Based on interview and record review, the facility failed to ensure for one of two sampled patients (Resident 1), Resident 1's physician was notified of Resident 1's low blood pressure (BP, amount of force blood uses to move through the body), when Resident 1's blood pressure values were above and below their baseline (average). This deficient practice had the potential for Resident 1 to suffer from complications such as dizziness, stroke, hospitalization, and even death. Findings: During a review of Resident 1's History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 1 was admitted to the facility with a medical history of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), depression (mental health condition affecting how you feel, think, and act), lymphoma (blood cancer [body cells grow and affect how other cells work] affecting how the body fights infections), lung and bladder cancer. During a concurrent interview and record review on 6/2/2025 at 3:15 p.m., with the Director of Nursing (DON), of Resident 1's Vitals Report, dated 12/27/2024 to 1/31/2024, Resident 1's BP readings ranged from 100/65 millimeters of mercury (mmHg, a unit of measure), to 132/75 mmHg. In the same interview and record review on 6/6/2025 at 3:15 p.m., with the DON, of Resident 1's Vitals Report, dated 12/27/2024, the record indicated Resident 1's BP on 12/27/2024 at 8:02 p.m. was 89/62 mmHg. The record further indicated Resident 1's BP on 12/28/2024 at 8:42 a.m. was 172/94, higher than Resident 1's baseline. Resident 1's BP was not checked between 12/27/2024 at 8:02 p.m. to 12/28/2024 at 8:42 a.m. (a total of 12 hours with no recheck). In the same interview and record review on 6/6/2025 at 3:15 p.m., with the DON, the DON stated there was neither a nurse to physician communication note, nor a note on the Resident 1's condition for the two BPs. The DON stated Resident 1's nurse should have rechecked the BP and called the doctor. The DON stated untreated BP could have created dizziness or other complications. During a review of the facility's policy and procedure (P&P) titled, Vital Signs, Weights, Height, dated 4/2025, the P&P indicated, The physician shall be notified when the vital signs are out of range from the resident's baseline for two or more consecutive episodes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adhere to professional standards of practice when Licensed Vocational Nurse 4 (LVN 4) did not record a resident's blood sugar after taking it for one (Resident 185) out of six residents observed during the dining observation task. This failure placed the resident at risk for complications such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) Findings: During a review of Resident 185's Face Sheet (admission record), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (high blood sugar). During a review of Resident 185' s Minimum Data Set (MDS, a resident assessment tool), dated 10/10/2024, the MDS indicated Resident 185 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 185 required set-up help (helper sets up) for eating and personal hygiene. During a review of Resident 185's Physician's Orders, dated 10/01/2022, the order indicated to take Resident 185's blood sugar twice a day at 7:30 a.m. and 4:30 p.m. During a review of Resident 185's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/17/2024, indicated LVN 4 took the blood sugar late at 5:49 p.m. on 12/17/2024. During an observation and interview with Resident 185 on 12/17/2024 at 4:20 p.m., observed and spoke with resident in the 3rd floor dining area. When Resident 185 was asked if a licensed nurse took her blood sugar before dinner, Resident 185 stated a licensed nurse has not checked her blood sugar yet. Observed the dining area from 4:20 p.m. until 5:32 p.m. At 5:32 p.m., Resident 185 started eating. During a concurrent record review and interview with LVN 4 on 12/17/24 at 5:35 p.m., LVN 4 stated she had checked Resident 185's blood sugar it at 3:25 p.m. but did not document the blood sugar value anywhere. LVN 4 stated the computer would only allow licensed nurses to document the value one hour before only and not anytime before that. LVN 4 stated she did not write down the value on a sheet of paper to put into the computer when it would allow them to document. LVN 4 stated it is important to document when the blood sugar was taken to avoid confusion. LVN 4 stated she will check Resident 185's blood sugar again. LVN 4 stated she should have documented the blood sugar value when it was originally taken. During an observation on 12/17/2024 at 5:42 p.m., observed LVN 4 wheeling Resident 185 out of the dining room to go to the resident's room to take the blood sugar. During an interview with the Director of Nursing (DON) on 12/18/2024 at 2:40 p.m., the DON stated LVN 4 should have documented the blood sugar after taken or else it is not done. The DON stated licensed nurses must follow the Medication Administration policy in that, although there was a blood sugar taken and no medication given, it is the same principle as with administering medication. The DON stated the blood sugar should be documented right after obtaining and before conducting medication administration for other residents. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, last reviewed 10/16/2024, the P&P indicated the individual administering the medication must initial the resident's MAR on the appropriate line and date for the specific day before administering the next resident's medication.

Based on observation, interview and record review, the facility failed to ensure a resident was provided a communication device (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) with the language that the resident was able to understand for one of one sampled resident (Resident 10). This deficient practice had the potential to prevent the resident from communicating with the staff and had the potential to delay receiving appropriate care/treatment the resident needed. Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted the resident on 6/7/2021 and readmitted the resident on 9/27/2022 with diagnoses including benign prostatic hyperplasia (prostate gland [gland in the male reproductive system] enlargement that can cause urination difficulty), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). The admission Record indicated Resident 10's preferred language was Farsi (foreign language). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 9/13/2024, the MDS indicated the resident had severely impaired cognition (thought processes) and required set-up assistance for eating and oral hygiene, and need supervision for upper body dressing and bed mobility. The MDS indicated Resident 10 needed moderate assistance for showering and lower body dressing. During a concurrent observation and interview on 12/17/2024 at 2:02 p.m., in Resident 10 's room with Certified Nursing Assistant 1 (CNA 1), observed Resident 10 in a wheelchair. The surveyor tried to interview Resident 10, but Resident 10 was not able to communicate in English. The surveyor did not observe any communication board in Resident 10's room or attached to Resident 10's wheelchair. CNA 1 stated that Resident 10 only speaks Farsi, but never saw a communication board in Resident 10's room. During a concurrent interview and record review on 12/18/2024 at 1:53 p.m., with Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 10's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) that addressed the resident's language barrier, initiated on 6/8/2021 and revised 12/17/2024. MDSN 1 stated that the care plan indicated that Resident 10 had a communication impairment (having difficulty understanding or expressing thoughts through speaking, writing, or body language) because Resident 10 speaks Farsi. MDSN 1 stated that interventions of the care plan indicated to provide Resident 10 with a communication board. MDSN 1 stated that this deficient practice had the potential to leave Resident 10's needs unmet. During an interview on 12/19/2024 at 12:30 p.m., with the Director of Nursing (DON), the DON stated that the communication board had to be provided to Resident 10 according to Resident 10's care plan interventions. The DON stated if a communication board was not in place, then the staff would not be able to communicate with the resident effectively and address the resident's needs. During a review of the facility's policy and procedure titled, Interpreter Services, last reviewed 10/16/2024, the policy indicated the facility shall have communication boards for residents who are unable to communicate.

Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM - designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set to the correct setting for one (Resident 480) out of five sample residents investigated under the care area of pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice had the potential to increase the resident's risk of skin breakdown. Findings: During a review of Resident 480's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 12/2/2024 with diagnoses including pressure-induced deep tissue damage of sacral region (a serious injury where the tissues deep beneath the skin over the sacrum [the bony area at the base of the spine] have been damaged due to prolonged pressure). During a review of Resident 480's Minimum Data Set (MDS - a resident assessment tool), dated 12/11/2024, the MDS indicated the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated the resident had one or more unhealed pressure ulcers/injuries and was at risk of developing pressure ulcers/injuries. During a review of Resident 480's physician's orders, an order, dated 12/3/2024, indicated to provide the resident with an LALM for wound management. During a review of Resident 480's care plan (a document that outlines a person's health needs, current medical conditions, and the specific treatments or care required to manage their health) for actual impaired skin integrity related to a sacrococcyx (the bony area at the base of the spine) pressure injury, initiated on 12/13/2024, the care plan indicated the goal that the risk to the resident's skin will be minimized. Among some of the listed interventions included LALM for wound management. On 12/16/2024 at 10 a.m., during an observation, observed Resident 480 asleep in bed. Observed the resident's LALM set to 400 pounds (lbs - unit of measurement). On 12/16/2024 at 10:11 a.m., during a concurrent interview and record review, reviewed Resident 480's current weight and physician orders with Registered Nurse 1 (RN 1). RN 1 stated the resident currently weighed 94 lbs. RN 1 stated although the physician's order did not specify a setting for the LALM, the wound doctor wanted it to be set according to the resident's weight. On 12/16/2024 at 10:12 a.m., during a concurrent observation and interview, Licensed Vocational Nurse 1 (LVN 1) confirmed that Resident 480's LALM mattress was currently set to 400 lbs. LVN 1 stated it should have been set according to the resident's weight, which was 94 lbs. LVN 1 stated the resident currently had an unhealed sacral pressure injury. On 12/20/2024 at 10:41 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident 480's LALM should have been set according to the resident's weight. The DON stated it was important for the LALM to be at the correct setting in order to help the resident's wound heal. The DON stated, if not set correctly, then there can be a delay in the healing process, or the resident's wound may not heal at all. During a review of the Operation Manual for the LALM, the Operation Manual indicated to set it according to the correct patient weight. During a review of the facility's policy and procedure titled, Wound and Skin Management, last reviewed and revised on 10/16/2024, the policy and procedure indicated that any resident who has pressure injuries will receive the necessary treatment and services to promote healing, prevent infections, and prevent new injuries from development .Licensed nurses will assure that the interventions [in the care plan] have been implemented .The interdisciplinary team (IDT - a group of professionals from different disciplines or areas of expertise who work collaboratively together to achieve a common goal), licensed nurses, and certified nursing assistants (CNAs) will assure the following preventative measures for residents at risk for skin breakdown - apply pressure redistribution devices for residents in bed based on the resident's individual

Based on observation, interview, and record review, the facility failed to ensure a licensed nurse did not leave a cup of medications unattended at a resident's bedside for one (Resident 223) out of five sampled residents investigated under the care area of accidents. This deficient practice had the potential for Resident 223 to miss a dose of medications and residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents. Findings: During a review of Resident 223's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 3/21/2024 with diagnoses including dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 223's Minimum Data Set (MDS - a resident assessment tool), dated 10/1/2024, the MDS indicated the resident had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). On 12/16/2024 at 10:25 a.m., during an observation, observed Resident 223 in her wheelchair. Observed a cup with eight medications inside on the resident's table. Resident 223 stated she takes her medications by herself all the time. On 12/16/2024 at 10:40 a.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated she should not have left the resident's medications unattended at the bedside because the resident was at risk for choking and should have been supervised taking her medications. LVN 2 stated the resident did not have an assessment for self-administration of medications. On 12/19/2024 at 1:47 p.m., during a concurrent interview and record review, reviewed Resident 223's assessments with Minimum Data Set Nurse 1 (MDS Nurse 1). MDS Nurse 1 confirmed that the resident did not have an assessment for self-administration of medications. On 12/20/2024 at 9:52 a.m., during an interview with the Director of Nursing (DON), the DON stated it was important not to leave medications unattended at the resident's bedside because the licensed nurse will not know whether or not the resident actually took the medication. The DON stated, in addition, that other residents would also have unauthorized access to the medications and could possibly experience adverse side effects. During a review of the facility's policy and procedure titled, Medication (Self-Administration), last reviewed and revised on 10/16/2024, the policy and procedure indicated that medications allowed to be left at the bedside may be done only on the specific order of the physician .Medications stored at bedside must not be accessible to other residents who may wander into rooms .Only the medications permitted for self-administration shall be left at bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 114's admission Record, the admission Record indicated that the facility initially admitted Resident 114 on 4/6/2022 and readmitted the resident on 8/16/2023 with diagnoses including hypertensive chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), Alzheimer's disease (a brain disorders that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), and 2019-nCov acute respiratory disease (Covid-respiratory illness that causes fever, coughing, and shortness of breath). During a review of Resident 114's Care plan initiated on 8/25/2023 and revised on 07/30/2024, the care plan indicated that Resident 114 had a respiratory system problem related to pneumonia (is an infection that inflames the air sacs [thin-walled structures composed of simple squamous epithelium] in one or both lungs) and being Covid positive. The care plan indicated an intervention to change oxygen tubing and label it every Sunday. During a review of Resident 114's MDS dated [DATE], the MDS indicated that the resident had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS further indicated that Resident 114 needed setup assistance for eating, and moderate-to-maximal assistance for showering, oral and toileting hygiene, and was dependent on the assistance of two or more helpers for lower body dressing. During a review of Resident 114's Physician's Order, the Physician's Order indicated an order dated 1/29/2024 for oxygen at 2L (measurement of oxygen flow) via nasal canula as needed (PRN) for shortness of breath. During an observation on 12/16/2024, at 9:27 AM, Resident 114 was observed in the dining room in a wheelchair with oxygen being administered to the resident via nasal canula. During a concurrent observation and interview on 12/16/2024 at 9:30 AM in the dining room with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated that the oxygen tubing was last changed and labeled on 12/8/2024. LVN 5 stated that according to the facility policy, the oxygen tubing and nasal canula should have been changed on Sunday, 12/15/2024. LVN 5 stated that not changing oxygen tubing and nasal canula every 7 days may lead Resident 114 developing a respiratory infection. During an interview on 12/19/2024 at 8:45 AM with the Infection Preventionist (IP), the IP stated that oxygen tubing had to be changed every Sunday and as needed and labeled with the date when it was last changed to prevent the possibility of Resident 114 developing a respiratory infection. During an interview on 12/19/2024 at 12:30 PM with the Director of Nursing (DON), the DON stated that the oxygen tubing had to be changed every seven days and labeled with date when it was last changed to prevent the possibility of Resident 114 developing a respiratory infection. During a review of the facility Policy and Procedure named Oxygen Management, last reviewed on 10/16/2024, the policy indicated : The oxygen cannula, mask, and tubing shall be dated and changed every seven (7) days and as needed. Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 114 and Resident 222) investigated under infection control and respiratory care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) were provided care consistent with professional standards of infection control practice by failing to: 1. Label Resident 222`s oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy), with the date and time it was last changed. 2. Change Resident 114's oxygen tubing with a nasal canula (a small flexible tube with two prongs that fit inside the nostrils, used to deliver extra oxygen) every seven (7) days. These deficient practices had the potential to place Resident 114 and Resident 222 at increased risk of infection and cause complications associated with oxygen therapy. Findings: 1. During a review of Resident 222's admission Record, the admission Record indicated that the facility admitted the patient on 3/1/2024, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), history of falling, and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, and uneasiness). During a review of Resident 222`s Minimum Data Set (MDS - a resident assessment tool) dated 10/01/2024, the MDS indicated the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 222 was dependent on staff (helper does all of the effort) for showering/bathing, lower body dressing, and toileting hygiene. The MDS further indicated that Resident 222 was using oxygen therapy (a treatment that provides you with supplemental, or extra, oxygen) while a resident at the facility. During a review of Resident 222`s Order Report dated 6/4/2024, the Order Report indicated to administer oxygen at two liters per minute via nasal canula (NC-a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath (SOB). The Order Report indicated to maintain the oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) greater than 92% at bedtime. During a review of Resident 222`s Order Report dated 8/31/2024, the Order Report indicated to change the oxygen tubing bag every Sunday and label the tube and the bag on Sundays. During a review of Resident 222`s Care Plan (written guide that organizes information about the resident's care) for COPD initiated on 4/3/2024, the care plan indicated a goal that the resident will verbalize ease of respiration every day for 90 days. The care plan indicated interventions to administer oxygen at 2 liters per minute as needed for SOB, to assess and monitor quality of breath, and to elevate the resident`s head of bed to position of comfort. During an observation on 12/16/2024 at 10:40 a.m. inside Resident 222's room, the resident was observed laying on her bed. Resident 222 was receiving oxygen at 2 liters per minute via NC. However, the oxygen tubing did not have a label including the date and time it was last changed. During a concurrent observation and interview on 12/16/2024 at 10:45 a.m. inside Resident 222's room, with Registered Nurse 3 (RN 3), RN 3 stated that Resident 222`s oxygen tubing did not have a label with the date and time it was last changed. The RN 3 stated that the facility staff is required to change the oxygen tubing once a week on Sundays. She (RN 3) stated the potential outcome of not changing patient`s oxygen tubing once per week as ordered by the physician is placing the patient at risk for respiratory infection. During an interview on 12/19/2024, at 8:49 a.m., with the facility`s Infection Preventionist (IP), the IP stated that the facility staff is required to change the oxygen tubing once per week on Sundays as ordered by the physician and label the tubing with the date and time it was changed. The IP stated Patient 222`s oxygen tubing was not labeled with the date and time it was last changed, and the potential outcome is the increased risk of infection for Resident 222. During a review of the facility Policy and Procedure named Oxygen Management, last reviewed on 10/16/2024, the policy indicated : The oxygen cannula, mask, and tubing shall be dated and changed every seven (7) days and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was documented evidence that non-pharmacological interventions (healthcare treatments that do not primarily involve medication) were attempted prior to administering as needed (PRN) opioid (medications prescribed by doctors to treat persistent or severe pain) pain medications on multiple dates for two (Residents 126 and 65) out of three sampled residents investigated under the care area of pain management. This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration (breathing). Findings: a. During a review of Resident 126's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 7/12/2021 and readmitted the resident on 10/26/2022 with diagnoses including hereditary and idiopathic (an illness that isn't connected to any particular cause) neuropathies (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), ankylosing spondylitis of unspecified sites in spine (a type of arthritis that causes inflammation in the spine and can affect other parts of the body, including the joints, ligaments, and tissues), and chronic pain syndrome (a condition where a person experiences persistent pain that lasts for an extended period [typically more than 3 months], often without a clear identifiable cause, and significantly impacts their daily life). During a review of Resident 126's Minimum Data Set (MDS - a resident assessment tool), dated 10/23/2024, the MDS indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated the resident received PRN pain medication but did not receive non-medication interventions for pain. During a review of Resident 126's care plan (a document that outlines a person's health needs, current medical conditions, and the specific treatments or care required to manage their health) for altered comfort - pain, initiated on 7/13/2021, the care plan indicated to provide for positioning, diversional activities, snacks, back to bed, gentle range of motion (ROM - the extent to which a joint can move in different directions) or massage, and walking for pain relief. On 12/19/2024 at 1:03 p.m., during a concurrent interview and record review, reviewed Resident 126's physician's orders with Minimum Data Set Nurse 1 (MDS Nurse 1). MDS Nurse 1 stated the resident had an order for tramadol (a specific type of narcotic medicine called an opioid that is approved to treat moderate to moderately severe pain in adults) 25 milligrams (mg - unit of measurement) by mouth every 6 hours as needed for pain 6-10/10, ordered on 7/25/2024. Reviewed the resident's 10/2024 Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) with MDS Nurse 1. MDS Nurse 1 confirmed that the resident received tramadol 25 mg on the following dates: 1. 10/16/2024 at 2:45 p.m. 2. 10/16/2024 at 10:39 p.m. 3. 10/18/2024 at 11:42 a.m. 4. 10/20/2024 at 10:17 p.m. 5. 10/22/2024 at 12:59 p.m. When asked if there was any documentation indicating that non-pharmacological interventions were attempted prior to administering the PRN opioid pain medication, MDS Nurse 1 stated she could not find any documentation indicating that non-pharmacological interventions were attempted prior to the administration of tramadol. MDS Nurse 1 stated it was important to first try non-pharmacological interventions because tramadol was a narcotic (a class of drugs that produce insensibility or stupor due to their depressant effect of the central nervous system), and narcotics had a lot of adverse side effects, so it is better if the resident received less of it. MDS Nurse 1 stated some common side effects of opioids included nausea and vomiting, severe headache, dependence, sedation, and constipation. On 12/20/2024 at 9:50 a.m., during an interview with the Director of Nursing (DON), the DON stated it was important for licensed nurses to first attempt non-pharmacological interventions prior to administering prn opioid pain medication because opioids have a lot of adverse side effects. The DON stated that non-pharmacological interventions should be attempted first because, sometimes, they can help with pain management, and the resident may not even need the medication. The DON stated some possible side effects of opioids included increased drowsiness, constipation, and risk for falls. During a review of the facility's policy and procedure titled, Pain Management, last reviewed and revised on 10/16/2024, the policy and procedure indicated that non-pharmacologic interventions must first be tried. Whether non-pharmacologic methods were tried should be documented on the PRN med sheet. Examples of non-pharmacologic methods include: 1. Distraction 2. Massage 3. Ambulation (walking) 4. Repositioning 5. Heat or cold applications 6. Music therapy 7. Provide additional snacks, consider warm milk 8. Provide additional staff time to comfort resident 9. Provide a quiet environment for resident to sleep 10. Ensure no constipation b. During a review of Resident 65's Face Sheet, the Face Sheet indicated the facility admitted the resident on 1/1/2024 and readmitted the resident on 8/20/2024 with diagnoses including cervical spinal stenosis (a narrowing of the spinal canal in the neck that compresses the spinal cord and nerves), polyneuropathy (a condition that occurs when multiple peripheral nerves in the body malfunction at the same time), and chronic pain syndrome. During a review of Resident 65's MDS, dated [DATE], the MDS indicated the resident had intact cognition and required moderate assistance from staff for most ADLs. During a review of Resident 65's care plan for altered comfort - potential for pain, initiated on 1/1/2024, the care plan indicated to provide for positioning, diversional activities, snacks, back to bed, gentle ROM or massage, and walking for pain relief. On 12/19/2024 at 1:23 p.m., during a concurrent interview and record review, reviewed Resident 65's physician's orders with MDS Nurse 1. MDS Nurse 1 stated the resident had an order for hydrocodone-acetaminophen (used to relieve moderate to severe pain) 5-325 mg by mouth twice a day as needed for moderate to severe pain 5-7/10, ordered on 12/3/2024. Reviewed the resident's 12/2024 MAR with MDS Nurse 1. MDS Nurse 1 confirmed that the resident received hydrocodone-acetaminophen 5-325 mg on the following dates: 1. 