catheter. The term external urinary collection devices by suction or pressure it is connected to a urinary drainage container such as a bag or a bottle . Set up .b. Use standard suction tubing, connect the purewick to external catheter to the collection canister. Peri-care and placement: a . Separate legs, gluteus muscles and labia. b. With soft gauze align distal end of the purewick . During an interview on 12/29/21, at 2 PM, the untitled facility document dated 3/3/21 was reviewed with Director of Nursing (DON). The DON stated, The canister is rinsed with water, it's like a bedpan. We don't disinfect them. We do not rinse the tubing. During a review of the facility Policy and Procedure titled, Cleaning and Disinfection of Resident Care Items and Equipment dated 10/2018, indicated, Policy Statement, Resident- care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendation and the Occupational Safety and Health Administration (OSHA) .c. (1) Non-critical resident-care items includes bedpans . (2) Most non-critical items can be decontaminated where they are used . Per CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) .4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices .4.b. Disinfect noncritical medical devices .with an Environmental Protection Agent (EPA) registered hospital disinfectant using the label's safety precautions and use directions .