12/5/2024 at 11:54 p.m. 2. 12/6/2024 at 7:58 p.m. 3. 12/7/2024 at 10:13 p.m. 4. 12/11/2024 at 8:41 p.m. When asked if there was any documentation indicating that non-pharmacological interventions were attempted prior to administering the PRN opioid pain medication, MDS Nurse 1 stated she could not find any documentation indicating that non-pharmacological interventions were attempted prior to the administration of hydrocodone-acetaminophen. MDS Nurse 1 stated it was important to first try non-pharmacological interventions because hydrocodone-acetaminophen was a narcotic, and narcotics had a lot of adverse side effects, so it is better if the resident received less of it. MDS Nurse 1 stated some common side effects of opioids included nausea and vomiting, severe headache, dependence, sedation, and constipation. On 12/20/2024 at 9:50 a.m., during an interview with the DON, the DON stated it was important for licensed nurses to first attempt non-pharmacological interventions prior to administering prn opioid pain medication because opioids have a lot of adverse side effects. The DON stated that non-pharmacological interventions should be attempted first because, sometimes, they can help with pain management, and the resident may not even need the medication. The DON stated some possible side effects of opioids included increased drowsiness, constipation, and risk for falls. During a review of the facility's policy and procedure titled, Pain Management, last reviewed and revised on 10/16/2024, the policy and procedure indicated that non-pharmacologic interventions must first be tried. Whether non-pharmacologic methods were tried should be documented on the PRN med sheet. Examples of non-pharmacologic methods include: 1. Distraction 2. Massage 3. Ambulation 4. Repositioning 5. Heat or cold applications 6. Music therapy 7. Provide additional snacks, consider warm milk 8. Provide additional staff time to comfort resident 9. Provide a quiet environment for resident to sleep 10. Ensure no constipation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to six (6) out of eight (8) sampled residents investigated under the storage of drugs and biologicals (Resident 219, Resident 36, Resident 4, Resident 51, Resident 214 and Resident 111) by failing to: 1. Label Resident 219's opened Lantus-100 (type of insulin [a hormone that works by lowering levels of sugar in the blood]) pen), with an open date to readily identify its beyond use date. This deficient practice had the potential for the for unintentional administration of possibly expired medications for Resident 219. 2. Ensure the opened (in-use) Olopatadine HCl solution (type of eye drops used to treat eye itching) 0.1% (measurement of concentration) vial was discarded after its beyond use date of 11/26/24 from medication cart team B on the second floor. This deficient practice had the potential for the Olopatadine HCl solution 0.1% to lose efficacy and be ineffective in the treatment of Resident 36's condition. 3. Ensure the opened (in-use) Even Care Glucose Control Solution (used to confirm that the meter [blood sugar machine] was working correctly) had a readable open date label to readily identify its beyond use date. This deficient practice had the potential for the Even Care Glucose Control Solution to lose efficacy and to be ineffective in the management of the residents' diabetes mellitus (DM - high blood sugar). 4. Discard a bottle of Opti-Fiber (brand name for a fiber solution to prevent constipation [difficulty emptying the bowels]) for Resident 4, that had expired 10/20/24, but was still in the medication cart. 5. Discard Resident 51's Ativan (a medication given to decrease anxiety [feelings of uneasiness]) blister pack (also known as bubble pack, a card holding usually medicinal tablets or capsules that are individually packaged in a clear plastic case sealed to the card) in which the physician's order ended in November 2024 but, the medication was still in the medication cart. 6. Discard a bottle of Simethicone 80 milligram (mg, a unit of measure for medications) tablets (medication used to relieve too much gas in the stomach and intestines) that had expired 10/2024 but was still in the medication cart. 7. Discard glucose control solution should have been used by 12/05/2024 but was still in the medication cart. These deficient practices had the potential for residents to receive medications that were ineffective, medication that was not intended for the resident, or to have glucose meter reading results to be incorrect. 8. Ensure eyedrops latanoprost ophthalmic (relating to the eye) and netarsudil ophthalmic solution 0.02% were not in the medication cart past the use by date for Residents 214 and 111. This deficient practice had the potential to result in the residents receiving medications that were ineffective. Findings: 1.During a review of Resident 219's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and major depressive disorder (a serious mental illness that can cause a persistent low mood, loss of interest, and other symptoms that affect how a person feels, thinks, and acts). During a review of Resident 219's Minimum Data Set (MDS, a resident assessment tool), dated 11/11/2024, the MDS Indicated Resident 219 had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) .The MDS indicated Resident 219 needed setup help only (helper sets up or cleans up only) with eating and supervision with most activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 219's Physician's Orders, the physician's order indicated an order for Lantus-100 (a medication to lower blood sugar) 18 units (a unit of measurement for medications) subcutaneously (under the skin) at 8:30 PM needed for hypertension (high blood pressure), dated 11/21/2024. During a review of Resident 219's Medication Administration Record, the administration record indicated that Resident 219 received Lantus-100 18 units on following dates: 1. 12/1/2024 at 8:30 p.m. 2. 12/2/2024 at 8:30 p.m. 3. 12/3/2024 at 8:30 p.m. 4. 12/4/2024 at 8:30 p.m. 5. 12/5/2024 at 8:30 p.m. 6. 12/6/2024 at 8:30 p.m. 7. 12/7/2024 at 8: 30 p.m. 8. 12/8/2024 at 8:30 p.m. 9. 12/9/2024 at 8:30 p.m. During a concurrent observation and interview, observed the contents of second floor medication cart B with Licensed Vocational Nurse 6 (LVN 6). An opened Lantus-100 pen was observed with no open date and no beyond used date. LVN 6 confirmed that Lantus-100 was not labeled with an open date. LVN 6 confirmed with the facility pharmacist that the Lantus-100 pen had to be discarded 28 days after opening. LVN 6 stated that the Lantus pen should be labeled with an open date to readily identify its beyond use date. 2. During a review of Resident 36's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), and glaucoma (an eye condition that occurs when the optic nerve is damaged, which can lead to vision loss or blindness). During a review of Resident 36's Minimum Data Set (MDS, a resident assessment tool), dated 11/20/2024, the MDS Indicated Resident 36 had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS further indicated Resident 36 needed setup help only (helper sets up or cleans up only) with eating and moderate assistance with most activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 36's Physician's Orders, the physician's order dated 7/31/2024 indicated an order for Olopatadine (type of eye drops used to treat eye itching) 0.1% (measurement of concentration) 1 drop in each eye once a day. During a review of Resident 36's Medication Administration Record, the administration record indicated that Resident 36 received Olopatadine on the following dates: 1. 12/1/2024 at 8:30 a.m. 2. 12/2/2024 at 8:30 a.m. 3. 12/3/2024 at 8:30 a.m. 4. 12/4/2024 at 8:30 a.m. 5. 12/5/2024 at 8:30 a.m. 6. 12/6/2024 at 8:30 a.m. 7. 12/7/2024 at 8:30 a.m. 8. 12/8/2024 at 8:30 a.m. 9. 12/9/2024 at 8:30 a.m. 10. 12/10/2024 at 8:30 a.m. 11. 12/11/2024 at 8:30 a.m. 12. 12/12/2024 at 8:30 a.m. 13. 12/13/2024 at 8:30 a.m. 14. 12/14/2024 at 8:30 a.m. 15. 12/15/2024 at 8:30 a.m. 16. 12/17/2024 at 8:30 a.m. 17. 12/18/2024 at 8:30 a.m. 18. 12/19/2024 at 8:30 a.m. During a concurrent observation and interview on 12/18/2024 at 9:27 a.m., observed the contents of the second floor medication cart B with Licensed Vocational Nurse 6 (LVN 6). Observed an opened Olopatadine HCl solution with an open date of 10/30 /2024 and a beyond used date of 11/26/2024. LVN 6 confirmed that the Olopatadine HCl solution should have been discarded after 11/6/2024 and should not have been stored in the cart. 3. During a concurrent observation and interview on 12/18/2024 at 9:27 a.m., observed an opened Even Care Glucose Control Solution for a blood sugar machine with an illegible (writing is not clear enough to be read properly) open date. LVN 6 confirmed that she could not read the open date on Even Care Glucose Control Solution. LVN 6 stated she confirmed with the facility pharmacist that the Even Care Glucose Control Solution had to be discarded 90 days after opening. LVN 6 stated that the illegible open date made it impossible to identify the correct ''beyond used date and had the potential to cause ineffective management of the residents' diabetes mellitus. During a review of the Even Care Glucose Solution manual, the manual indicated that newly open bottles of control solution must be marked with an open date on the space provided on the control solution labels and discarded 90 days after opening. During an interview on 12/20/2024 at 9:47 a.m., with the Director of Nursing (DON), the DON stated it was important for medications not to be kept in the cart or used beyond their expiration date because the medication may be ineffective. The DON stated that if a medication was ineffective, then the president's health condition may get worse or remain untreated. The DON stated that the Even Care Glucose Control Solution should have had an open and beyond used date to make sure that the blood sugar level was monitored effectively for residents with DM. During a review of the facility's policy and procedure titled, Drug Storage/Inventory Inspection, last reviewed and revised on 10/16/2024, the policy and procedure indicated that drugs shall not be kept in stock after the expiration date on the label. No unusable drugs shall be stored, distributed, or administered. Unusable drugs include outdated drugs, broken drug packages and damaged drugs, mislabeled drugs, drugs with illegible labels, deteriorated drugs, contaminated drugs, and recalled drugs. All drugs scheduled to expire during the next 60 days of the inspection shall be replaced. 8a. During a review of Resident 214's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 5/13/2024 with diagnoses including glaucoma (a group of eye diseases that damage the optic nerve) and peripheral opacity of the cornea of the left eye (when the clear surface of your eye becomes scarred). During a review of Resident 214's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2024, the MDS indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 214's physician's orders, an order, dated 7/26/2024, indicated to administer netarsudil 0.02% eyedrops one drop to the right eye at bedtime for glaucoma. During a review of the Medication Package Insert for netarsudil, the package insert indicated that, after opening, the product may be kept at 36 - 77 degrees Fahrenheit for up to six weeks. On 12/19/2024 at 2:03 p.m., during a concurrent observation and interview, observed the contents of fourth floor medication cart A with Licensed Vocational Nurse 2 (LVN 2). Observed an opened bottle of netarsudil 0.02% eyedrop with an open date of 10/22/2024. LVN 2 stated she confirmed with the facility pharmacist that the netarsudil was good for up to 42 days after opening. LVN 2 stated that the bottle of netarsudil was past the 42 days and should not have been in the cart. On 12/20/2024 at 9:47 a.m., during an interview with the Director of Nursing (DON), the DON stated it was important for medications not to be kept in the cart or used beyond the expiration date because the medication may be ineffective. The DON stated, if a medication was ineffective, then the resident's health condition may get worse or remain untreated. During a review of the facility's policy and procedure titled, Drug Storage/Inventory Inspection, last reviewed and revised on 10/16/2024, the policy and procedure indicated that drugs shall not be kept in stock after the expiration date on the label. No unusable drugs shall be stored, distributed, or administered. Unusable drugs include: outdated drugs, broken drug packages and damaged drugs, mislabeled drugs, drugs with illegible labels, deteriorated drugs, contaminated drugs, and recalled drugs. All drugs scheduled to expire during the next 60 days of the inspection shall be replaced. 8b. During a review of Resident 111's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 5/9/2016 and readmitted the resident on 11/25/2024 with diagnoses including glaucoma. During a review of Resident 111's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition and required maximal assistance from staff for most ADLs. During a review of Resident 111's physician's orders, an order, dated 11/25/2024, indicated to administer latanoprost 0.005% one drop to both eyes at bedtime for glaucoma. During a review of the Medication Package Insert for latanoprost, the package insert indicated that, once a bottle is opened for use, it may be stored at room temperature up to 77 degrees Fahrenheit for six weeks. On 12/19/2024 at 2:03 p.m., during a concurrent observation and interview, observed the contents of fourth floor medication cart A with LVN 2. Observed an opened bottle of latanoprost 0.005% eyedrop with an open date of 10/26/2024. LVN 2 confirmed with the pharmacy that the latanoprost was good for up to 42 days after opening. LVN 2 stated that the bottle of latanoprost was past the 42 days and should not have been in the cart. On 12/20/2024 at 9:47 a.m., during an interview with the Director of Nursing (DON), the DON stated it was important for medications not to be kept in the cart or used beyond the expiration date because the medication may be ineffective. The DON stated, if a medication was ineffective, then the resident's health condition may get worse or remain untreated. During a review of the facility's policy and procedure titled, Drug Storage/Inventory Inspection, last reviewed and revised on 10/16/2024, the policy and procedure indicated that drugs shall not be kept in stock after the expiration date on the label. No unusable drugs shall be stored, distributed, or administered. Unusable drugs include: outdated drugs, broken drug packages and damaged drugs, mislabeled drugs, drugs with illegible labels, deteriorated drugs, contaminated drugs, and recalled drugs. All drugs scheduled to expire during the next 60 days of the inspection shall be replaced. 4-7. During a review of Resident 4's Face Sheet (admission record), the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hyperlipidemia (high cholesterol). During a review of Resident 4' s Minimum Data Set (MDS, a resident assessment tool), dated 12/12/2024, the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 4 required moderate assistance (helper does less than half the effort) with personal hygiene. During a review of Resident 4's Physician's Order, dated 7/29/2024, the Physician's Orders indicated an order for Benefiber Healthy Shape powder (fiber powder) two teaspoons (a unit of measure for medications), give in eight ounces (a unit of measure for medications) of water as needed once a day for constipation. During a review of Resident 4's Care Plan (CP) for Constipation, initiated 8/25/2022, the CP indicated a goal that the resident will have a bowel movement at least every three days for three months. The care plan indicated an intervention to give medication as needed. During a review of Resident 51's Face Sheet (admission record), the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included anxiety. During a review of Resident 51' s MDS, dated [DATE], the MDS indicated Resident 51 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 51 was dependent (helper does all the effort) on staff for dressing and personal hygiene. During a review of Resident 4's Physician's Order, dated 11/12/2024, the Physician's Orders indicated an order for Ativan 0.5 mg tablet by mouth every 12 hours for 14 days (ending 11/26/2024), as needed for general anxiety manifested by agitation/restlessness as evidenced by trying to get out of bed. During a medication cart observation on 12/18/2024 at 3:40 p.m. for Medication Cart 3B, with Licensed Vocational Nurse 3 (LVN 3), on 12/18/2024 at 3:40 p.m., observed Glucose Control Solution with a Beyond-Use Date of 12/05/2024. LVN 3 stated the date indicated is the last day the solution should be used. Observed a bottle of Resident 4's Fiber Powder with an expiration date of 10/20/2024. LVN 3 stated the Fiber Powder should have been removed on 10/20/2024. Observed bottle of Simethicone 80 mg tablets with an expiration date indicated:10/2024. LVN 3 stated the medication should have been discarded on 10/2024. Observed the bubble pack for Ativan 0.5 mg tablets for Resident 51. Reviewed Resident 51's Physician's Orders which indicated Ativan 0.5 mg tablets were discontinued on 11/26/2024. LVN 3 stated they should have been removed when they received the order to discontinue the medication. During an interview with Registered Nurse 2 (RN 2) on 12/19/2024 at 10:06 a.m., RN 2 stated Resident 51's Ativan order was an as needed order valid for 14 days only. RN 2 stated when the order ended, the medication should have been removed from the medication cart. RN 2 stated if there is no order for the medication, it should not be in the medication cart. During an interview with the Director of Nursing (DON) on 12/20/2024 at 10:50 a.m., the DON stated it is important to not use the glucose control solution beyond the use by date because the glucose reading could be affected by the outdated solution giving an incorrect glucose reading. During an interview with the DON on 12/19/2024 at 3:58 p.m., the DON stated medications with no order should be removed from the medication cart. The DON stated the staff are to call the pharmacy to come and take the medication from the medication cart. The DON stated this should be done the day the medication was discontinued or by the next day if the pharmacy is not available the day of the order discontinuation. The DON stated this was important to avoid possible medication error such as a resident accidentally receiving the unordered medication. The DON stated it is important for medications to not be used past their expiration date because there was a potential for a resident to receive an ineffective medication. During a review of the facility's policy and procedure (P&P) titled, Disposition of Controlled (medications that the use and possession of are controlled by the federal government) and Non-Controlled Medication (medications such as over the counter or physician prescribed medications that are considered not controlled), last reviewed 10/16/2024, the P&P indicated when a controlled substance is discontinued or expired, the medication shall be stored in an appropriately locked and secure area. The policy indicated the pharmacist is to be notified when controlled substances are discontinued or expired. The policy indicated when a non-controlled medications is discontinued or expired, the medication shall be removed from the medication cart and placed in a secured medication room in the designated containers for disposition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 8's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/1/2023 and readmitted the resident on 12/17/2024 with diagnoses including dysphasia, unspecified dementia, and type two diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 8's MDS dated [DATE], the MDS indicated that the resident's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 8 required staff supervision when eating. During a review of Resident 8's Physician Order Report dated 11/1/2024, the order indicated that the resident should be provided with a no added salt (NAS) mechanical soft diet with a nectar thick consistency fluid (fluids that are thicken than regular, still pourable but flows more slowly). During a review of Resident 8's Nutritional assessment dated [DATE], the assessment indicated that the resident's diet was upgraded from pureed diet (when all food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) to mechanical soft diet. During a review of Resident 8's Care Plan for Nutritional Alteration, initiated on 4/1/2024, the care plan indicated a care goal that the resident will not experience significant weight loss for the next three months. The care plan interventions were to provide a mechanical soft diet as ordered by the physician, and to monitor and record meal/supplement intake. During a dining observation on 12/16/2024 at 12:20 p.m., Resident 8 was observed sitting at a table with his wife and eating his lunch. Resident 8's lunch menu ticket indicated NAS-mechanical soft diet with nectar thick liquids. The lunch menu ticket indicated chopped corned beef, chopped [NAME] salad with tomato, chopped cabbage, and chopped boiled potatoes. Observed Resident 8's plate included corn beef, cabbage, and potatoes which were not chopped as per lunch menu ticket. Resident 8 was trying to cut the potatoes, placed the uncut cabbage on the side and did not touch the uncut corn beef. During a concurrent observation and interview on 12/16/2024 at 12:26 p.m., with the facility's Speech-Language Pathologist (SLP), observed Resident 8's lunch tray. The SLP stated that Resident 8's lunch tray was not a mechanical soft diet as ordered but instead a regular diet. The SLP stated that Resident 8 was served his wife's tray, which is not a mechanical soft diet tray. The SLP stated staff made a mistake and served Resident 8 a meal which was not chopped, which is a deficient practice. The SLP stated the potential outcome is Resident 8's inability to chew and a potential to choke. During a concurrent interview and record review on 12/18/2024 at 1:40 p.m., with the facility's Registered Dietician 2 (RD 2), reviewed Resident 8's physician orders. RD 2 stated that Resident 8's diet order is mechanical soft diet. RD 2 stated during lunch on 12/16/2024, Resident 8 did not receive mechanical soft diet as ordered by his physician. RD 2 stated that the staff served Resident 8 his wife's lunch tray which was not mechanical soft diet. RD 2 stated the potential outcome of not providing a mechanical soft diet to a resident is the non-compliance with a physician order and an increased risk of choking. During an interview on 12/19/2024 at 1:30 p.m., with the DON, the DON stated that the facility is required to serve meals based on the residents' physician orders. The DON stated Resident 8 was not provided with a mechanical soft diet as ordered by his physician. The DON further stated the potential outcome of not serving mechanical soft to a resident as ordered by the physician is an increased risk of choking and the resident's inability to consume the food which could lead to possible weight loss. During review of the facility's policy and procedure (P&P) titled, Meal Identification, reviewed 10/2024, the P&P indicated that to assist in setting up and serving the correct food trays/diets to residents, the dietary services department will use appropriate identification (e.g., color coded or computer-generated diet cards) to identify the various diets for each resident. Nursing staff shall check food trays for the correct diet before serving the residents. If there is an error, the nurse supervisor will notify the dietary department immediately so that the appropriate food tray can be served. During a review of the facility's P&P titled, Therapeutic Diets, reviewed 10/2024, the P&P indicated that mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. The dietary services manager will establish and use a ray identification system to ensure that each resident receives his or her diet as ordered. Based on observation, interview, and record review, the facility failed to meet the nutritional needs for four of 49 sampled residents (Resident 35, Resident 68, Resident 163, and Resident 8) by failing to provide a mechanical soft diet as ordered by the physician by failing to: 1. Ensure kitchen staff placed chopped squash on the tray table for residents on mechanical soft (diet that is ground or chopped for those that have difficulty swallowing or have missing teeth) and dysphagia diets (diet that is chopped or pureed [prepared in a way similar to a pudding] for those with difficulty swallowing) for Resident 35, Resident 68, and Resident 163. 2. Ensure staff did not accidentally serve Resident 8 the incorrect diet when being served lunch. These deficient practices had the potential to place the residents at risk for choking which could then lead to hospitalization and death. Findings: 1.a. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident on 10/9/2021 with diagnoses that included dysphagia (difficulty swallowing). During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool), dated 10/11/2024, the MDS indicated Resident 35 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 35 was on a mechanically altered diet (diet requiring a change in texture of food or liquids). During a review of Resident 35's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) for Nutritional Status, initiated 10/11/2024, the care plan indicated an intervention that Resident 35 was prescribed a mechanical soft diet. During a review of Resident 35's Tray Card (a piece of paper that indicates the specific textured meal being served to a resident based on their physician ordered diet, usually placed on the tray beside the meal so staff can check the actual meal being served with what is on the paper), dated 12/18/2024, the Tray Card indicated Resident 35 was prescribed a mechanical soft diet and in bolded writing indicated, chopped roasted squash. 1.b. During a review of Resident 68's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2022 and re-admitted the resident on 9/17/2022 with diagnoses that included dementia (a progressive state of decline in mental abilities). During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 68 was on a mechanically altered diet. During a review of Resident 68's Care Plan for Nutritional Status, initiated 7/31/2024, the care plan indicated an intervention that Resident 68 was prescribed a mechanical soft diet. During a review of Resident 68's Tray Card, dated 12/18/2024, the Tray Card indicated Resident 35 was prescribed a mechanical soft diet and in bolded writing indicated, chopped roasted squash. 1.c. During a review of Resident 163's admission Record, the admission Record indicated the facility admitted the resident on 7/19/2023 with diagnoses that included dementia. During a review of Resident 163's MDS, dated [DATE], the MDS indicated Resident 163 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 163 was prescribed a mechanically altered diet. During a review of Resident 163's Care Plan for Nutritional Alteration, initiated 7/25/2024, the care plan indicated a goal that the resident will not have significant weight loss for three months. The care plan indicated an intervention that Resident 163 was prescribed a mechanical soft diet. During a review of Resident 163's Tray Card, dated 12/18/2024, the Tray Card indicated Resident 163 was prescribed a mechanical soft diet and in bolded writing indicated, chopped roasted squash. During a concurrent observation, interview, and record review on 12/18/2024 at 11:55 a.m., with Registered Dietician 1 (RD 1) and Food Services Director (FSD), reviewed the Kitchen Menu Spread Sheet for 12/18/2024 which indicated squash should be chopped for residents on mechanical soft and dysphagia diets. When asked where the chopped squash was for the residents on mechanical soft and dysphagia diets, RD 1 stated that item was not on the tray table. RD 1 stated they would check to see when the item would be sent to the dining area. The FSD stated the cooks did not want to chop the squash because it would fall apart and be mushy. Observed Resident 35, Resident 68, and Resident 163 received their food with squash that had not been chopped. During an interview on 12/18/2024 at 1 p.m., with RD 1, RD 1 stated the residents on the mechanical soft diet should have received the chopped squash because they are to follow the menu so that residents are not put at risk for choking. RD 1 stated chopping the squash ensured the squash skin would be removed. During an interview on 12/18/2024 at 1:14 p.m., with [NAME] 1, [NAME] 1 stated if they cut the squash, it would be too mushy but that the squash should have been chopped. [NAME] 1 stated they ran out of time to chop the squash before transporting from the kitchen to the tray tables in the resident dining areas. [NAME] 1 stated his assistant chops the squash but had not chopped it. [NAME] 1 stated they should have chopped the squash before sending it to the resident dining areas. [NAME] 1 stated they should have followed the menu because it puts residents at risk for choking. [NAME] 1 stated when the squash was first sent to the dining area it was not chopped, but he chopped the next batch and sent that to the 1st floor dining area and the other dining rooms. During an interview on 12/19/2024 at 4:23 p.m., with the Director of Nursing (DON), the DON stated it is important for dietary staff to follow the menu spreadsheet to reduce the risk of possible choking. During a concurrent interview and record review on 12/20/2024 at 10 a.m., with RD 1, reviewed the facility's policy and procedure titled, Menus, and Mechanical Soft Diet, both last reviewed 10/16/2024. RD 1 stated the Dietary Menu Spreadsheet is what the kitchen staff follow in preparing meals indicated by the physician's prescribed order for a resident. The Menu policy indicated menus are written and approved by Registered Dieticians to achieve the dietary standards stated in the Diets manual. RD 1 stated the Diets manual refers to the food texture for a certain type of diet such as a mechanical soft diet. The Menu policy indicated therapeutic diets will be provided for each resident in accordance with the prescribed physician order by a person lawfully authorized to give such an order. Reviewed the Mechanical Soft Diet policy with RD 1. RD 1 stated according to the policy, vegetables, such as squash, are to be chopped, well cooked, soft vegetables. RD 1 stated since squash had a skin, it would also apply to the reference tough skins are removed from the Fruits section of the policy. During a review of the facility's policy and procedure titled, Mechanical Soft Diet, last reviewed 10/16/2024, the policy indicated the foods are the same as the Regular diet, but are modified in texture, such as ground or chopped. The policy indicated chopped well cooked soft vegetables. During a review of the facility's policy and procedure titled, Menus, last reviewed 10/16/2024, the policy indicated menus are written and approved by Registered Dieticians to achieve the dietary standards stated in the Diets manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to report an incident of alleged abuse involving one of one sampled resident (Resident 1) to the Department in accordance with State law within five working days of the incident. Resident 1 made sexual allegations against one CNA 1 who worked at the facility. This deficient practice had the potential for the underreporting of abuse incidents and a delay in an investigation of abuse allegations, placing the affected Resident 1 and/or other residents at risk for potential further abuse. Findings: During a concurrent interview and record review on 3/27/2024 at 10:08 a.m. with Director of Nursing Services (DON), Resident 1's initial psychiatric evaluation, dated 2/23/2024, was reviewed. The initial psychiatric evaluation indicated that Resident 1 was admitted on [DATE], to the Skilled Nursing Facility section. with a diagnosis including mild cognitive impairment (a mental condition related to a disconnection with reality) amongst other past medical history. During a review of Resident 1's Initial Psychiatric Evaluation (a commonly use assessment used to diagnose mental disorders), dated 2/23/2024, the initial psychiatric evaluation indicated Resident 1's diagnosis of unspecified psychosis (a mental condition related to a disconnection with reality) rule out major neurocognitive disorder (a decreased in mental function and loss of ability to do daily task) with psychosis. During an interview on 3/27/2024 at 10:15 a.m. with Social Worker (SW), SW stated that the staff initially reported the incident on 2/16/2024, and SW went to meet and interview Resident 1. SW stated that Resident 1 changed the story three days (2/19/2024) later, SW stated that Resident 1 reported that CNA 1 did something sexual to his wife. During an interview on 3/27/2024, at 10:34 a.m., with CNA 1, CNA 1 stated that he (CNA 1) had been working at the facility for two years. CNA 1 stated that he (CNA 1) got the assignment, he (CNA 1) opened the door to Resident 1's room and saw her (Resident 1's wife) coming out of the bathroom around 7 a.m. on 2/16/24. CNA 1 stated that he (CNA 1) offered to pick up her (Resident 1's wife) clothes and she (Resident 1's wife) went back to the bed. Resident 1 approached CNA 1 and told CNA 1 to get out of the room. CNA 1 reported what happened to the charge nurse (CN). CN informed CNA 1 to exchange resident with another CNA. CNA 1 stated that he (CNA 1) never went back to the room of Resident 1. Since then, CNA 1 stated that he (CNA 1) had never been to the room, CNA 1 said that he (CNA 1) had been assigned to a different area and different floor and continued to work for the remainder of his (CNA 1) shift. During an interview on 3/27/2024, at 10:50 a.m., with the Charge Nurse (CN), CN stated that the assignment was done on 2/16/2024. CN stated that CNA 1 came to CN and told CN Resident 1 does not want me in the room. CN stated that she removed CNA 1 from the scene but CNA 1 continued to take care of other residents for the remainder of the shift. CN stated that she (CN) did not have a conversation with Resident 1. During an interview on 3/27/2024, at 11:02 a.m., with Social Worker (SW) and DON, SW stated not reported because they did their own investigation, the abuse allegation was not reported to CDPH. SW stated we knew he was delusional; however, it was not reported to any licensing agency. SW stated that the importance is to have a third-party review to make sure nothing occurred. So that the third-party gives a chance to investigate. Both the SW and the DON stated that this allegation of abuse should have been reported to the agency (CDPH) and the individual (CNA 1) should have been suspended pending the outcome of the investigation. Both DON and SW verbalized understanding of this process. During a review of the facility's policy and procedure (P&P) titled Abuse and Crime Prevention and Reporting, dated 10/2023, the P&P indicated, when an allegation or reasonable suspicion occurs see Table A for agency reporting process and timeline, as per Title 42. CDPH District Office. Occurrence Alleged or Known incident involves abuse or serious bodily injury. Written or Electronic Report cover letter and SOC 341 or 342 within 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent further potential abuse when CNA 1 was allowed to finish his (CNA 1) shift after an allegation of abuse was made by one of one sampled resident (Resident 1) in accordance with the facility's policy and procedure regarding abuse investigation. This deficient practice had the potential for exposing Resident 1 and other residents to potential abuse by the alleged perpetrator by not removing him (CNA 1) from the facility pending investigation of the abuse allegation and allowing him (CNA 1) to work for the remainder of his (CNA 1) shift. Findings: During a concurrent interview and record review on 3/27/2024 at 10:08 a.m. with the Director of Nursing Services (DON), Resident 1's initial psychiatric evaluation, dated 2/23/2024, was reviewed. The initial psychiatric evaluation indicated that Resident 1 was admitted on [DATE] to the Skilled Nursing Facility section with a diagnosis including mild cognitive impairment (a mental condition related to a disconnection with reality) amongst other past medical history. During a review of Resident 1's Initial Psychiatric Evaluation (a commonly use assessment used to diagnose mental disorders), dated 2/23/2024, the initial psychiatric evaluation indicated Resident 1's diagnosis of unspecified psychosis (a mental condition related to a disconnection with reality) rule out major neurocognitive disorder (a decreased in mental function and loss of ability to do daily task) with psychosis. During an interview on 3/27/2024 at 10:15 a.m. with Social Worker (SW), SW stated that the staff initially reported the incident on 2/16/2024, and SW went to meet and interview Resident 1. During the initial interview on 2/16/24, Resident 1 did not mention any sexual allegation. SW stated that Resident 1 changed the story three days (2/19/2024) later, SW said that Resident 1 reported that CNA 1 did something sexual to his (Resident 1)wife. During an interview on 3/27/2024, at 10:34 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that he (CNA 1) had been working at the facility for two years. CNA 1 said that he (CNA 1) got the assignment, he (CNA 1) opened the door to Resident 1's room and saw Resident 1's wife coming out the bathroom around 7 a.m. CNA 1 stated that he (CNA 1) offered to pick up her (Resident 1's wife) clothes and she (Resident 1's wife) went back to the bed. Resident 1 approached CNA 1 and told CNA 1 to get out from the room. CNA 1 reported what happened to the charge nurse (CN). CN informed CNA 1 to exchange resident with another CNA. CNA 1 said that he (CNA 1) never went back to the room. Since then, CNA 1 stated that he had never been to the room, CNA 1 said that he had been assigned to a different area and different floor instead of being sent home. During an interview on 3/27/2024, at 10:50 a.m., with the Charge Nurse (CN), CN stated that the assignment was done on 2/16/2024. CN stated that CNA 1 came to CN and told CN Resident 1 does not want me in the room. CN stated that she removed CNA 1 from the scene, but CNA 1 continued to take care of other patients during the remainder of the shift. CN said that she (CN) did not have a conversation with Resident 1. During a review of the facility's policy and procedure (P&P) titled, Abuse and Crime Prevention and Reporting, dated 10/2023, the P&P indicated, if the suspected perpetrator is an identifiable employee, remove the employee from providing care. The abuse prevention coordinator or designee will consider suspension of the employees in collaboration with HR. In this case CNA 1 continued working for the remainder of his shift on 2/16/2024 and returned to the care of the same resident on 2/18/2024 as per CNA Assignment Worksheet 7-3 shift as verified by the DON.

Based on observation, interview, and record review, the facility failed to ensure a resident was not wearing a hospital gown for multiple days despite the resident's request to wear her own personal clothes for one of one sampled resident (Resident 63) investigated under resident rights. This deficient practice resulted in the resident not being treated with dignity and respect which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 63's Face Sheet (admission record) indicated the facility admitted the resident on 4/6/2021, with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems) and insomnia (persistent problems falling and staying asleep). A review Resident 63's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 1/12/2024, indicated that Resident 63 had the ability to make self-understood and had the ability to understand others. The MDS indicated Resident 63 is dependent on staff for personal hygiene and lower body and upper body dressing. During a concurrent observation and interview on 1/23/2024 at 8:40 a.m., observed Resident 63 laying in bed, awake and wearing a hospital gown. Resident 63 stated that for three days now she had been wearing a hospital gown and has told the nurse that she wants to wear her own clothes, but the staff never changed her. Resident 63 stated that she prefers to wear her own clothes. During a concurrent observation and interview on 1/25/2024 at 9:38 a.m., with Registered Nurse 2 (RN 2), observed Resident 63 in bed wearing a hospital gown. When Resident 63 was asked if she wants to change into her own clothes, Resident 63 in the presence of RN 2, stated that she's tired of wearing a hospital gown and she's been wearing it for several days now. RN 2 stated that using personal clothing instead of a hospital gown can promote the resident's dignity and the fact that this is their home, they should look and feel at home and not as a patient. A review of the facility's policy and procedure titled, Residents/Patient Rights, last reviewed on 10/2023, indicated, The facility protects and promotes the rights of each resident/patient. The resident/patient has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .

Based on observation, interview, and record review, the facility failed to accommodate a resident's preference of keeping his urinal (a container used to collect urine) by his bedside for one of one sampled resident (Resident 21) investigated for accommodation of needs. This deficient practice violated the resident's right to make choices. Findings: A review of Resident 21's Face Sheet (admission record) indicated the facility admitted the resident on 12/4/2019 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 21's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/20/2023, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision for most activities of daily living (ADLs - the fundamental skills people need to care for themselves). A review of Resident 21's Care Plan (a document that summarizes a resident's health conditions, care needs, and treatments) for risk for falls and injury related to dementia initiated on 12/26/2019, indicated the resident had a fall on 1/27/2020 when he tried to walk to the bathroom, lost his balance, and fell. The goal indicated that the resident would reduce the severity of a fall-related injury. An intervention was for Resident 21 to use his urinal at the bedside, which was initiated on 1/27/2020. During a concurrent observation and interview on 1/22/2024 at 3:01 p.m., Resident 21 stated that Registered Nurse 1 (RN 1) had told him he could not keep his urinal by his bedside but had to leave it in the bathroom instead. Resident 21 stated it did not make any sense for him to keep getting up to go to the bathroom to use his urinal. Observed Resident 21's urinal on the sink counter in the bathroom. During an interview on 1/24/2024 at 3:31 p.m., with RN 1, RN 1 stated that Resident 21 preferred to keep his urinal on his bedside table, but the Certified Nursing Assistants (CNAs) were instructed to put it back in the bathroom because they were in-serviced (a training that takes place while someone is working and learning new skills) that it was for infection control (policies and procedures that prevent or stop the spread of infections in healthcare settings) purposes. RN 1 stated that Resident 21 continued to put it back by his bedside. During an interview on 1/24/2024 at 3:35 p.m., with Minimum Data Set Nurse 2 (MDS Nurse 2), MDS Nurse 2 stated that Resident 21 had a fall on 1/27/2020 when he tried to walk to the bathroom. During an interview on 1/25/2024 at 9:38 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she had explained to Resident 21 that it was better for him to keep his urinal in the bathroom due to infection control reasons, but the resident kept putting his urinal back by his bedside. During an interview on 1/25/2024 at 11:50 a.m., with the Director of Nursing (DON), the DON stated if it was Resident 21's preference to keep his urinal by his bedside, then the facility should try to accommodate him. The DON stated it was important to accommodate the resident's needs because he had the right to make decisions about his own care. The DON stated it was a potential violation of the resident's right to make decisions if the facility did not attempt to accommodate his needs. A review of the facility's policy and procedure titled, Accommodation of Needs, last reviewed on 10/2023, indicated that in order to create an individualized, home-like environment, each resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents.

Based on interview and record review, the facility failed to ensure a copy of the resident's advance directive (a written statement of a person's wishes regarding medical treatment) is kept in the resident's chart and easily retrievable for one of eight sampled residents (Resident 215) investigated for advance directive. This deficient practice had the potential to create confusion which could lead to conflict with the resident's wishes regarding their health care. Findings: A review of Resident 215's Face Sheet (admission record) indicated the facility originally admitted the resident on 6/27/2022 and readmitted the resident on 7/23/2023 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 215's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/5/2023, indicated that Resident 215 sometimes made self-understood and sometimes understood others. The MDS indicated Resident 215 was dependent on staff for personal hygiene, toileting, oral hygiene and eating. During a concurrent interview and record review on 1/25/2024 at 8:08 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 215's Physician Orders for Life-Sustaining Treatment (POLST- a portable medical order form that records patients' [resident's] treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) dated 10/14/2022. Resident 215's POLST indicated that Resident 215 executed an advance directive dated 8/6/2022. RN 2 was unable to locate Resident 215's advance directive in the resident's record. RN 2 stated that if a resident has executed an advance directive it must be in the resident's medical chart or electronic record to make sure that the resident's healthcare wises are honored. RN 2 stated not following the resident's wishes is a violation of their rights. A review of the facility's policy and procedure titled, Advance Directive, last reviewed on 10/2023, indicated, A resident/patient's choice about advance directive will be respected .should the resident/patient indicate that he or she has issued advance directives about his or her care and treatment, the facility will require that a copy of such directives be included in the medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 19's Face Sheet indicated the facility admitted the resident on 7/26/2023 and readmitted the resident on 9/14/2023 with diagnoses that included Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements), vascular dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life caused by brain damage from impaired blood flow to the brain), and need for assistance with personal care. A review of Resident 19's MDS dated [DATE], indicated the resident usually understood others and usually was able to make herself understood. The MDS further indicated the resident required substantial/maximal assistance (the helper does more than half the effort) for showering, dressing, putting on footwear, and rolling left to right. During a concurrent observation and interview on 1/24/2024 at 7:49 a.m., with LVN 2, observed Medication Cart A located in the hallway at the nursing station. Observed Medication Cart A unattended and the computer screen facing the dining room with staff and residents present. Observed the computer screen displayed Resident 19's MAR. Observed LVN 2 walking down the hallway towards Medication Cart A. Upon arrival at Medication Cart A, LVN 2 stated she was in Resident 19's room administering the resident's medications. LVN 2 observed the computer screen and stated she left the computer screen open to Resident 19's MAR while she went to the resident's room. LVN 2 stated she should not have left the computer screen open for privacy issues. During an interview on 1/24/2024 at 9:12 a.m., with Registered Nurse 1 (RN 1), RN 1 stated computer screens should not be left open to a resident's MAR when unattended. RN 1 stated it was a Health Insurance Portability and Accountability Act (HIPAA, a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed) issue and a resident's medication is considered private and confidential. During a concurrent interview and record review on 1/25/2024 at 9 a.m., with the DON, reviewed the facility's policy and procedure titled, Resident/Patient Rights, last reviewed 10/2023. The DON stated the facility's policy and procedure was not followed because it created a privacy issue when the computer screen was left open to a resident's MAR and the resident information could be seen. The DON stated it could potentially result in residents feeling upset that others would know what medications they take, and the residents have a right to privacy. A review of the facility's policy and procedure titled, Resident/Patient Rights, last reviewed 10/2023, indicated the facility protects and promotes the rights of each resident/patient. The resident/patient has a right to a dignified existence and self-determination. Facility staff will assist residents/patients in exercising their rights. Residents have the right to be assured confidential treatment of financial and health records. Based on observation, interview, and record review, the facility failed to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) provided bodily privacy to a resident while the resident was in the bathroom for one of two sampled residents (Resident 38) investigated for dignity. 2. Ensure a resident's rights to personal privacy and confidentiality of their personal and medical records by failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not leave an unattended computer screen in a public area displaying a resident's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for one of two sampled residents (Resident 19). This deficient practice violated the residents' right to privacy. Findings: 1. A review of Resident 38's Face Sheet (admission record) indicated the facility originally admitted the resident on 11/8/2021 and readmitted the resident on 7/27/2022 with diagnoses including obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/13/2023, indicated the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance with toileting transfer. During an observation on 1/22/2024 at 2:46 p.m., observed the bathroom door wide open and Resident 38 sitting on the toilet with CNA 1 at his side. Observed Resident 38's alert and oriented (person is awake, aware, and responsive to their surroundings) roommate and an alert and oriented female resident inside the room. During an interview on 1/22/2024 at 2:55 p.m., with CNA 1, CNA 1 stated that she should have provided privacy to Resident 38 by closing the bathroom door. During an interview on 1/25/2024 at 9:53 a.m., with the Director of Staff Development (DSD), the DSD stated she provided in-services (training that takes place while someone is working and learning new skills) to Certified Nursing Assistants (CNAs) regarding personal privacy during patient care. The DSD stated it was important to preserve the residents' dignity because it's one of the residents' rights. The DSD stated that privacy should have been provided to Resident 38 while he was in the bathroom by having the door closed in order to preserve his dignity. The DSD stated that Resident 38 could possibly feel that his privacy had been invaded if the other residents had seen him. During an interview on 1/25/2024 at 11:43 a.m., with the Director of Nursing (DON), the DON stated that CNA 1 should have closed the bathroom door to provide privacy to Resident 38. The DON stated it was important to provide the resident privacy because it can emotionally affect the resident if someone else were to see him at a time when he needed personal privacy. A review of the facility's policy and procedure titled, Residents/Patient Dignity and Privacy, last reviewed on 10/2023, indicated that the facility provides care for residents/patients in a manner that respects and enhances each resident/patient's dignity, individuality, and right to personal privacy. Each resident/patient's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with residents/patients, staff carries out activities which assist the resident/patient in maintaining and enhancing his or her self-esteem and self-worth. Use a closed door, a drawn curtain, or both, to shield the resident/patient during all personal care and treatment procedures.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a centralized document of a resident's condition, diagnosis, the nursing team's goals for the resident, and measure of the resident's progress) for a resident's use of an antibiotic (medicine that fights bacterial infections) for one of six sampled residents (Resident 224) investigated for antibiotic use. This deficient practice had the potential to result in failure to deliver necessary care and services. Findings: A review of Resident 224's Face Sheet (admission record) indicated the facility admitted the resident on 12/5/2023 and readmitted the resident on 1/3/2024 with diagnoses including enterocolitis (inflammation of the digestive tract) due to clostridium difficile (C-diff - a bacterium that causes diarrhea and colitis [inflammation of the colon]). A review of Resident 224's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/7/2024, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required maximum assistance from staff for bed mobility, transfers, and toileting. During a concurrent interview and record review on 1/25/2024 at 8:21 a.m., with Minimum Data Set Nurse 2 (MDS Nurse 2), reviewed Resident 224's physician's orders and care plans from 1/3/2024 to 1/25/2024. MDS Nurse 2 stated Resident 224 had a physician's order for vancomycin (antibiotic used to treat colitis) 125 milligram (mg- unit of measurement) by mouth every six hours for C-diff, started on 1/3/2024. Upon review of Resident 224's care plans, MDS Nurse 2 stated she could not find a care plan for the resident's use of vancomycin. MDS Nurse 2 stated it was important to have a care plan for the use of vancomycin so that staff were aware of what possible adverse reactions (undesired harmful effect resulting from a medication or other intervention) they needed to watch out for. MDS Nurse 2 stated that, without a care plan, the resident could possibly experience side effects or an adverse reaction, and the staff would not know what to do. During an interview on 1/25/2024 at 11:48 a.m., with the Director of Nursing (DON), the DON stated that if a resident is taking an antibiotic, then there should be a care plan for it. The DON stated it was important to have a care plan because it guides the resident's care and allows for staff to know what interventions should be implemented. The DON stated that the care plan would also have included the side effects and adverse reactions that staff needed to watch out for. The DON stated that, without the guidance of a care plan, staff would not know what interventions need to be implemented. A review of the facility's policy and procedure titled, The Resident Care Plan, last reviewed on 10/2023, indicated the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. Healthcare professionals involved in the care of the resident shall contribute to the resident's written care plan. Professionals from each discipline write the portion of the plan that pertains to their field, including their approach to the resident's current problem(s). Although the Care Area Assessments trigger most problem areas, all other problems not identified in the CAAs must also be included in the care plan. It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated.

Based on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's health conditions, care needs, and treatments) to reflect an actual choking incident for one of four sampled residents (Resident 142) investigated for care plans. This deficient practice had the potential to result in the resident not receiving appropriate care and treatment specific to the resident's needs. Findings: A review of Resident 142's Face Sheet (admission record) indicated the facility originally admitted the resident on 2/6/2020 and readmitted the resident on 8/10/2023 with diagnoses including dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness), Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements), and dysphagia (difficulty swallowing). A review of Resident 142's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/10/2023, indicated that the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for all activities of daily living (ADLs - the fundamental skills people need to do every day to live independently and keep themselves safe and healthy). A review of Resident 142's Situation, Background, Assessment, and Recommendation report (SBAR - a structured communication framework that helps teams share information about a patient's condition or other issue), dated 11/24/2023, indicated the resident had a chocking incident. A review of Resident 142's Care Plan titled, Nutritional Status, initiated on 2/11/2022, indicated Resident 142 had a chocking incident on 2/10/2021. During a concurrent interview and record review on 1/24/2024 at 1:51 p.m., with Minimum Data Set Nurse 2 (MDS Nurse 2), reviewed Resident 142's SBAR dated 11/24/2023, care plan titled, Nutritional Status, and care plans from 11/24/2023 to 1/24/2024. MDS Nurse 2 stated that on 11/24/2023, Resident 142 had a choking incident while being assisted with feeding by a Certified Nursing Assistant (CNA). Upon review of Resident 142's care plans, MDS Nurse 2 stated she could not find a care plan addressing the choking incident that occurred on 11/24/2023 nor could she find any new interventions that were implemented. MDS Nurse 2 stated the incident should have been care planned with new interventions so that staff were aware of how to intervene next time. MDS Nurse 2 stated, if there was no care plan to address the incident, then the resident could have another choking incident in the future. During an interview on 1/25/2024 at 11:45 a.m., with the Director of Nursing (DON), the DON stated that Resident 142's care plan should have been updated to address the choking episode and include new interventions. The DON stated it was important to update the care plan with new interventions to ensure that another choking incident does not occur again. The DON stated that, without a care plan, staff would not know how to prevent the same incident from happening again. A review of the facility's policy and procedure titled, Care Plans - Comprehensive, last reviewed on 10/2023, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient's medical, nursing, mental and psychological needs is developed for each resident/patient. Care plans are revised as changes in the resident/patient's condition dictate.

Based on interview and record review, the facility failed to ensure a physician's order for hydrocodone-acetaminophen (medication used to relieve moderate to severe pain) 10-325 milligrams (mg- unit of measurement) every six hours as needed (PRN) for back pain was clarified to prevent overmedicating one of one sampled resident (Resident 101) investigated under pain management. Resident 101's physician order for hydrocodone-acetaminophen 10-325mg every six hours PRN did not include a pain scale (numeric rating scale: Zero is considered no pain; one to three is mild pain; four to six is moderate pain, and seven to 10 is severe pain). This deficient practice had the potential to result in adverse event (undesired harmful effect resulting from a medication or other intervention) such as respiratory depression (shallow breathing rate) which could lead to cardiac arrest (a condition in which the heart suddenly stops beating) and death. Findings: A review of Resident 101's Face Sheet (admission record) indicated the facility admitted the resident on 8/1/2023 with diagnoses that included chronic lower back pain and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Resident 101's Minimum Data Set (MDS - an assessment and care screening tool) dated 1/11/2023, indicated the resident had the capacity to make self-understood and the capacity to understand others. The MDS indicated that the resident required partial moderate assistance with toileting hygiene, shower, and upper and lower body dressing. During a concurrent interview and record review on 1/23/2024 at 2:39 p.m., with Registered Nurse 2 (RN 2), reviewed Resident 101's physician's orders. Resident 101's physician's orders indicated an order for hydrocodone-acetaminophen 10-325 mg tablet by mouth every six hours PRN for back pain dated 8/1/2023 and an order for hydrocodone-acetaminophen 10-325 mg tablet by mouth every six hours for back pain dated 10/25/2023. RN 2 stated the order for hydrocodone-acetaminophen 10-325 mg PRN should have been clarified with the provider and specified the pain scale of when to give the medication. RN 2 stated that the medication orders overlap and are confusing. RN 2 stated that this medication has a black box warning (means that there is reasonable evidence of an association of a serious hazard with the drug) and can have adverse effects such as addiction and respiratory depression which can result to a serious outcome such as death. RN 2 stated the facility did not have a policy that addressed pain scale indication for pain medications. A review of the document titled, Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, undated, indicated, When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. Clinicians should always exercise caution when prescribing opioids and monitor all patients closely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered medications via the physician ordered oral (PO, by mouth) route (location at which a drug is administered) for one of 14 sampled residents (Resident 61) investigated during the Medication Administration task. This deficient practice had the potential to reduce medication effectiveness, increase the risk of toxicity (the degree to which a substance is poisonous), and increased the likelihood of obstruction of the gastrostomy tube (G-tube- a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine). 2. Ensure LVN 1 completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, and administered) of controlled medications (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological [related to the mental and emotional state of a person] dependence) by failing to sign the Controlled Medication Count Sheet (a document used to track the administration of controlled substances) for tramadol (a controlled drug used to treat moderate to severe pain) for one of 14 sampled residents (Resident 115) investigated during the Medication Administration task. 3. Ensure licensed nursing staff completed documentation indicating reconciliation of controlled medications at every change of shift on the Floor Narcotic Release form for three of five medication carts observed (Fourth Floor Medication Cart A, Fourth Floor Medication Cart B, and Third Floor Medication Cart B) investigated during the Medication Storage task. This deficient practice had the potential for inaccurate reconciliation of controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of prescription drugs for their use for unintended purposes) of controlled medications. Findings: 1. A review of Resident 61's Face Sheet (admission record) indicated the facility admitted the resident on 7/20/2023 with diagnoses including Alzheimer's disease (a form of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]), dysphagia (difficulty swallowing), and encounter for attention to gastrostomy tube, arthritis (a condition that causes pain and swelling in the joints), and gout (a type of arthritis). A review of Resident 61's Minimum Data Set (MDS- an assessment and care screening tool) dated 10/27/2023, indicated Resident 61 sometimes had the ability to make himself understood and sometimes had the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, eating, bathing, dressing, mobility, and personal hygiene. A review of Resident 61's physician orders, indicated the following: -Allopurinol (a medication to treat gout) 100 milligram (mg, a unit of measurement) tablet, one tablet orally (PO, by mouth) once a day at 8:30 a.m., dated 7/20/2023. -Clopidogrel (a medication that prevents blood clots (clumping together of blood cells) 75 mg, one tablet PO once a day at 8:30 a.m., dated 7/20/2023. -Tylenol (a medication to treat pain) 325 mg tablet, two tablets PO twice a day at 8:30 a.m. and 4:30 p.m., dated 7/20/2023. -Lansoprazole (a medication that reduces the amount of acid in the stomach) 15 mg disintegrating (dissolves in the mouth or in water) tablet, 15 mg PO once a day, every other day at 8:30 a.m., dated 1/22/2024. During a concurrent medication pass observation, interview, and record review on 1/23/2024 at 7:49 a.m., with LVN 1, reviewed Resident 61's physician orders and medication bubble packs (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) for allopurinol, Tylenol, clopidogrel, and lansoprazole. LVN 1 stated Resident 61's medications are administered via g-tube. Observed LVN 1 prepare Resident 61's medications. LVN 1 then entered the resident's room and administered Resident 61's medications via g-tube. LVN 1 exited the room and again reviewed the bubble packs and physician orders for Resident 61's medications. LVN 1 stated the bubble pack labels (tool for communicating drug information to healthcare professionals and patients) and physician orders indicated to administer allopurinol, Tylenol, clopidogrel, and lansoprazole by mouth. LVN 1 stated about a week prior she also administered Resident 61's medications via g-tube. LVN 1 stated the indicated ordered route of administration should be checked before every medication administration and she did not check the route prior to administering Resident 61's medications. LVN 1 stated it was a medication error because she administered Resident 61's medications by g-tube and not by mouth. LVN 1 stated it was important to administer via the correct route to ensure the medications are properly administered and absorbed. During a concurrent interview and record review on 1/23/2024 at 8:55 a.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 61's physician orders. MDS Nurse 1 stated Resident 61 did not have any medications ordered to be administered via g-tube. MDS Nurse 1 stated Resident 61 was capable of swallowing crushed medications in apple sauce and had the g-tube for feeding only. MDS Nurse 1 stated medications must be administered per the physician's ordered route. MDS Nurse 1 stated it was a medication error to give Resident 61 his medications via the g-tube. During an interview on 1/23/2024 at 11:07 a.m., with the Director of Nursing (DON), the DON stated he was made aware Resident 61's medications were not administered per the physician's ordered PO route. The DON stated the route of medication administration is important because the physician had ordered it. The DON stated when administering medications, the nurse should read the physician's order and compare it with the label on the medication bubble pack to prevent any medication errors. During a concurrent interview and record review on 1/25/2024 a.m., with the DON, reviewed the facility's policy and procedure titled, Medication Administration, last reviewed 10/2023. The DON stated Resident 61 tolerates PO medication administration and medications are to be administered via the PO route. The DON stated the facility's policy and procedure was not followed because LVN 1 did not follow the right method of administration. The DON stated when the right method of administration is not used it could possibly result in an adverse event (undesired harmful effect resulting from a medication or other intervention) resulting in possible hospitalization of the resident. A review of the facility's policy and procedure titled, Medication Administration, last reviewed 10/2023, indicated medications will be administered in timely manner and as prescribed by the resident's attending physician written/verbal order. The individual administering the medication must ensure that the right medication, right dosage, right time and right methods of administration are verified before the medication is administered (e.g. review of drug label, physician's order, etc.). 2. A review of Resident 115's Face Sheet indicated the facility admitted the resident on 10/10/2022 with diagnoses including paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots [clumping together of blood cells] in the heart), hypotension (low blood pressure), and depression (persistent feelings of sadness and loss of interest that can interfere with daily living). A review of Resident 115's MDS dated [DATE] indicated Resident 61 had the ability to make herself understood and had the ability to understand others. The MDS further indicated the resident required partial assistance by staff for dressing, and setup assistance for eating, toileting, and personal hygiene. A review of Resident 115's History and Physical, dated 1/2/2024, indicated Resident 61 had a history of right hip sciatica (a nerve) pain and the resident was able to make her needs known and make her own medical decisions. A review of Resident 115's physician orders, indicated an order for tramadol 50 mg tablet, give 25 mg PO every six hours as needed for moderate pain, dated 6/29/2023. During a concurrent medication pass observation and interview on 1/23/2024 at 7:49 a.m., with LVN 1, observed LVN 1 prepare Resident 115's tramadol. LVN 1 unlocked the narcotic drawer, removed the tramadol bubble pack, removed the half tablet of tramadol, and placed it in a cup. LVN 1 then placed the bubble pack back in the locking drawer. LVN 1 walked to Resident 115 and administered the medication. LVN 1 returned to the medication cart and documented the medication administration in the Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis). LVN 1 stated the medication pass was complete and walked away from the medication cart. Observed LVN 1 did not document the removal of the tramadol medication on the Controlled Medication Count Sheet. During a concurrent interview and record review on 1/23/2024 at 8:44 a.m., with LVN 1, reviewed Resident 115's Controlled Medication Count Sheet for tramadol. LVN 1 stated tramadol was a controlled substance and the process for administering controlled substances was to document the administration in the MAR and to sign the Controlled Medication Count Sheet when the medication is removed from the bubble pack and administered to the resident. LVN 1 stated she did not document on Resident 61's Controlled Medication Count Sheet for tramadol. LVN 1 stated it was important to sign the Controlled Medication Count Sheet right when the medication is administered because she may not remember to sign it later and it could cause a discrepancy in the narcotic count when compared with the MAR. During an interview on 1/23/2024 at 8:55 a.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), MDS Nurse 1 stated tramadol is a narcotic. MDS Nurse 1 stated when narcotics are administered the licensed nurse signs the Controlled Medication Count Sheet and the MAR. MDS Nurse 1 stated the Controlled Medication Count Sheet should be signed immediately to indicate a narcotic was removed from the bubble pack and administered to the resident. MDS Nurse 1 stated the licensed nurse must sign when they remove the narcotic because they may forget to come back later to sign. MDS Nurse 1 stated the MAR and Controlled Medication Count Sheet must be taken very seriously and they must be accurate because narcotics cause addiction and are prone to go missing or stollen. During a concurrent interview and record review on 1/25/2024 a.m., with the DON, reviewed the facility's policy and procedure titled, Controlled Drugs - Patient Care Units, last reviewed 10/2023. The DON stated it was the facility's policy and a standard of practice for medication administration to sign the Controlled Medication Count Sheet right after administering tramadol. The DON stated the facility's policy was not followed because LVN 1 did not sign right away, and it created a potential for narcotic discrepancies. A review of the facility's policy and procedure titled, Controlled Drugs - Patient Care Units, last reviewed 10/2023, indicated the storage, distribution and accounting of all controlled drugs will be done in accordance with all federal and state laws and standards of professional pharmacy practice. The Department of Pharmacy services will be responsible for the proper safekeeping of all controlled substances within the facility. Documentation of administration of control substances will be done in the MAR and the controlled substance count sheet. A controlled substance administration sheet shall be issued with all controlled substances. Nurses shall sign out on the sheet when a controlled substance is administered and must verify that the count is correct. 3.a. During a concurrent interview and record review on 1/23/2024 at 4:13 p.m., with LVN 3, reviewed the Fourth Floor Medication Cart B Floor Narcotic Release forms for 11/2023, 12/2023, and 1/2024. LVN 3 stated at every change of shift the oncoming and retiring licensed nurse count all the narcotics and document on the Floor Narcotic Release form. LVN 3 stated both the oncoming and retiring nurse should sign the form. LVN 3 reviewed the Floor Narcotic Release forms and noted the following missing signatures: -On 11/28/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. -On 12/3/2023, the 11 p.m. to 7 a.m. oncoming nurse's signature was missing. -On 12/3/2023, the 7 a.m. to 3 p.m. retiring nurse's signature was missing. -On 1/18/2024, the 7 a.m. to 3 p.m. retiring nurse's signature was missing. During a concurrent interview and record review on 1/24/2024 at 4:38 p.m., with MDS Nurse 1, reviewed the Fourth Floor Medication Cart B Narcotic Release forms for 11/2023, 12/2023, and 1/2024. MDS Nurse 1 stated the Floor Narcotic Release form is completed by the oncoming and retiring nurse at every shift when they count the narcotics to ensure the count is accurate. MDS Nurse 1 stated the count is done by both nurses and both nurses sign the form together when the key for the narcotics drawer, and responsibility for the narcotics, is passed to the oncoming nurse. MDS Nurse 1 stated it was important to complete the count because narcotics are a controlled drug and any discrepancies need to be identified. MDS Nurse 1 stated it was important to document the count because if it wasn't documented then it was not done. 3.b. During a concurrent interview and record review on 1/25/2024 at 7:49 a.m., with LVN 4, reviewed the Third Floor Medication Cart B Floor Narcotic Release form for 1/2024. LVN 4 stated narcotics are counted together by the oncoming and retiring nurse at the start and end of every shift to transfer the responsibility of the narcotics and make sure all narcotics are accounted for and there are no errors like a missing narcotic. LVN 4 stated narcotics are a scheduled medication and are highly addictive and the most abused medication that can could lead to missing drugs. LVN 4 stated it was important to ensure narcotics did not go missing and were available when residents were in pain. LVN 4 reviewed the Floor Narcotic Release form for 1/2024 and stated on 1/7/2024 the 3 p.m. to 11 p.m. retiring nurse's signature was missing. During a concurrent interview and record review on 1/25/2024 at 8:23 a.m., with Registered Nurse 1 (RN 1), reviewed the Third Floor Medication Cart B Floor Narcotic Release form for 1/2024 and stated the retiring nurse on 1/7/2024 did not sign the form. RN 1 stated if the narcotic count process is not followed then it could lead to medication discrepancies in the narcotic medication count. 3.c. During a concurrent interview and record review on 1/25/2024 at 11 a.m., with LVN 5, reviewed the Fourth Floor Medication Cart A Floor Narcotic Release forms for 12/2023 and 1/2024. LVN 5 stated narcotics are counted at the end of every shift to make sure the count is correct, and all narcotics are accounted for. LVN 5 stated narcotics are counted because they are pain pills and are medications that residents can become addicted to and they can be stolen. LVN 5 reviewed the Fourth Floor Medication Cart A Floor Narcotic Release form for 12/2023 and 1/2024 and noted the following missing signatures: -On 12/21/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. -On 12/22/2023, the 3 p.m. to 11 p.m. retiring nurse's signature was missing. -On 12/30/2023, the 3 p.m. to 11 p.m. oncoming nurse's signature was missing. -On 12/30/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. -On 1/3/2023, the 3 p.m. to 11 p.m. oncoming nurse's signature was missing. -On 1/3/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. -On 1/4/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. LVN 5 stated it was important to document the narcotic count because in nursing if it was not documented then it didn't happen. During a concurrent interview and record review on 1/25/2024 at 9 a.m., with the DON, reviewed the facility's policy and procedure titled, Controlled Drugs - Patient Care Units, last reviewed 10/2023. The DON stated when the licensed nurses sign the Floor Narcotic Release forms together, they are agreeing that the narcotics were checked together and that every medication was reconciled, and it has been documented. The DON stated narcotics are a high-risk medication that needs to be accounted for, reconciled, and any issue reported to a supervisor. The DON stated when the forms were not signed, the facility's process was not followed, and it could lead to an integrity issue of controlled medications. The DON stated the facility's policy was not followed because if it was not documented then it was not done. A review of the facility's policy and procedure titled, Controlled Drugs - Patient Care Units, last reviewed 10/2023, indicated the storage, distribution and accounting of all controlled drugs will be done in accordance with all federal and state laws and standards of professional pharmacy practice. The Department of Pharmacy services will be responsible for the proper safekeeping of all controlled substances within the facility. All controlled medication will be kept double-locked and secured at all times. A nurse authorized to administer resident medications may carry the keys to the controlled substance storage area. At the completion of each nursing shift the oncoming and off going nurses will count and reconcile controlled medication. Each nurse will sign that such counts on the Controlled Substance Count Sheet is accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the refrigerator temperature was maintained per the facility's policy and procedure for refrigerated stored medications for one of three medication rooms (Medication Room A) and two of two sampled residents (Resident 90 and 209) investigated during the Medication Storage and Labeling task. This deficient practice had the potential to result in residents receiving medications that have decreased in efficacy resulting in mismanagement of resident illness. Findings: a. A review of Resident 209's Face Sheet (admission record) indicated the facility admitted the resident on 7/3/2023 and readmitted the resident on 8/27/2023 with diagnoses including type two diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]) and unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). A review of Resident 209's Minimum Data Set (MDS- an assessment and care screening tool) dated 1/12/2024, indicated Resident 209 had the ability to make herself understood and had the ability to understand others. A review of Resident 209's physician orders indicated an order for insulin (a medication used in the treatment and management of diabetes) glargine (a long-acting insulin) insulin pen (injection device), 16 units (U- a unit of measurement) subcutaneous (under the skin) once a morning at 8:30 a.m., dated 12/11/2023. b. A review of Resident 90's Face Sheet indicated the facility admitted the resident on 3/10/2014 and readmitted the resident on 8/26/2017 with diagnoses including type 2 diabetes mellitus and vascular dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life caused by brain damage from impaired blood flow to the brain) with behavioral disturbance, and unspecified psychosis (a mental state characterized by disorganized thoughts or incoherent speech) not due to a substance or known physiological condition. A review of Resident 90's MDS, dated [DATE], indicated Resident 90 sometimes had the ability to make herself understood and sometimes had the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, and mobility. A review of Resident 90's physician orders indicated an order for lorazepam (a medication used to treat anxiety (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), two milligrams (mg, a unit of measurement), give 0.5 mg oral (by mouth) every six hours as needed for anxiety manifested by restlessness related to shortness of breath, dated 12/15/2023 with an end date of 12/25/2024. During a concurrent medication room storage observation, interview, and record review on 1/23/2024 at 10:02 a.m. with Minimum Data Set Nurse 1 (MDS Nurse 1), observed Medication Room A and reviewed the Medication Refrigerator/Room Temperature Logs for 12/2023 and 1/2024. MDS Nurse 1 stated the temperature log indicated the refrigerator containing drugs shall be maintained between 36 degrees Fahrenheit (F, a unit of measurement) and 46 F. MDS Nurse 1 reviewed the temperature logs and noted the following temperatures below 36 F: -On 12/1/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35 F. -On 12/12/2023 at 6 p.m. to 8 p.m., the refrigerator temp was 35.7 F. -On 12/17/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.9 F. -On 12/17/2023 at 6 p.m. to 8 p.m., the refrigerator temp was 35 F. -On 12/18/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.0 F. -On 12/19/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.2 F. -On 12/26/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.5 F. -On 12/26/2023 at 6 p.m. to 8 p.m., the refrigerator temp was 35.7 F. -On 12/28/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.9 F. -On 12/30/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.9 F. -On 12/30/2023 at 6 p.m. to 8 p.m., the refrigerator temp was 35.7 F. -On 1/1/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.0 F. -On 1/1/2024 at 6 p.m. to 8 p.m., the refrigerator temp was 35.6 F. -On 1/2/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.6 F. -On 1/7/2024 at 6 p.m. to 8 p.m., the refrigerator temp was 35.4 F. -On 1/15/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.4 F. -On 1/17/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.2 F. -On 1/19/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.5 F. -On 1/22/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.2 F. MDS Nurse 1 then opened the refrigerator and stated the following was located inside: -One box and vial of solution labeled tuberculin purified protein derivative (PPD, used to aid in the diagnosis of tuberculosis [an infectious disease that most often affects the lungs]). -One Basalgar Kwik Pen (brand of insulin glargine), labeled for Resident 209. -One bag containing lorazepam labeled for Resident 90. MDS Nurse 1 stated when the refrigerator temperature was out of range the maintenance department should have been notified because it was important to keep medications at a safe temperature for administration to residents. MDS Nurse 1 stated medications kept out of the manufacture guidelines for temperature range could affect the efficacy and expiration of the medications. MDS Nurse 1 stated insulin not stored at the correct temperature could result in mismanagement of a diabetic resident resulting in hyperglycemia (high blood sugar). During a concurrent interview and record review on 1/25/2024 at 9 a.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Medication Administration, last reviewed 10/2023 and the Medication Refrigerator/Room Temperature Logs for 12/2023 and 1/2024. The DON stated the temperature went below the facility's policy and procedure and the manufacture guidelines for medication storage of insulin, PPD, and lorazepam storage. The DON stated when the medication refrigerator went below 36 F it could alter the chemistry of the medication and eventually affect the potency of the drugs. The DON stated when insulin doesn't work properly the resident's blood sugar is affected resulting in hyperglycemia with potential for a change of condition (sudden clinically important deviation from a patient's baseline in physical, cognitive [the mental process of acquiring knowledge and understanding through thought, experience, and the senses], behavioral, or functional domains) and hospitalization. The DON stated when lorazepam is affected then a resident's anxiety will remain the same or worsen which may result in unnecessary dose adjustments. The DON stated when the PPD test is affected, it could possibly result in inaccurate screenings for TB resulting in the possibility of the spread of TB in the facility. The DON stated when the temperature was out of range it should have been reported and was not. A review of the facility's policy and procedure titled, Medication Administration, last reviewed 10/2023, indicated the purpose of the policy was to ensure refrigeration temperatures are appropriate in order to maintain stability of medications stored in patient refrigerators found at the nurse's stations on each floor. All refrigerated drug storage areas and rooms will be inspected twice daily to ensure compliance with drug storage standards. Refrigerator temperature range: 36 F to 46 F. All refrigerators that store medications will be monitored twice daily for adequate temperature control. Nursing staff will be responsible for checking and logging temperatures in all medication storage areas twice daily. Daily temperatures will be logged on the Medication Refrigerator/Room Temperature Log, the log must include the date, temperature, and the initials of person checking. If refrigerator temperatures fall out of 36 F to 46 F range is out of range, the Maintenance Department and Pharmacy Services must be notified immediately, and corrective actions must be documented on the refrigerator log. It shall be the Pharmacists responsibility to determine the stability/usability of the drugs stored when the temperature is out of range.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure the licensed nursing staff disinfected the silver metal trays used to hold and transport resident medications before and after preparing resident medications for seven of 14 sampled residents (Resident 61, 115, 171, 184, 207, 224, and 4) investigated during the Medication Administration task. These deficient practices had the potential to spread communicable diseases and infections among staff and residents. 2. Ensure a gallon of distilled water is not placed on the floor beside an oxygen concentrator in the resident`s room for one of one resident (Resident 210) investigated under Infection Control. This deficient practice had the potential to result in waterborne illnesses caused by drinking a water or using the water as humidifier (add moisture to indoor air) which is contaminated by disease-causing microbes (tiny living things that are found all around us and are too small to be seen by the naked eye). Findings: 1.a. A review of Resident 61's Face Sheet (admission record) indicated the facility admitted the resident on 7/20/2023 with diagnoses including Alzheimer's disease (a form of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]), and dysphagia (difficulty swallowing). A review of Resident 61's Minimum Data Set (MDS- an assessment and care screening tool) dated 10/27/2023 indicated Resident 61 sometimes had the ability to make himself understood and sometimes had the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, eating, bathing, dressing, mobility, and personal hygiene. A review of Resident 115's Face Sheet indicated the facility admitted the resident on 10/10/2022 with diagnoses including paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots [clumping together of blood cells] in the heart), hypotension (low blood pressure), and depression (persistent feelings of sadness and loss of interest that can interfere with daily living). A review of Resident 115's MDS dated [DATE], indicated Resident 61 had the ability to make herself understood and had the ability to understand others. The MDS further indicated the resident required partial assistance by staff for dressing, and setup assistance for eating, toileting, and personal hygiene. During a concurrent medication pass observation and interview on 1/23/2024 at 7:49 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 prepare Resident 61's medications on the medication cart work surface and placed the prepared medications inside a silver metal tray. LVN 1 walked into Resident 61's room and placed the metal tray on the resident's nightstand. LVN 1 did not clean the nightstand prior to placing the metal tray. LVN 1 administered Resident 61's medications and then removed the silver metal tray from the nightstand and walked back and placed the tray on the medication cart work surface. LVN 1 did not disinfect the metal tray or cart. LVN 1 moved the metal tray to the side and prepared Resident 115's medications on the cart's work surface. LVN 1 then placed Resident 115's medications in the metal tray and walked to Resident 115 and administered the medications. LVN 1 stated she placed the metal tray on Resident 61's nightstand, then placed the metal tray on the medication cart and did not clean the metal tray or medication cart prior to preparing and administering Resident 115's medications. LVN 1 stated the metal tray should be cleaned between residents for infection control. LVN 1 stated if Resident 61's nightstand was contaminated with a virus or bacteria it could spread to Resident 115. During an interview on 1/23/2024 at 8:55 a.m., with the Minimum Data Set Nurse 1 (MDS Nurse 1), MDS Nurse 1 stated the medication nurses use the silver metal trays to transport resident medications from the medication carts to the residents. MDS Nurse 1 stated the tray should be cleaned every time the tray goes into a resident's room and between each resident. MDS Nurse 1 stated the medication cart should be cleaned if the used tray touched the medication cart. MDS Nurse 1 stated cleaning the tray and medication cart was just like hand washing between residents and was important to prevent passing a virus or infection from one resident to another. 1.b. A review of Resident 184's Face Sheet indicated the facility admitted the resident on 9/21/2023 with diagnoses including sepsis (a life-threatening complication of an infection), neutropenia (decreased white blood cells [part of the body's immune system] leading to increased susceptibility to infection), malignant neoplasm of right female breast (breast cancer, a disease in which cells in the breast grow out of control). A review of Resident 184's MDS dated [DATE], indicated Resident 184 had the ability to make herself understood and had the ability to understand others. The MDS further indicated the resident required substantial assistance by staff for dressing, toileting, bathing, mobility, and transfer. A review of Resident 171's Face Sheet indicated the facility admitted the resident on 11/2/2023 and readmitted the resident on 12/7/2023 with diagnoses including Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning). A review of Resident 171's MDS dated [DATE], indicated Resident 184 had the ability to make himself understood and had the ability to understand others. The MDS further indicated the resident required supervision by staff for dressing, personal hygiene, and mobility. During a concurrent medication administration observation and interview on 1/24/2024 at 8:16 a.m. with LVN 2, observed LVN 2 prepare Resident 184's medications on the medication cart work surface and placed the medications in a silver metal tray. Observed LVN 2 walk with the metal tray into Resident 184's room and placed the metal tray directly on Resident 184's rolling bedside table containing Resident 184's personal objects. LVN 2 did not clean the bedside table prior to placing the metal tray. Observed LVN 2 administer Resident 184's medications, walk to Resident 184's restroom, and placed the tray on the restroom sink while LVN 2 washed her hands. Observed LVN 2 exit Resident 184's room, transported the metal tray back and placed the tray on the work surface of the medication cart. LVN 2 did not disinfect the silver metal tray. LVN 2 stated she had completed Resident 184's medication pass and would prepare Resident 171's medications. Observed LVN 2 move the metal tray from the work surface and placed it on a binder on top of the medication cart. LVN 2 did not disinfect the work surface or the metal tray. Observed LVN 2 prepare Resident 171's medications on the medication cart work surface, placed the medications in two cups and walked to Resident 171's room and administered the medications to Resident 171. LVN 2 stated she did not clean the metal tray after placing it on Resident 19's bedside table and restroom sink and then after placing it on the medication cart. LVN 2 stated she did not disinfect the medication cart prior to preparing Resident 171's medications. LVN 2 stated the metal tray and medication cart should be disinfected before and after each resident to prevent spreading of infection from one resident to another. During an interview on 1/24/2024 at 9:12 a.m., with Registered Nurse 1 (RN 1), RN 1 stated a resident's table is considered dirty and when the silver metal tray is placed on the table, then it is considered dirty as well. RN 1 stated when the silver metal tray is brought out of the resident's room, it must be disinfected with the purple wipes (disposable wipes that kill bacteria and viruses) on the inside and outside of the metal tray before placing it on the medication cart. RN 1 stated disinfecting the metal tray is for infection control purposes and prevents the transfer of any germs or anything else from one surface to another surface and from resident to resident to prevent making residents sick with colds or even coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) which residents can have without having any signs or symptoms. During a concurrent interview and record review on 1/25/2024 a.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Medication Administration, lasted reviewed 10/2023. The DON stated the facility uses the silver metal trays and they should be cleaned after the metal tray leaves the medication cart, goes into a resident's room, and then returns. The DON stated the metal trays are cleaned because they can potentially be contaminated with bacteria, germs, and viruses and could contaminate the medication cart where another resident's medications are prepared. The DON stated the facility's policy and procedure was not followed for infection control during administration of medications. A review of the facility's policy and procedure titled, Medication Administration, lasted reviewed 10/2023, indicated established facility infection control procedures must be followed during administration of medication (e.g. handwashing and aseptic technique [a method used to prevent contamination with microorganisms]). 1.c. A review of Resident 207's Face Sheet indicated the facility admitted the resident on 4/12/2023 with diagnoses including acute respiratory failure (occurs when the lungs can't get enough oxygen into the blood). A review of Resident 207's MDS dated [DATE], indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision from staff for most activities of daily living (ADLs - activities related to personal care). A review of Resident 224's Face Sheet indicated the facility admitted the resident on 12/5/2023 and readmitted the resident on 1/3/2024 with diagnoses including enterocolitis (inflammation of the digestive tract) due to clostridium difficile (C-diff - a bacterium that causes diarrhea and colitis [inflammation of the colon]). A review of Resident 224's MDS, dated [DATE], indicated the resident had intact cognition and required maximum assistance from staff for bed mobility, transfers, and toileting. A review of Resident 4's Face Sheet indicated the facility admitted the resident on 7/26/2023 with diagnoses including Parkinsonism and dementia. A review of Resident 4's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for chair/bed-to-chair transfer. During a medication administration observation on 1/23/2024 at 4:34 p.m., observed LVN 6 place Resident 224's medications on a metal medication tray and take it to the resident's room. Upon conclusion of the medication administration, observed LVN 6 take the metal medication tray into the bathroom and placed it on the sink's countertop while she performed hand hygiene. Observed LVN 6 take the metal medication tray back to the medication cart without disinfecting it. During a continued medication administration observation on 1/23/2024 at 4:40 p.m., observed LVN 6 place Resident 4's medications on the undisinfected metal medication tray and take it to the resident's room. Observed LVN 6 place the metal medication tray on Resident 4's nightstand. Upon conclusion of the medication administration, observed LVN 6 take the metal medication tray back to the medication cart without disinfecting it. During a continued medication administration observation and interview on 1/23/2024 at 4:48 p.m., observed LVN 6 place Resident 207's medications on the undisinfected metal medication tray and take it to the resident's room. Observed LVN 6 place the metal medication tray on Resident 207's bedside table. Upon conclusion of the medication administration, observed LVN 6 take the metal medication tray back to the medication cart without disinfecting it. Upon interview, LVN 6 confirmed by stating that she did not disinfect the medication tray between Resident 224, Resident 4, and Resident 207. During an interview on 1/25/2024 at 9:47 a.m., with the Infection Preventionist (IP), the IP stated that the licensed nurses should be disinfecting the medication tray between going from resident to resident. The IP stated it was important to do so in order to not spread infection among the residents. The IP stated, if not disinfected, there was a potential for residents to contract an infection. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 10/2023, indicated that established infection control procedures must be followed during the administration of medication (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.). 2. A review of Resident 210's Face Sheet indicated the facility originally admitted the resident on 7/5/2022 and readmitted the resident on 11/25/2023 with diagnoses that included muscle weakness and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 210's MDS dated [DATE], indicated that Resident 210 had the ability to make self-understood and ability to understand others. The MDS indicated Resident 210 required moderate assistance from staff for personal hygiene and toileting hygiene. During a concurrent observation and interview on 1/23/2024 at 9:37 a.m., with Certified Nurse Assistant 2 (CNA 2), observed a gallon of water on the floor beside Resident 210's oxygen concentrator (takes air in and purifies it for use by individuals who require medical oxygen). CNA 2 stated that the gallon of water should not be placed on the floor for infection control. A review of Resident 210's physician's order dated 11/25/2023, indicated an order for oxygen at two liters per minute (LPM- unit of measurement) via nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) with bilevel positive airway pressure (BIPAP- machine that helps with breathing) every shift as needed. During an interview on 1/25/2024 at 11:53 a.m., with Registered Nurse 2 (RN 2) RN 2 stated that Resident 210 is on oxygen therapy and uses a BIPAP machine which uses distilled water for humidification (makes dry air wetter). RN 2 stated that the water container should not be placed on the floor because floors are contaminated and may potentially place the resident at risk for infection which could lead to sickness. A review of the Centers for Disease Control and Prevention (CDC) source material titled, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 4 (CNA 4) and Housekeeping 1 (HSKP 1) were not conversing with each other in another language while CNA 4 was feeding a resident in the dining room for one (Resident 167) out of one sampled resident investigated for dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 167's Face Sheet indicated the facility admitted the resident on 4/1/2022, with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system [includes the brain, spinal cord, and a complex network of nerves] and the parts of the body controlled by the nerves), dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or inability to move one side of the body). A review of Resident 167's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/18/2023, indicated the resident was severely impaired in cognitive (thought processes) skills for daily decision making and required extensive assistance from staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. On 1/4/2023 at 8:45 a.m., during an observation, observed Resident 167 sitting between CNA 4 and HSKP 1 in the dining room. Observed CNA 4 and HSKP 1 conversing with each other in another language while CNA 4 was feeding Resident 167. On 1/4/2023 at 8:54 a.m., during an interview, CNA 4 stated she was conversing with HSKP 1 about the news on the television. CNA 4 stated they have been in- serviced (training intended for those actively engaged in a profession) about not speaking in another language in front of residents, especially if the resident does not speak the language. CNA 4 stated it can affect the resident's sense of dignity. On 1/5/2023 at 11:21 a.m., during an interview, the Director of Staff Development (DSD) stated staff should not be conversing with each other in another language because the resident may think he/she was being talked about. The DSD stated if the resident has a cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect his/her everyday life), it may trigger a behavioral response. The DSD stated it was also important to maintain the resident's sense of dignity. On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated that staff should not be conversing with each other in another language, especially in front of a resident. The DON stated it was a dignity issue. The DON stated it didn't matter if the resident was cognitively impaired. A review of the facility's policy and procedure titled, Residents/Patient Dignity and Privacy, last reviewed on 10/2022, indicated that the facility provides care for residents/patients in a manner that respects and enhances each resident/patient's dignity, individuality, and right to personal privacy. Dignity means that when interacting with residents/patients, staff carries out activities which assist the resident/patient in maintaining and enhancing his or her self-esteem and self-worth. Care for residents/patients in a manner that maintains dignity and individuality - include the resident/patient in conversation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess one of one sampled resident (Resident 25) for self-administration of medications after the resident expressed a desire to have some control over her medications. This deficient practice violated the residents' right to be assessed for capacity and be informed of their ability or inability to self-administer medications Findings: A review of Resident 25's Face Sheet indicated the facility admitted the resident on 11/28/2022, with diagnoses including hypertension (high blood pressure), generalized muscle weakness, and anxiety disorder. A review of Resident 25's MDS, dated [DATE] indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 25 required two-person extensive assistance with bed mobility and toilet use; required two-person total assistance with transfer; required one-person extensive assistance with dressing and personal hygiene; and required setup and supervision with eating. A review of Resident 25's admission History and Physical (H&P), dated 11/29/2022, indicated the resident reported she did not like to give control and preferred to take her own medications. The H&P indicated Resident 25 had an intact (not altered, broken, or impaired) decision-making capacity. During an interview on 1/3/2023 at 12:16 p.m., Resident 25 stated she would like to have an authority over her medications. Resident 25 stated she has not been assessed for self-administration of medication even after she brought it up to the facility multiple times. Resident 25 stated the facility operated in a one size fits all. During an interview on 1/5/2023 at 8:24 a.m., RN 2 stated Resident 25 expressed a desire to administer her own medications on admission on [DATE]. RN 2 stated the facility did not initiate an assessment for self-administration of medication because the facility was waiting for the resident's doctor to assess the resident first. RN stated the facility informed the resident's physician about the resident's desire to self-administer medications and was told by the resident's physician no self-administration at this time. RN 2 stated the facility did not have a self-administration of medication assessment for the resident that would have indicated that the resident was deemed incapable of self-administering of medications but should have had one. RN 2 stated a care plan should have been initiated and the resident should have been informed and educated that she was not deemed capable at this time. During an interview on 1/5/2023 at 4:10 p.m., the Director of Nursing (DON) stated when Resident 25 had expressed a desire to self-administer medications, the facility should have assessed the resident. The DON stated when the facility felt that the resident was not qualified to self-administer medications, the facility should have still done a formal assessment and informed the resident of the result. The DON stated the resident was not informed accordingly and as a result the resident had become unhappy. The DON stated it was the resident's right to be assessed and periodically reassessed for capacity to self-administer medications. A review of the facility's P&P, titled, Medication (Self Administration), dated 10/2022, indicated, Each resident/patient who desires to self-administer medications will be assessed as to their competency by the Interdisciplinary team to determine self practice . Residents/patients who have been deemed not competent to administer medications will not be allowed to do so without further drug education and reassessment .

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN - a written notification to the resident or responsible party of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services with benefit days remaining) and the Notice of Medicare Noncoverage (NOMNC - written notice informing the beneficiary of his or her right to an expedited review of services termination from Medicare Part A services) in a timely manner for two of three sampled residents (Residents 426 and 427). This deficient practice had the potential to result in residents or responsible parties not being able to exercise their rights to decide their care. Findings: A review of Resident 426's Face Sheet indicated the facility admitted the resident on 5/1/2014 with diagnoses including Coronavirus disease-2019 acute respiratory disease [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection], Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and osteoarthritis (degenerative joint disease in which the tissues in the joint break down over time). A review of Resident 426's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/6/2022, indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 426's SNF Beneficiary Protection Notification Review Form indicated the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted, and the last covered day of Medicare Part A service was 8/31/2022. The document further indicated the SNF ABN and NOMNC forms were provided to the resident but both forms were not acknowledged. A review of Resident 427's Face Sheet indicated the facility admitted the resident on 6/28/2022 with diagnoses that included non-infective gastroenteritis (inflammation of the lining of the stomach and intestines) and colitis (inflammation of the large intestine) and generalized muscle weakness. A review of Resident 427's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/1/2022, indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 427's SNF Beneficiary Protection Notification Review Form indicated the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted, and the last covered day of Medicare Part A service was 7/28/2022. A review of Resident 427's SNF ABN form indicated the resident received the notice and signed the form on 7/28/2022. A review of Resident 427's NOMNC form indicated the resident received the notice and signed the form on 7/28/2022. During a concurrent interview and record review, on 1/5/2023 at 9:41 a.m., reviewed Resident 426's and Resident 427's SNF ABN and NOMNC forms with the Medical Records Director (MRD). MRD stated medical records staff provide the SNF ABN and NOMNC forms to the resident once the Minimum Data Set (MDS) nurse informs the resident regarding the change in coverage status. The MRD stated if the resident does not have the capacity to make decisions, the MDS nurse would speak with the family member over the phone and the medical records staff would email the SNF ABN and NOMNC forms to have them review and sign the forms and return the signed forms via email or fax. The MRD stated the facility had initiated Resident 426's discharge from Medicare Part A services with benefit days remaining and that the resident's last covered day was on 8/31/2022. The MRD reviewed Resident 426's SNF ABN and NOMNC forms and verified both forms were blank. The MRD stated an email was sent with SNF ABN and NOMNC forms attached on 8/31/2022 to Resident 426's family member. However, the MRD confirmed the forms were not acknowledged as there was no response from Resident 426's family member and stated that there was no follow up email sent. The MRD stated both NOMNC and the SNF ABN forms should have been provided via email at least two days prior to Resident 426's last covered day of 8/31/2022 following the facility's policy. The MRD further stated the facility should have followed up with Resident 426's family member to ensure the forms were reviewed and acknowledged. The MRD also reviewed Resident 427's SNF ABN and NOMNC forms and verified both notices were provided to the resident on 7/28/2022. The MRD stated the facility had initiated Resident 427's discharge from Medicare Part A services with benefit days remaining and that the resident's last covered day was on 7/28/2022. The MRD confirmed the SNF ABN and NOMNC forms were provided to Resident 427 on the last covered day and stated they should have been given at least two days prior per facility policy. The MRD stated the SNF ABN form should be provided timely to let the resident and family know that they will be financially responsible for the cost when the coverage for Medicare Part A services end. The MRD further stated the NOMNC form should be provided timely to let the resident and family know that resident no longer meets the requirement for being covered under Medicare Part A services and that the coverage is about to end. A review of the facility's policy and procedure titled, 7020 Medicare Notice of Medicare Non-coverage/Advance Beneficiary Notice, last revised on 11/21/2018, indicated the facility will give an advance, completed copy of the Notice of Medicare Non-coverage (NOMNC) to enrollees receiving skilled nursing no later than two days before the termination of services. The policy further indicated medical records will monitor completion of NOMNC via discharge monitor from Medicare Part A on the discharge monitor.

Based on observation and interview, the facility failed to ensure one of one sampled resident (Resident 141) was provided with homelike environment by failing to make the bed with clean linens and pillow. This deficient practice had the potential to negatively affect Resident 141's quality of life. Findings: A review of Resident 141's Face Sheet indicated the facility admitted the resident on 3/2/2021, with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 141's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/8/2022, indicated the resident had a severe cognitive (relating to thinking, reasoning, or remembering) impairment (loss or damage). The MDS indicated Resident 141 required one-person extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene; and required two-person extensive assistance with transfer. During a concurrent observation and interview on 1/3/2023 at 10:58 a.m., in Resident 141's room, observed with Certified Nursing Assistant 5 (CNA 5) the resident's bed unmade, two blue wedge cushion pillows on the floor with crumpled bed linens resting on top of them, and a pillow on top of the headboard of the bed while the resident was sitting in his wheelchair next to the bed. CNA 5 stated the bed was undone and the bed linens were resting on top of wedge cushion pillows that were on the floor. CNA 5 stated he was only covering for the CNA assigned to the resident and he was not sure whether the linens and wedge cushion pillows were clean or dirty. CNA 5 stated he would not leave the bed undone and would not leave the wedge cushion pillows on the floor with linens on top because it was not a professional practice and did not promote a homelike environment for the resident. During an interview on 1/5/2023 at 11:20 a.m. Registered Nurse 3 (RN 3) stated leaving the bed unmade and leaving wedge cushion pillows on the floor with linens were not appropriate and did not ensure a homelike environment for Resident 141. RN 3 stated the facility is the resident's home and the resident is in the facility because he needed to be cared for. RN 3 stated being in an institution was already traumatizing for the resident and ensuring a homelike environment would allow for the resident to feel important and comfortable. RN 3 stated even though the resident had dementia, the resident still had some periods of lucidity (having, showing, or characterized by an ability to think clearly and rationally). RN 3 further stated even though the resident may not have complained, it was still the facility's responsibility to ensure the resident was provided with a clean and homelike environment. During an interview on 1/5/2023 at 2:31 p.m., the Administrator (ADM) stated the facility did not have a policy and procedure (P&P) for homelike environment. During an interview on 1/5/2023 at 4:28 p.m., the Director of Nursing (DON) stated it was not appropriate to leave Resident 141's bed unmade and leave the wedge cushion pillows on the floor. The DON stated the resident should have been provided with a comfortable homelike environment because it would give the resident a sense of cleanliness and a sense of dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the resident's care plan to reflect a change in the physician's order for pressure ulcer's (PU - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) treatment for one (Resident 204) of three residents investigated for pressure ulcers. This deficient practice had the potential to result in a delay in or lack of delivery of care and services. Findings: A review of Resident 204's Face Sheet indicated the resident was admitted , on 9/02/2022 and readmitted on [DATE], with diagnoses that included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) and diabetes mellitus type 2 (a chronic disease characterized by high levels of sugar in the blood). A review of Resident 204's Minimum Data Set (MDS-a standardized assessment and screening tool), dated 9/10/2022, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required one-person extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and one-person total assistance with bathing. A review of the Physician Order Report indicated a physician order, dated 1/03/2023, for zinc oxide ointment (a medicine used to treat or prevent minor skin irritations such as burns, cuts, and diaper rash) 20% apply sparingly, special instructions to wash coccyx with warm water and soap, pat dry, and apply thin layer of zinc oxide dressing every shift for maintenance. During a concurrent interview and record review, on 1/06/2023 at 2:45 p.m., with Minimum Data Set Nurse 3 (MDS Nurse 3), Resident 204's care plan on pressure ulcer, initiated on 9/16/2022, was reviewed. The care plan indicated the goal that Resident 204 would have no signs of infection during the healing process with a target date of 10/16/2022. The care plan approach indicated hydrogel (a gel that gently increases the moisture level within the wound, encouraging moist wound healing through debridement {the removal of dead or infected skin tissue to help a wound heal}) as ordered. MDS Nurse 3 stated the resident's care plan should be individualized and should have been revised timely to reflect the change in the treatment order. The MDS Nurse 3 stated the care plan should reflect the current physician's orders for accuracy, so the nurses were aware of the resident's plan of care. A review of the facility's policy and procedure titled, Care Plans - Comprehensive, last reviewed 10/2022, indicated a policy to develop and individualized comprehensive care plan that includes measurable objectives and timetables to the resident's medical, nursing, mental and psychological needs. The policy indicated care plans reflect the treatment goals are reviewed and/or revised as the resident's condition changes and at least quarterly. The policy indicated that documentation must be consistent with the resident's care plan.

Based on interview and record review, the facility failed to provide quality care in accordance with professional standards of nursing practice by failing to ensure Xarelto (blood-thinning medication used to treat and prevent blood clots) was held for a resident experiencing hematuria (blood in the urine) as ordered by the physician for one of one sampled resident (Resident 211). This deficient practice placed Resident 211 at risk for further bleeding and had to potential to result in adverse side effects including hypotension (low blood pressure), dizziness, and shortness of breath. Findings: A review of Resident 211's Face Sheet indicated the facility admitted the resident, on 4/27/2022, with diagnoses that included chronic kidney disease (gradual loss of kidney function in filtering wastes and excess fluids from the blood) stage 3, anemia (condition in which the body does not have enough healthy red blood cells to carry oxygen to the body's tissues), and gastrointestinal hemorrhage (mild to severe bleeding that starts in the digestive tract often appearing in the stool or vomit). A review of Resident 211's Minimum Data Set (MDS - an assessment and care screening tool), dated 11/4/2022, indicated the resident had the ability to make self usually understood and had the ability to usually understand others. The MDS further indicated Resident 211 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 211's physician order, ordered on 4/29/2022, indicated Xarelto tablet 10 milligrams (mg - unit of measure) oral once a day for deep vein thrombosis (DVT - a medical condition that occurs when a blood clot forms in a deep vein within the body) prophylaxis, ordered on 4/29/2022. A review of Resident 211's care plan for anticoagulant (a group of medications that decrease your blood's ability to clot) use related to Xarelto, revised on 11/3/2022, indicated a goal that the resident would have no signs and symptoms of adverse bleeding times three months and an intervention to observe for signs of active bleeding that includes blood in the urine. A review of Resident 211's progress note, dated 12/27/2022 at 3 a.m., by Licensed Vocational Nurse 10 (LVN 10), indicated resident was noted with pinkish urine in diaper and hematuria. The progress note indicated Medical Doctor 1 (MD 1) was made aware with orders to hold Xarelto one time in a.m. today, follow up with primary medical doctor (PMD), and labs. A review of Resident 211's progress note, dated 12/27/2022 at 3:07 a.m., by MD 1 indicated the following orders: - Closely monitor, call if more hematuria noted. - Hold Xarelto until further evaluation by PMD/nurse practitioner. - Labs in a.m.: Complete blood count (CBC), basic metabolic panel (BMP), iron (Fe), and B12 panel. - Follow up with PMD early in a.m. A review of Resident 211's Medication Administration Record (MAR) for 12/2022 indicated Xarelto was administered to the resident on 12/27/2022 at 8:30 a.m. by Licensed Vocational Nurse 7 (LVN 7). The MAR further indicated the resident continued to receive Xarelto daily from 12/28/2022 to 1/5/2023. During a concurrent interview and record review, on 1/5/2023 at 2:42 p.m., LVN 7 reviewed Resident 211's record and verified the order for Xarelto 10 mg oral daily has been active since ordered on 4/29/2022. LVN 7 confirmed the Xarelto order was never discontinued or modified for the medication to be held. LVN 7 then reviewed Resident 211's MAR and confirmed she administered Xarelto for Resident 211 on 12/27/2022. LVN 7 stated she received report from LVN 10, who worked the previous shift, that Resident 211 was noted with hematuria and that MD 1 was informed. However, LVN 7 stated she was not informed that MD 1 gave an order to hold Xarelto due to hematuria. LVN 7 reviewed Resident 211's progress note, dated 12/27/2022 at 3 a.m., documented by LVN 10, and verified the note indicated an order was received to hold Xarelto one time in a.m. and to follow up with PMD. LVN 7 verified that she missed reading the progress note and was not aware of the order since it was not communicated to her by LVN 10. LVN 7 confirmed Resident 211's Xarelto should have been held on 12/27/2022 following the physician's order and that the order to hold the medication should have been placed. LVN 7 confirmed LVN 10 did not enter an order to hold Xarelto and stated that the licensed nurse receiving the order was responsible for entering any orders made by physician over the phone right away. LVN 7 further stated Resident 211 continued to have hematuria in the morning of 12/27/2022 during her shift which she communicated to the PMD. However, LVN 7 stated she did not ask the PMD if she wanted to continue to hold the Xarelto. LVN 7 further reviewed Resident 211's progress note, dated 12/27/2022 at 3:07 a.m., by MD 1 and verified orders to hold Xarelto until further evaluation by the PMD or nurse practitioner. LVN 7 stated she should have held the Xarelto on the morning of 12/27/2022 and followed up with the PMD to clarify if she wanted to hold the medication since the resident was still having hematuria during her shift. LVN 7 confirmed resident did not have another episode of hematuria since 12/27/2022 upon reviewing the progress notes but stated there was potential outcome for further bleeding and hematuria by failing to hold the medication. During a concurrent interview and record review, on 1/5/2023 at 5:40 p.m., the Director of Nursing (DON) confirmed that LVN 10 had received an order from the physician to hold Xarelto one time due to hematuria per Resident 211's progress note dated 12/27/2022 at 3 a.m. and also verified that no orders were placed to hold the Xarelto on 12/27/2022 upon reviewing Resident 211's physician orders. The DON confirmed Xarelto should have been held on 12/27/2022 and stated LVN 10 should have entered the order immediately upon receiving it. The DON reviewed Resident 211's MAR for 12/2022 and confirmed Xarelto was given on 12/27/2022. The DON stated LVN 7 should have held the Xarelto since the resident was still having hematuria during her shift to prevent further bleeding and confirmed LVN 7 should have clarified with Resident 211's PMD upon reviewing the MD 1's progress notes from 12/27/2022 to determine whether they should hold the medication once the resident was evaluated. The DON further stated administering an anticoagulant while Resident 211 is observed with hematuria can potentially result in worsening hematuria, drop in blood pressure, and dizziness. A review of the facility's policy and procedure titled, Physician Orders, last reviewed on 10/2022, indicated the facility shall ensure that all physician orders are completely and accurately implemented and all telephone orders are signed in a timely manner. The policy and procedure further indicated the licensed nurse will record telephone orders on the physician order sheet with the name of the prescribing physician and the date, time, and signature of the person receiving the order and that telephone orders will be transcribed and implemented promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 71's Face Sheet indicated the facility admitted the resident, on 5/04/2021, with diagnoses that included unspecified dementia with behavioral disturbances and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning). A review of Resident 71's History and Physical, dated 5/5/2021, indicated the resident had anxiety (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), was hard of hearing, was not ambulatory, could not transfer independently, was confused and disoriented. A review of Resident 71's MDS, dated [DATE], indicated the resident rarely/never had the ability to be understood by others and rarely/never had the ability to make self-understood. The MDS indicated the resident required extensive assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 71's Fall Risk Predictive Factors Assessment form, dated 11/10/2022, indicated the resident was a high risk for falls due to impaired mobility, poor judgement and safety awareness, medication usage and predisposing diseases/conditions. A review of Resident 71's Care Plan (CP) titled, At Risk for Falls/Injuries, initiated 8/4/2021, indicated the resident had an unwitnessed fall on 9/10/2021 and was found lying flat on the floor beside the left side of the bed. The CP indicated a goal to reduce the risk of fall with the following approaches: maintain safe environment free from clutter, adequate lighting, remove or identify safety hazards. During an observation, on 1/03/2023 at 12:05 p.m., observed Resident 71 lying in bed, unattended by staff, with the bed in the high position. During an interview, on 1/03/2023 at 2:40 p.m., Licensed Vocational Nurse 5 (LVN 5) stated she cared for Resident 71 and the resident was confused and was a high risk for falls. LVN 5 stated the resident was not able to verbalize her needs and was not able to walk but was able to move. During an observation, on 1/03/2023 at 2:45 p.m., observed Resident 71 lying in bed, unattended by staff, with the bed in the high position. During an observation and interview, on 1/03/2023 at 2:50 p.m., Certified Nursing Assistant 4 (CNA 4) assessed Resident 71 and stated the resident's bed was in the high position. CNA 4 stated she left the bed in the high position and forgot to lower it when she changed the resident earlier in the day. CNA 4 lowered Resident 71's bed to the low position and stated it was a big mistake. CNA 4 stated the importance of keeping the bed in the low position and they (residents) could try to stand up and could fall. During an interview, on 1/03/2023 at 3 pm, LVN 5 stated it was not okay to leave Resident 71's bed in the high position because she was a high risk for falls and had an actual fall in the facility. During an interview and record review, on 1/5/2023 at 11:30 a.m., the Director of Nursing (DON) stated the residents' beds should never be kept in the high position because they could fall. The DON reviewed Resident 71's CPs and stated the resident had a fall while in the facility. The DON stated it was standard practice to keep the bed in the low position and the importance of the bed in the low position was to reduce injury if Resident 71 fell. A review of the facility policy and procedure titled, Fall Reduction/Prevention Program, last reviewed 10/2022, indicated the purpose of the policy was to ensure the resident environment remained as free from accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. All residents would be assessed for fall risk and when such risk was identified, the resident would be noted as a fall risk with appropriate interventions placed in the medical record. Based on observation, interview, and record review, the facility failed to ensure the residents' safety for two of three sampled residents (Residents 71 and 101) investigated under the accidents care area by failing to ensure the staff did not leave residents unattended with the bed in the high position. This deficient practice placed Resident 71 and 191 at risk for falls and serious injuries that include possible fractures and bleeding. Findings: a. A review of Resident 101's Face Sheet indicated the facility admitted the resident, on 2/27/2022, with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and acquired absence of limb from history of left above knee amputation. A review of Resident 101's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/9/2022, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 101 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and was totally dependent on staff for transfers. A review of Resident 101's Fall Risk Predictive Factors Assessment, dated 12/13/2022, indicated the resident was a high risk for falls. During an observation, on 1/03/2023 at 1:50 p.m., observed Resident 101 lying in bed with the bed in elevated position with no staff present. During a concurrent observation and interview, on 1/03/2023 at 1:55 p.m., Certified Nursing Assistant 6 (CNA 6) observed and verified Resident 101's bed was in an elevated position while being left unattended. CNA 6 stated she was in the room earlier and had left the resident to obtain supplies that she needed to change the resident. CNA 6 stated the bed should be kept in the lowest position for residents who are high fall risk. CNA 6 stated it was fine to keep the height of the bed elevated for Resident 101 since she never saw the resident attempt to get out of bed. During an interview, on 1/03/2023 at 2:40 p.m., Licensed Vocational Nurse 4 (LVN 4) reviewed Resident 101's most recent quarterly Fall Risk Predictive Factors Assessment, dated 12/13/2022, and confirmed the resident was a high risk for falls. LVN 4 stated the bed should be returned to its lowest position any time staff left residents identified as a high fall risk unattended by themselves including leaving the resident's room briefly to get supplies. LVN 4 stated a staff member should have stayed with the resident if the bed was to remain elevated. LVN 4 stated it was important to keep the bed in the lowest position for high fall risk residents to ensure the resident's safety and to reduce the severity of the injury if the resident were to fall from bed. During an interview, on 1/05/2023 at 5:27 p.m., the Director of Nursing (DON) stated staff may raise the height of the bed while providing care for residents. However, the DON stated it was standard practice to keep the bed in low position and staff were expected to lower the bed once they were done providing care or if they must leave the resident. The DON confirmed CNA 6 should have lowered the height of the bed once she left the resident unattended even if it was for a short period of time. The DON stated the importance of implementing low beds for high fall risk residents to lessen the impact of a fall from bed in case a fall occurred and therefore potentially reduce the chances for major injury. A review of the facility policy and procedure titled, Fall Reduction/Prevention Program, last reviewed 10/2022, indicated the purpose of the policy was to ensure the resident environment remained as free from accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. All residents would be assessed for fall risk and when such risk was identified, the resident would be noted as a fall risk with appropriate interventions placed in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Replace a refrigerated emergency kit (e-kit, medications available for use in an emergency situation or a new medication order in which the ordered medication has not yet arrived from pharmacy) within 72 hours. This had the potential for residents to not receive a medication in an emergency situation which may result in pain, injury, or loss of life. 2. Failed to properly dispose a controlled medication (substances that have accepted medical use, have potential for abuse, and may also lead to physical and or psychological dependence) hydrocodone-acetaminophen 5-325 milligram (mg, a unit of measure) tab when it was found taped inside the medication bubble pack (plastic packaging in which a medication is stored until ready to be used). This deficient practice had the potential to place the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: a. During the First Floor Medication Room observation on 01/03/23 at 10:13 a.m. with Registered Nurse 2 (RN 2), observed an e-kit from the refrigerator with a missing medication. RN 2 opened the e-Kit and removed the paper that indicated Humalog insulin (an injectable medication to lower blood sugar) had been removed for Resident 86 on 12/11/2022 at 10:30 a.m. RN 2 stated that was the date the medication was removed from the container. RN 2 stated when a medication is removed from the e-kit, the licensed nurse who removes the medication calls the pharmacist to replace the e-kit immediately. RN 2 was unsure how long an e-kit could be in use before returning it to the pharmacy. A review of Resident 86's Face Sheet (admission record) indicated the facility originally admitted the resident on 8/12/2021 with diagnoses that included diabetes mellitus (a condition that affects how the body uses blood sugar [glucose]). A review of Resident 86's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/17/2022, indicated Resident 86 was cognitively intact (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 86 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, and personal hygiene. A review of Resident 86's Physician's Order, dated 12/11/2022, indicated the following orders: 1. Humalog insulin 100 units per milliliter (units/ml, a unit of measure) subcutaneous injection (injecting a medication by needle into the fatty tissue underneath the skin) one time on 12/11/2022. 2. Humalog insulin 100 units/ml subcutaneous injection for 3 units for diabetes mellitus before meals, dated 12/14/2022. During a concurrent record review and interview with the Director of Nurses (DON) on 1/05/2023 at 2:40 p.m., reviewed the facility's policy and procedures titled, Supply of Medications used in Emergency Situations, reviewed 10/2022. The DON stated Resident 86 had a new order for Humalog insulin on 12/11/2022. The DON stated the e-kit should have been replaced within 72 hours although the facility's policy and procedures did not specify a time frame, only as soon as possible. The DON stated there is potential for a resident to not get that type of insulin if they have high blood sugar. b. During the Second Floor Medication Cart A observation on 1/05/2023 at 3:45 p.m., in the presence of Licensed Vocational Nurse 6 (LVN 6), observed Resident 168's bubble pack for the medication, hydrocodone (a narcotic medication to treat pain) 5-325 milligrams (mg, a unit of measure) tablet. Under the 28th bubble pack, there was a hydrocodone tablet in which the card had been punched out with a piece of tape in its place to hold the medication in the bubble pack. LVN 6 stated she did not know which licensed nurse did that but the licensed nurse should have wasted the medication with another licensed nurse and then documented on the 28th line on the controlled drug record sheet (controlled medication accountability record). During an interview with RN 5 on 1/05/2023 at 4 p.m., she observed Resident 168's bubble pack for the medication, hydrocodone 5-325 mg tablets in which the medication in the 28th pocket was taped shut. RN 5 stated the process is that the licensed nurse should waste the medication with another licensed nurse and then document on the 28th line on the controlled drug record sheet. A review of Resident 168's Face Sheet (admission record) indicated the facility originally admitted the resident on 11/09/2021 with diagnoses that included chronic pain (pain that is ongoing and lasts longer than six months). A review of Resident 168's MDS, dated [DATE], indicated Resident 168 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 168 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, and personal hygiene. A review of Resident 168's Physician's Order, dated 11/15/2022, indicated an order for hydrocodone-acetaminophen 5-325 mg by mouth every four hours as needed for moderate to severe pain. During an interview with the DON on 1/05/2023 at 4:30 p.m., he stated the hydrocodone tablet should not have been taped into the bubble pack. The DON stated the process is that the licensed nurse should waste the medication with another licensed nurse and then document on the 28th line on the controlled drug record sheet. The DON stated there was a potential for medication diversion for this controlled drug. During an interview with the DON and concurrent record review on 1/11/2023 at 12:13 p.m., reviewed policy and procedures titled, Controlled Drugs - Patient Care Units, reviewed 10/2022. The policy indicated any controlled substance wasted (dropped, contaminated, refused by the patient/resident, partial doses, spit out doses, etc.) must be documented directly in the automated dispense cabinet (a computerized medicine cabinet for hospitals and healthcare settings) and/or Medication Administration Record (MAR). The DON stated, since the controlled drug was not in an automated dispensing cabinet, the equivalent of that would be documentation on the controlled medication count sheet on paper. The DON stated the waste should also be documented in the resident's MAR. The DON stated the wasting process is to be completed and documented by two licensed nurses.

Based on interview and record review, the facility failed to ensure the consultant pharmacist's recommendations regarding the use of lactulose (medication used to treat constipation) and docusate sodium (medication used to soften stool and treat constipation) were acted upon for one of six sampled residents (Resident 12) investigated under the care area of unnecessary medications. This deficient practice had to potential for Resident 12 to receive unnecessary medications and placed the resident at risk for adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) and side effects (expected, well-known reaction that occurs with a predictable frequency and may or may not rise to the level of being an adverse consequence). Findings: A review of Resident 12's Face Sheet indicated the facility admitted the resident on 6/2/2022, and most recently readmitted the resident on 8/10/2022, with diagnoses that included acute respiratory failure (a serious condition that develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low level of oxygen in the body tissues), gastroesophageal reflux disease (a digestive disorder where stomach acid repeatedly flows back into the tube connecting the mouth and stomach) without esophagitis (inflammation of the muscular tube that passes food and drink from the mouth to the stomach) and generalized muscle weakness. A review of Resident 12's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/22/2022, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 12 required limited assistance with bed mobility, transfers, and personal hygiene, and required extensive assistance from staff with dressing and toileting. A review of Resident 12's physician orders indicated the following: - Docusate sodium tablet 100 milligrams (mg - unit of measure) oral twice a day for diagnosis of constipation, ordered on 8/10/2022. - Lactulose solution (strength: 10 gram/15 milliliters [mL]) 15 mL oral at bedtime for diagnosis of constipation, ordered on 8/10/2022. A review of the Consultant Pharmacist's Medication Regimen Review (MRR - a thorough evaluation of the drug regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), dated 9/30/2022, indicated the following recommendation for Resident 12: - Please add hold for loose bowel movement (BM) to the following orders: docusate sodium and lactulose. During a concurrent interview and record review, on 1/6/2023 at 2:04 p.m., the Director of Nursing (DON) stated the consultant pharmacist conducts a monthly MRR by reviewing every resident's charts and identifying irregularities (use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services and includes use of medications without adequate indication, monitoring, duration and excessive dose). The DON stated a report containing identified irregularities is sent from the consultant pharmacist to the DON and medical records. The DON explained he provides pharmacy recommendations directed towards nursing to the Registered Nurse (RN) unit managers to follow through and medical records sends the pharmacy recommendations to the physicians for any recommendations requiring a physician response. The DON stated the pharmacy recommendations should be responded to as soon as practicable and prior to the next pharmacist visit for the monthly MRR. The DON reviewed the Consultant Pharmacist's Medication Regimen Review for September 2022 and verified pharmacy recommendation for Resident 12 to include instructions to hold for loose BM in the orders for docusate sodium and lactulose. The DON then reviewed Resident 12's physician's order for lactulose and confirmed the order has not been updated since it was placed on 8/10/2022 and does not contain instructions to hold for loose BM as recommended by the consultant pharmacist. The DON further reviewed Resident 12's physician's order for docusate sodium and verified the instructions to hold for loose stool was addressed late and added to the order, under special instructions, on 1/5/2023. The DON stated the RN unit manager should have reviewed the consultant pharmacist's MRR and made sure the order for lactulose was updated to include the recommended instructions. The DON further stated the instructions should have been included in Resident 12's order for docusate sodium timely before the consultant pharmacist conducted the next monthly MRR for October 2022. The DON stated the importance of following through on the pharmacy recommendations for the resident's safety to ensure medications are not given unnecessarily by cueing the nurse to hold the medication if the resident is having loose BM. A review of the facility's policy and procedure titled, Consultant Pharmacist Medication Regimen Review, last reviewed on 10/2022, indicated all consultation summaries of recommendations are sent to the Director of Nursing and may be sent to the Medical Director. The policy and procedure further indicated the physician or other responsible parties receiving the pharmacist's review and the Director of Nursing act upon the recommendation in accordance with the interpretive guidelines as issued by the Centers for Medicare & Medicaid Services (CMS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 76's Face Sheet admission Record indicated the facility admitted the resident on 12/29/2020 with diagnoses including congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), and peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/11/2022, indicated the resident was able to understand others and make herself understood and had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 76 required set up supervision with eating, one-person extensive assistance with personal hygiene, dressing, and locomotion on and off the unit, two-person extensive assistance with bed mobility, transfers, and toileting. A review of Resident 76's care plan for risk for falls related to history of multiple falls, knee buckling during transfers initiated on 2/2/2016 and edited on 7/10/2022, indicated the call light to be placed within easy reach of the resident. During an observation on 1/3/2022 at 10:09 a.m., in Resident 76's room, observed the resident's call light placed in the call light holder fixed to the wall at the head of the bed, and not within resident's reach while the resident was sitting in the wheelchair near the foot of the bed. During a concurrent observation and interview on 1/3/2022 at 10:20 a.m., Certified Nursing Assistant 5 (CNA 5) confirmed that the call light was placed in the holder on the wall and was not within Resident 76's reach. CNA 5 stated Resident 76 knows how to use the call light and can make her needs known. CNA 5 stated that the call light should have been within the resident's reach so the resident would be able to call for assistance and not try to get up and end up falling. During an interview on 1/3/2022 at 10:52 a.m., Registered Nurse 3 (RN 3) stated that the call light should have been within Resident 76's reach for the resident to be able to call for assistance and for staff to meet her needs. RN 3 also stated that not having the call light within the resident's reach for the resident to call for assistance placed the resident at risk for fall or injury. A review of the facility's policy and procedure titled, Answering Call Lights last reviewed on 10/2022 indicated the purpose of the policy to ensure that all resident call lights are answered timely and appropriately. The policy indicated that all residents using call lights have their needs and requests responded to and met. Call light will be ensured to be within easy reach when the resident is in bed or confined to a chair. Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for three of three sampled residents (Residents 63, 52, and 76). This deficient practice had the potential to delay necessary care and services to the residents. Findings: a. A review of Resident 63's Face Sheet indicated the facility admitted the resident on 7/12/2021, with diagnoses including Coronavirus disease-2019 acute respiratory disease [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection], chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problem) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest. A review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/21/2022, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated Resident 63 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 63's Care Plan Review, dated 10/18/2022, indicated an intervention for fall risk to provide call light within easy reach with return demonstration. During an observation, on 1/3/2023 at 10:10 a.m., observed Resident 63 sitting in a wheelchair on the right side near the foot of the bed. Observed call light placed in a holder fixed to the wall near the head of the bed. During an interview, on 1/3/2023 at 10:11 a.m., Resident 63 stated she is not able to reach the call light from where she is sitting. During a concurrent observation and interview, on 1/3/2023 at 10:23 a.m., Licensed Vocational Nurse 3 (LVN 3) observed and verified Resident 63's call light was out of resident's reach. Observed LVN 3 remove call light from the holder on the wall and place it next to the resident. LVN 3 stated Resident 63 is able to verbalize her needs and knows how to use the call light. LVN 3 stated the call light should be placed within easy reach of Resident 63 for staff to be able to attend to the resident's needs promptly whenever she presses the call light to request for help. During an interview, on 1/5/2023 at 5:23 p.m., the Director of Nursing (DON) stated call lights should be placed within reach for all residents within the facility regardless of whether they are able to use the call light or not, and staff should respond to residents when they press the call light as soon as practicable per facility policy. The DON stated the certified nursing assistant (CNA) or licensed nurse should have made sure to place the call light within reach of Resident 63 upon assisting the resident out from bed onto her wheelchair. The DON further stated the importance of ensuring residents have easy access to call lights for staff to respond to and address the resident's requests timely and for the resident's safety. A review of the facility's policy and procedure titled, Answering Call Lights, last reviewed on 10/2022, indicated when the resident is in bed or confined to a chair, be sure the call light is within easy of the resident. b. A review of Resident 52's admission Record indicated the facility originally admitted the resident on 11/11/2019 and readmitted on [DATE], with diagnoses including osteoarthritis (occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates), angina pectoris (a type of chest pain caused by reduced blood flow to the hear), and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 52's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/20/2022, indicated that the resident`s cognitive (thought processes) skills for daily decision making is severely impaired and required extensive assistance on staff for bed mobility, toilet use, and personal hygiene. On 01/03/23 04:51 p.m., observed Resident 52 awake in bed and did not respond when spoken to. Observed call light placed on top of a bedside table, more than an arm's length away from the resident`s bed. On 01/03/23 at 04:44 p.m., during a concurrent observation and interview, observed call light on top of the bedside table, more than an arm`s length away from the resident. Certified Nursing Assistant 1 (CNA 1) confirmed that the call light was not within resident`s reach. CNA 1 explained that one way to prevent the resident from falling is to make sure the call light is within reach for the resident to call for assistance. A review of Resident 52's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 11/19/2019, indicated the resident is at risk for falls and self -care deficits due to impaired mobility following cerebrovascular accident and dementia. The goal indicated that the resident's risk for falls will be reduced daily for ninety days, with interventions including keeping call light in reach while in bed. A review of the facility's policy and procedures titled, Answering Call Lights, last reviewed in 10/2022, indicated the purpose of this policy is to ensure that all resident/patient call lights are answered timely and appropriately. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Answer the resident's call as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 24's Face Sheet indicated the facility admitted the resident on 10/10/2019 and readmitted the resident on 9/22/2022, with diagnoses including paroxysmal atrial fibrillation (afib, an irregular and often very rapid heart rhythm that can lead to blood clot formation in the heart) and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs). A review of Resident 24's Minimum Data Set (MDS - an assessment and screening too) dated 10/14/2022, indicated the resident sometimes had the ability to be understood by others and sometimes had the ability to make self-understood. The MDS indicated the resident required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene. The MDS further indicated the resident received an anticoagulant medication while in the facility. A review of Resident 24's Physician Orders indicated an order for Eliquis (apixaban, an AC medication), tablet 2.5 milligrams (mg, a unit of measurement), orally for a diagnosis of afib, give twice a day at 8:30 a.m. and 4:30 p.m., dated 9/22/2022. During a concurrent interview and record review on 1/4/2023 at 1:45 p.m., reviewed Resident 1's care plan with RN 1. RN 1 stated Eliquis is a high-risk medication and residents taking this medication places the resident at risk for bleeding. RN 1 stated there was no documented evidence of a care plan that specifically addressed usage of an AC. RN 1 stated there should be a care plan for AC usage with interventions including monitoring the resident for presence of hematuria, bloody stool, or gastrointestinal bleeding and monitoring for laboratory tests results. During a concurrent interview and record review on 1/4/2023 at 2:15 p.m., reviewed Resident 24's care plans with the Minimum Data Set Nurse 1 (MDS Nurse 1). MDS Nurse 1 stated there was no documented evidence of a CP for AC usage. MDS Nurse 1 also stated that there should be a CP in order to alert the (team) that the resident was receiving Eliquis and the resident needed to be monitored for the side effects of AC usage such as increased bleeding, hematuria, or bleeding from any other part of the body, and to notify the physician if there were any issues. During a concurrent interview and record review on 1/5/2023 at 1 p.m., reviewed Resident 24's care plans with the Director of Nursing (DON). The DON stated a skin CP was not an adequate CP for monitoring the side effects and use of Eliquis. The DON stated is it important to have an AC usage CP to ensure monitoring of the side effects of the medication such as bruising, bleeding of the gums, hematuria, and nose bleeding. A review of the facility policy and procedure titled, Care Plan - Comprehensive, last reviewed 10/2022, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient's medical, nursing, mental and psychological needs is developed for each resident/patient. The facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's care plan has been designed to: incorporate identified problem areas, incorporate risk factors associated with identified problems, and aid in preventing or reducing declines in the resident functional status. CP goals and objectives are defined as the desired outcome for a specific resident. Goals and objectives are entered on the CP so that all disciplines have access to such information and are able to modify and or adjust as needed for desired outcomes. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: 1. Severe or unexplained bruising 2. Signs of active bleeding 3. Severe decrease in plasma hemoglobin 4. Blood in stool, urine, vomit, or sputum 5. Bleeding of gums, eyes, or nose 6. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. New DVT (acute, usually unilateral, edema [swelling] with or without pain) IV. New PE (chest pain, shortness of breath, tachycardia, cough, fever) V. Stoke (facial drooping, arm weakness, speech difficulties) The protocol guidance for Eliquis therapy indicated clinical monitoring included monitoring for signs and symptoms of bleeding during therapy and monitoring for signs and symptoms of thromboembolism during therapy. Based on interview and record review, the facility failed to: a. Implement the comprehensive person-centered care plan to provide Passive Range Motion (PROM-the range of motion that is achieved when an outside force (such as a therapist) causes movement of a joint ) exercises and Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) for ambulation as ordered by the physician for two out of three residents ( Residents 128 and155) investigated under Comprehensive Care Plans. These deficient practices resulted to failure in providing the necessary care and services and have the potential to minimize the facility's ability to measure resident progress and adjustment of services and treatments as needed to prevent further decline in functional mobility and joint range of motion (ROM, full movement potential of a joint). b. Develop a comprehensive person-centered care plan (CP) in order to meet residents medical, nursing, mental, and psychosocial needs by failing to develop a care plan that addressed the resident's use of an anticoagulant (AC, a class of medications used to prevent or reduce coagulation [the process by which a blood clot is formed]) for one of one resident (Resident 24) reviewed for anticoagulant use. This deficient practice had the potential for the resident taking unnecessary medication and licensed nurses not monitoring the adverse side effects of the anticoagulant. Findings: a. A review of Resident 128's Face Sheet (admission Record) indicated the facility admitted the resident on 9/14/2020, with diagnoses including osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), and low back pain. A review of Resident 128's Minimum Data Set, dated [DATE] (MDS, a standardized assessment and care-screening tool) indicated the resident cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is intact. The MDS indicated the resident required staff assistance with moving from seated to standing position, moving on and off the toilet, and surface to surface transfer (transfer between bed and chair or wheelchair). On 01/03/2023 05:15 p.m., during a concurrent observation and interview, observed Resident 128 sitting on the wheelchair. The resident stated that she has osteomyelitis (inflammation or swelling that occurs in the bone) and had surgery in 2016. According to the resident, she is supposed to be walked everyday by the staff but was only walked one-time last week. The resident stated the staff used to walk her five times a week but not anymore. The resident stated that if she does not get her five times a week walking exercises, she may lose the ability to walk. The resident further stated she has not spoken to her doctor about it. A review of Resident 128's physician's order dated 6/17/2021, indicated for RNA to ambulate [resident] with front-wheeled walker (FWW, type of mobility aid with wide base of support) as tolerated once a day, five times a week (FWW 5x/wk). A review of Resident 128`s Care Plan for Self- Care Deficits and Impaired Mobility, related to general weakness, dated 6/29/21, indicated an intervention for RNA ambulation with FWW 5x/wk as tolerated. A review of Resident 128`s Nursing Rehab Time Log, indicated the number of days the resident was provided RNA ambulation, as follows: 1. October 2022- 20 days; 2. November 2022- 11 days; 3. December 2022- 5 days. On 01/05/23 at 02:19 p.m., during a concurrent interview and record review, reviewed Resident's physician's order for RNA ambulation with RN 4. Registered Nurse 4 (RN4) stated that based on Resident 128`s physician order for RNA Ambulation, she should be provided 20 days in a month of RNA assisted ambulation. According to RN 4, their RNA staff was out with an illness but is not an excuse for not providing ambulation exercises. RN4 also stated, if no RNA program is provided to a resident such as walking exercises, then a resident can decline to the point that her ambulation will be affected. A review of the facility`s policy and procedure titled Restorative Nursing Program, dated 10/2022, indicated that a Restorative Nursing Program helps maintain the strength, endurance and function of residents. It also helps in functional mobility and activities of daily living (ADL`s). The program allows residents to feel in control of their lives and to accept or adapt to the limitation of disability by following and individualized program established by the skilled rehabilitation staff. A review of the facility`s policy and procedure titled Physician Orders, dated 10/2022, indicated that this facility shall ensure that all physician orders are completely and accurately implemented, and all telephone orders are signed in a timely manner. A review of the facility`s policy and procedure titled Care-Plans Comprehensive, dated 10/2022, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient`s medical, nursing, mental, and psychological needs is developed for each resident/patient. b. A review of Resident 155's Face Sheet (admission Record) indicated the facility admitted the resident on 8/07/2021, with diagnoses including osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), hyperlipidemia (an abnormally high concentration of fats in the blood), and dependence on wheelchair. A review of Resident 155's Minimum Data Set, dated [DATE] (MDS, a standardized assessment and care-screening tool) indicated the resident cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact. The MDS indicated the resident required extensive assistance with bed mobility, transfer, toilet use, personal hygiene, and bathing. A review of Resident 155's physician's order dated 6/21/2022, indicated an order for Certified Nurse Assistant (CNA) to provide Passive Range of Motion exercises to both lower extremities twice daily during activities of daily living care (ADL- are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of Resident 155`s Care Plan for Self- Care Deficits and Impaired Mobility related to generalized weakness, dated 9/09/2021, indicated a goal for the resident to gain independence in ADL activities and mobility within 90 days. The Care Plan outlined interventions or approaches, including but not limited to CNA for PROM exercises to both lower extremities three times a week as tolerated. On 01/05/23 at 09:51 a.m., during a concurrent interview and record review, reviewed Resident 155's CNA task documentation and licensed nurses Weekly Summary with RN 4 for the month of December 2022. RN 4 was unable to find documentation of the PROM exercises and stated that if it is not documented that means it was not done. RN 4 stated that the CNAs are supposed to implement this intervention and document in their task. According to RN4, if the PROM exercises to the resident`s lower extremities are not done, these can lead to contractures and functional decline. A review of the facility`s policy and procedure titled Restorative Nursing Program, dated 10/2022, indicated that a Restorative Nursing Program helps maintain the strength, endurance, and function of residents. It also helps in functional mobility and activities of daily living (ADL`s). The program allows residents to feel in control of their lives and to accept or adapt to the limitation of disability by following and individualized program established by the skilled rehabilitation staff. A review of the facility`s policy and procedure titled Physician Orders, dated 10/2022, indicated that this facility shall ensure that all physician orders are completely and accurately implemented, and all telephone orders are signed in a timely manner. A review of the facility`s policy and procedure titled Care-Plans Comprehensive, dated 10/2022, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient`s medical, nursing, mental, and psychological needs is developed for each resident/patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion by: 1. Failure to ensure elbow splints were applied for one of three residents (Resident 53) investigated under the Position/Mobility care area. This deficient practice had the potential to result in decreased range of motion and worsening contractures for Resident 53. 2. Failure to ensure a resident received Restorative Nursing Assistant (RNA - nursing aide program that helps residents to maintain their function and joint mobility) program to help maintain strength, endurance, and functional mobility for one of two residents (Resident 44) investigated under Quality of Care. This deficient practice resulted to failure in providing the necessary care and services and had the potential to lead to an injury in the event of a fall accident. Findings: A review of Resident 53's Face Sheet indicated the facility admitted the resident, on 4/4/2016 and readmitted on [DATE], with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and dependence on a wheelchair. A review of Resident 53's Minimum Data Set (MDS - an assessment and screening too), dated 11/21/2022, indicated the resident rarely/never had the ability to be understood by others and rarely/never had the ability to make self-understood. The MDS indicated the resident was totally dependent on staff for bed mobility, transfer, and locomotion; and the resident required extensive assistance with dressing, eating, toilet use, and personal hygiene. A review of Resident 53's physician orders indicated a nursing order, dated 12/14/2022, that indicated to please provide an elbow flexion contracture splint (a splint [a rigid or flexible device used to hold something in place] used to treat the tightening of muscles, tendons, and ligaments of the elbow that cause a decrease in range of motion)(comfy [a brand of splint]), please have the pt (patient) wear elbow flexion splint for 2 hours on (and) 2 hours off. A review of Resident 53's Care Plan (CP) titled, (Resident 53) has self-care deficits and impaired mobility r/t (related to): advance age; non-ambulatory; and diagnoses of dementia, hypertensive heart disease (heart problems that occur with high blood pressure) with CKD (chronic kidney disease (a condition that results in the loss of kidney function) initiated 12/23/2019 and last edited 11/17/2022, indicated the resident's goal was to maintain activities of daily living and mobility. The CP approach indicated the RNA (Restorative Nurse Aide, a certified nursing assistant with additional training to provided care and services to ensure residents maintain or regain functional gains made in physical, occupational and speech therapy) was to provide elbow comfy orthoses (splint). During an observation on 1/03/2023 at 10:55 a.m., Resident 53 was lying in bed with no elbow splints applied. During an observation and interview, on 1/4/2023 at 12:55 p.m., Certified Nursing Assistant/Restorative Nurse Aide 1 (CNA/RNA 1) assessed Resident 53 and stated the resident used only the hand splints (palmar splints, splints used to prevent contracture of the palms) that were currently applied. Observed no elbow splints applied to the resident. During an observation and interview, on 1/05/2023 at 11:35 p.m., Registered Nurse 1 (RN 1) assessed Resident 53 and stated the resident used hand splints for contractures. RN 1 stated Resident 53 was not wearing elbow splints. RN 1 stated splints were applied and removed by CNA/RNAs. During an interview and record review, on 1/05/2023 at 11:40 a.m., with RN 1 and CNA/RNA 1, CNA/RNA 1 stated she cared for Resident 53 and did not apply elbow splints to the resident because there was no task in the computer to apply them. CNA/RNA 1 stated the process to provide RNA services was the Physical Therapist (PT) or Occupational Therapist (OT) trained and educated the CNA/RNAs on the (RNA) orders, there was a daily task in the computer for the RNA (order), the CNA/RNA provided the service, then they documented on the RNA task that RNA was completed. CNA/RNA 1 stated there was no documentation that the elbow splints were applied because there was no task. RN 1 reviewed Resident 53's medical chart and stated there was no documented evidence that the elbow splints were applied. During a concurrent observation, interview, and record review, on 1/05/2023 at 12 p.m., with the Rehab Director (RD) and the OT, the OT reviewed Resident 53's OT Discharge Summary and Physician Orders and stated the resident should be wearing bilateral elbow splints two hours on and two hours off daily. The OT stated she trained the RNAs on the use of the elbow splints. The OT stated the elbow splints were therapeutic and prevented further contractures. The RD stated the elbow splints were not to make the contractures better, but to prevent worsening of the contractures. The RD stated if the splints were not applied, the risk would be worsening of the contracture and pain or discomfort. During an interview and record review, on 1/05/2023 at 12:35 p.m., RN 1 reviewed Resident 53's order for elbow splints and stated the OT did not correctly enter the RNA order for elbow splints in the computer and that was why the elbow splints were not applied. During an interview, on 1/05/2023 at 1 p.m., the RD stated the Director of Nursing (DON) explained to her it was a matter of how the order for the elbow splints was entered into the computer (on 12/14/2022) that resulted in CNA/RNAs not applying the elbow splints. The RD stated it was important to enter the RNA orders correctly to ensure the service was provided and the resident did not have a decline in function. During a concurrent interview and record review, on 1/6/2023 at 10:30 p.m., the DON reviewed the facility policy and procedure for RNA and stated the policy indicated RNA services should be done as ordered and the treatment must be documented by the CNA/RNA who completed service. The DON stated Resident 53's elbow splints should have been applied by the CNA/RNA to prevent contractures. The DON stated without documented evidence that RNA was completed, it is considered not done. A review of the facility policy and procedure titled, Restorative Nursing Program, last reviewed 10/2022, indicated a RNA program helps to maintain strength, endurance and function of residents. An individualized RNA program for a resident may be referred by a doctor or upon the recommendation by a nurse or therapist which then requires a physician order stating the type of care and frequency of the treatment. The RNA program will start after the completion of a skilled rehabilitation treatment plan and additional training provided by the rehabilitation staff. RNA will follow physician and skilled rehabilitation staff orders. The RNA program established by the skilled therapist regarding the needs of each resident must be for the maintenance of current functional status. RNA documentation will be completed and should contain information pertaining to residents currently in the program. Daily treatment must be initialed on a monthly tracking sheet. Weekly summaries must indicate resident treatment level of assistance, assistive devices, and specific progress made during the week. b. A review of Resident 44`s Face Sheet indicated the facility admitted the resident, on 05/03/2022 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), abnormalities of gait and mobility (any deviations from normal walking or gait), and hyperlipidemia (an abnormally high concentration of fats in the blood). A review of the MDS, dated [DATE], indicated Resident 44's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS also indicated Resident 4 required extensive assistance for bed mobility, transfer, dressing, toilet use, and for personal hygiene. A review of Resident 44`s Physical Therapy Discharge summary, dated [DATE], indicated a recommendation for a Restorative Nursing Program with a goal for resident to be able to walk in corridor and in room with assistance of one staff and balance will be steady by performing restorative nursing interventions. Restorative Nursing Interventions included the use of gait belt and use of walker with one staff providing assistance. A review of Resident 44` Fall Risk Predictive Factors Assessment (eight clinical condition parameters with corresponding score), dated 11/15/2022, indicated the resident had a balance problem while standing with fall history in the past three months. Resident 44 had a score of 20 indicating high risk for fall. A review of Resident 44` Safety Events- Post Accident Assessment and Interventions, dated 11/03/2022, indicated the resident had an unwitnessed fall in her room with no apparent injury. The assessment indicated that the resident had a balance deficit and an unstable gait. A review of Resident 44` Safety Events- Post Accident Assessment and Interventions, dated 11/29/2022, indicated the resident had an unwitnessed fall in front of her room with no apparent injury. The assessment indicated that the resident has a balance deficit and an unstable gait. A review of Resident 44`s Care Plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 11/15/2022, indicated a problem of Self-Care Deficit and Impaired Mobility related to impaired balance. The CP did not include an intervention to provide Restorative Nursing Program. On 01/05/23 at 08:16 a.m., during Resident 44`s record review and concurrent interview with Registered Nurse 4 (RN4), RN 4 stated that the resident was discharged from Physical Therapy Treatment on 09/28/2022 with recommendations for RNA program. RN 4 stated based on the PT recommendations, Resident 44 should have been enrolled in an RNA program for functional maintenance and mobility. RN 4 stated that one of the goals of an RNA program was to maintain the level of functional mobility and prevent functional decline. RN4 stated if no RNA program was provided to a resident such as walking exercises, then a resident could decline to the point that her ambulation would be affected. RN4 explained that when a resident was discharged from PT, the PT staff would obtain an order for RNA from the primary care physician. RN4, after reviewing Resident 44`s medical records confirmed that there was no order for RNA program written for the resident. RN4 stated if the RNA program had been provided and focus on functional mobility, it could have prevented those fall incidents. On 01/05/23 at 10:07 AM, during Resident 44`s record review and interview with the Rehabilitation Director (RD), the RD confirmed that there was no order obtained for an RNA program. RD stated RNA program could help the residents improve their balance and the risk of fall could be minimized. A review of the facility`s policy and procedure titled Restorative Nursing Program, dated 10/2022, indicated that a Restorative Nursing Program helps maintain the strength, endurance and function of residents. It also helps in functional mobility and activities of daily living (ADL`s-). The program allows residents to feel in control of their lives and to accept or adapt to the limitation of disability by following and individualized program established by the skilled rehabilitation staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** g. A review of Resident 86's Face Sheet admission Record indicated the facility originally admitted the resident on 8/12/2021 and readmitted the resident on 11/14/2021 with diagnoses including end stage renal disease (ESRD - a medical condition in which a person's kidneys stop functioning on a permanent basis) on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and atrial fibrillation (a. fib. - an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). A review of Resident 86's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated11/17/2022 indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 86 required two-person extensive assistance with bed mobility, transfer, and toilet use; required one-person extensive assistance with dressing and personal hygiene; and required setup and supervision with eating. A review of Resident 86's Physician's Order dated 1/2023 indicated: 1. Eliquis 2.5 milligrams (mg - a unit of measurement of weight) by mouth once a day on Monday, Wednesday, and Friday at 10:30 a.m. 2. Eliquis 2.5 mg by mouth once an evening at 4:30 p.m. 3. Eliquis 2.5 mg by mouth once a day on Sunday, Tuesday, Thursday, and Saturday at 8:30 a.m. A review of Resident 86's Care Plan dated 2/18/2022 indicated observe for signs and symptoms of bleeding. During a concurrent interview and record review on 1/52023 at 8:37 a.m., Registered Nurse 2 (RN 2) stated Resident 86 was taking Eliquis. RN 2 stated the facility did not have a monitoring for side effects of Eliquis for Resident 86 since 12/2/2022 but should have had one. RN 2 stated because of the risk for bleeding, it was important to monitor the resident for signs and symptoms of bleeding such as bruising, blood in stool, blood in urine, and a drop in blood pressure. RN 2 stated the purpose of monitoring and recording the side effects of Eliquis were to get a bigger picture to be able to report to the resident's physician accordingly. A review of the facility's policy and procedure (P&P), titled, Anticoagulation (a substance that is used to prevent and treat blood clots in blood vessels and the heart) Management & Monitoring Policy, dated 10/2022, indicated, The resident/patient will be monitored for signs and symptoms of bleeding at treatment initiation, throughout the entire duration of treatment, and after discontinuation of an anticoagulant agent . Based on interview and record review, the facility failed to: 1. Ensure an adequate indication with specific behavioral manifestations to monitor for the use of Ativan (lorazepam, a benzodiazepine [a class of medications used to treat anxiety, a mental condition characterized by excessive apprehensiveness about real or pceived threats, and insomnia]) for one of 22 sampled residents (Resident 132) investigated for unnecessary medications. 2. Ensure licensed nurses adequately monitored residents on Eliquis (apixaban - an anticoagulant [used to prevent blood clots from forming]) for adverse reactions or adverse side effects (unwanted undesirable effects that are possibly related to a drug) for eight of 22 sampled residents (Residents 24, 37, 137, 204, 86, 147, 58, and 154) investigated for unnecessary medications. 3. Ensure licensed nurses adequately monitored residents on Xarelto (rivaroxaban - an anticoagulant [used to prevent blood clots from forming]) for adverse reactions or adverse side effects (unwanted undesirable effects that are possibly related to a drug) for one of 22 sampled residents (Resident 3). These deficient practices had the potential to result in residents receiving unnecessary medication and placed the residents at risk for adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) of prolonged use of medications. Findings: a. A review of Resident 132's Face Sheet indicated the facility admitted the resident on 2/2/2017 and readmitted the resident on 1/25/2021 with diagnoses that anxiety disorder (a mental health condition that may result in feelings of nervousness, panic, and fear) psychophysiological insomnia (the inability to sleep that may result from a stressor combined with fear of being unable to sleep) and atrial fibrillation (a. fib., an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). A review of Resident 132's Minimum Data Set (MDS - an assessment and screening too) dated 11/3/2022, indicated the resident had the ability to be understood by others and had the ability to make self-understood. The MDS indicated the resident required limited assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS further indicated the resident received antianxiety medication while in the facility. A review of Resident 132's Physician Orders indicated the following order: - Ativan - Schedule IV (a controlled substance), Tablet: 0.5 milligram (mg, a unit of measurement), amount (to administer): 0.25 mg orally. Special instructions: diagnosis: Anxiet (anxiety) manifested by (m/b) overly concern of health. Hold (do not administer) for sedation, (give) at bedtime; 10 p.m., dated 9/14/2021. During an interview and record review on 1/5/2023 at 10:45 a.m., Licensed Vocational Nurse 5 (LVN 5) stated she cared for Resident 132 and the resident was administered a low dosage of Ativan in the evenings because she gets restless and anxious towards the night. LVN 5 reviewed Resident 132's Physician Orders and Medication Administration Record (MAR) and stated the Ativan order indicated to monitor every shift for overly concern of health. LVN 5 stated she was not sure how to monitor for overly concern of health, but she documented in the MAR the number of times the resident manifested the behavior and it never occurred on her shift. LVN 5 stated the manifestation did not seem like a very specific behavior that could be monitored. LVN 5 stated they should probably monitor the number of times the resident verbalized concerns regarding her health. LVN 5 stated the behavior to monitor would be the verbalization of concern. LVN 5 stated she should clarify with the physician regarding the behavior manifestation to monitor because it should be more specific to monitor for the behavior occurrence. During an interview and record review on 1/5/2023 at 10:55 a.m., RN 1 stated when a resident receives Ativan in the facility, they monitor specific behaviors. RN 1 stated Resident 132 was receiving Ativan and verbalizes concerns regarding her medications. RN 1 stated there are other ways to manifest overly concern of health that include pacing or similar behaviors, but Resident 132 verbalizes concerns about medications and her health. RN 1 stated it is important to have measurable, specific behavior manifestations to monitor and document to assess the appropriateness of the medication and attempt a gradual dose reduction (GDR) to determine if a resident still needs a medication or doesn't meet the criteria for the medication to be given. During an interview on 1/5/2023 at 11:20 a.m., the Director of Nursing (DON) stated for Ativan, and other antianxiety medications, the importance of having a specific targeted behavior is to be able to measure the behavior to know if the medication is appropriate and to know if a high risk medication is necessary. The DON stated Resident 132's manifested behavior to monitor for the use of Ativan should include the verbalization of concerns to be more specific and measurable. A review of the facility policy and procedure titled, Medication Psychotherapeutic Drug (used to treat problems in thought processes of individuals with both perceptual and behavioral disorders) Management, last reviewed 10/2022, indicated the purpose of the policy and procedure was to provide an interdisciplinary approach to care that promotes the functional ability of each individual resident in conjunction with providing a therapeutic environment where only those medications with therapeutic benefit are utilized avoiding all unnecessary drugs. Psychotherapeutic drugs will only be utilized with a physician order and will never be used for the convenience of staff. Psychotropic medication shall be prescribed by a qualified licensed practitioner and conform to Federal and State law. All orders for psychotropic medications must be complete in order to be dispensed by the pharmacy. A complete order must include a valid diagnosis of the condition it is being prescribed for, the name of the medication, dose, route, duration, and indication for use. The medication would be written in the Medication Administration Record with the manifestations for the drug, i.e. hitting other etc. Documentation will occur each shift with the number of times this behavior has occurred. Nurses will identify and document any new onset or worsening of behavioral symptoms, including whether the behavior presents a risk for adverse consequences to the resident or others. b. A review of Resident 24's Face Sheet indicated the facility admitted the resident on 10/10/2019 and readmitted the resident on 9/22/2022 with diagnoses that included paroxysmal atrial fibrillation (a. fib., an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs). A review of Resident 24's Minimum Data Set (MDS - an assessment and screening too) dated 10/14/2022, indicated the resident sometimes had the ability to be understood by others and sometimes had the ability to make self-understood. The MDS indicated the resident required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene. The MDS further indicated the resident received anticoagulant medication while in the facility. A review of Resident 24's Physician Orders indicated an order for Eliquis tablet 2.5 milligrams (mg, a unit of measurement), orally for a diagnosis of a. fib., give twice a day at 8:30 a.m. and 4:30 p.m., dated 9/22/2022. During an interview and record review on 1/4/2023 at 1:45 p.m., Registered Nurse 1 (RN 1) stated Eliquis is a high-risk medication and residents that take Eliquis have a risk for bleeding. RN 1 stated residents on Eliquis should be monitored for signs and symptoms of bleeding. RN 1 reviewed Resident 24's medical chart and stated there was no documented evidence that the resident was monitored for Eliquis usage. During an interview on 1/4/2023 at 2 p.m., Licensed Vocational Nurse 5 (LVN 5) stated she was caring for Resident 24 and was aware the resident was on Eliquis. LVN 5 stated she did not monitor the resident for signs and symptoms of bleeding. During an interview and record review on 1/4/2023 at 2:15 p.m., Minimum Data Set Nurse 1 (MDS Nurse 1) stated nurses need to monitor for signs and symptoms of bleeding for residents taking anticoagulants. MDS Nurse 1 stated bleeding is an adverse reaction to an anticoagulant medication, and it is significant and important to recognize the early signs of an adverse reaction to a medication. MDS Nurse 1 stated any issues would be reported to the physician. MDS Nurse 1 reviewed Resident 24's medical chart and stated there was no documentation of monitoring for bleeding. During an interview and record review on 1/5/2023 at 1 p.m., the Director of Nursing (DON) stated it was important to ensure monitoring for the side effects of Eliquis usage including monitoring for bruising, bleeding of the gums, hematuria (presence of blood in the urine), and nose bleeding, etc. The DON reviewed Resident 24's medical chart and stated there was no documentation of monitoring for Eliquis usage. The DON stated the facility policy and procedure indicated to monitor for side effects of anticoagulant usage. The DON stated documentation was important because if it was not documented, then it was not done. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits in order to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: I. Severe or unexplained bruising II. Signs of active bleeding III. Severe decrease in plasma hemoglobin (component of the blood that transports oxygen in the body) IV. Blood in stool, urine, vomit, or sputum V. Bleeding of gums, eyes, or nose VI. Hematoma (a pool of blood outside the blood vessel) or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. New deep vein thrombosis (DVT- a blood clot in a deep vein, usually in the legs) (acute, usually unilateral, edema [swelling] with or without pain) V. New pulmonary embolism (PE - a blood clot that blocks and stops blood flow to an artery in the lung) (chest pain, shortness of breath, tachycardia [heart rate that exceeds the normal resting rate], cough, fever) VI. Stroke (facial drooping, arm weakness, speech difficulties) The protocol guidance for Eliquis therapy indicated clinical monitoring included monitoring for signs and symptoms of bleeding during therapy and monitoring for signs and symptoms of thromboembolism during therapy. c. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 1/24/2020 and readmitted the resident on 12/30/2022 with diagnoses including left first and second toe amputation (removal of a limb by trauma, medical illness, or surgery), atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), and peripheral vascular disease (PVD - a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/21/2022, indicated the resident had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated the resident required supervision with eating; one-person limited assistance with personal hygiene and locomotion on and off unit; and one-person extensive assistance with bed mobility, transfers, dressing, toileting, and bathing. During an interview on 1/5/2023 at 11:11 a.m., Licensed Vocational Nurse 9 (LVN 9) stated that nurses just visually monitor residents who are on anticoagulants but there was no task in the Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) to monitor the residents for bruising or bleeding. LVN 9 verified that there was no documented evidence that the resident was being monitored for bleeding. LVN 9 stated it was important to monitor the resident for bruising or bleeding so the physician would know if the medication needed to be discontinued. During a concurrent interview and record review on 1/5/2023 at 11:42 a.m., Registered Nurse 3 (RN 3) stated Resident 3 had a physician's order for rivaroxaban (anticoagulant - medication that helps prevent blood clots) 15 milligrams (mg - a unit of measurement) oral (by mouth) once an evening for atrial fibrillation. Upon review of Resident 3's MAR dated 1/5/2023, the resident received rivaroxaban 7 times since readmission on [DATE]. When asked if the nurses are monitoring the resident for bruising or bleeding, RN 3 stated that monitoring is not part of the physician's order and there was no documented evidence indicating licensed nurses were monitoring the resident for bruising or bleeding. RN 3 stated it was important to know if the resident had any bruising or bleeding so the physician would know if the medication needed to be discontinued. During a concurrent interview and record review on 1/6/2023 at 10:40 a.m., the Director of Nursing (DON) stated it was important to ensure monitoring for the side effects of anticoagulant usage was done including monitoring for bruising, bleeding of the gums, hematuria, and nose bleeding, etc. The DON verified that there was no documented evidence of monitoring for rivaroxaban use. The DON stated the facility policy and procedure indicated to monitor for the side effects of anticoagulant use. The DON stated documentation was important because if it was not documented, then it was not done. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits in order to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: I. Severe or unexplained bruising II. Signs of active bleeding III. Severe decrease in plasma hemoglobin IV. Blood in stool, urine, vomit, or sputum V. Bleeding of gums, eyes, or nose VI. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. New DVT (acute, usually unilateral, edema [swelling] with or without pain) V. New PE (chest pain, shortness of breath, tachycardia [heart rate that exceeds the normal resting rate], cough, fever) VI. Stroke (facial drooping, arm weakness, speech difficulties) d. A review of Resident 37's Face Sheet indicated the facility admitted the resident on 11/26/2019 and readmitted the resident on 11/12/2022 with diagnoses including congestive heart failure (CHF - a condition in which the heart doesn't pump blood as efficiently as it should), atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/9/2022, indicated the resident was severely impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated the resident required one-person extensive assistance with eating; two-person extensive assistance with personal hygiene; and two-person total assistance with bed mobility, transfers, dressing, toileting, and bathing. During a concurrent interview and record on 1/5/2023 at 2:59 p.m., Licensed Vocational Nurse 8 (LVN 8) confirmed that Resident 37 had a physician's order of apixaban (anticoagulant - medication that helps prevent blood clots) 2.5 milligrams (mg - a unit of measurement) oral (by mouth) twice a day for atrial fibrillation. Upon review of Resident 3's Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional), dated 1/5/2023. The resident received apixaban 27 times from 12/23/2022 to 1/5/2023. LVN 8 stated Resident 37 was not being monitored for signs of bruising or bleeding every shift and nurses were just visually observing residents for signs of bleeding. LVN 8 stated monitoring for bleeding was not part of the order and task in the MAR and there was no documented evidence of monitoring. LVN 8 stated it was important to monitor residents on anticoagulant if the residents had any bruising or bleeding so the physician would know if the medication needed to be discontinued. During an interview on 1/5/2023 at 3:05 p.m. Registered Nurse 6 (RN 6) there was no documented evidence indicating licensed nurses were monitoring the resident for bruising or bleeding. RN 6 stated monitoring for signs of bleeding was not part of the physician's order and task in the MAR. RN 6 stated residents should be monitored for bruising or bleeding so the physician would know if the medication needed to be discontinued. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits in order to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: I. Severe or unexplained bruising II. Signs of active bleeding III. Severe decrease in plasma hemoglobin IV. Blood in stool, urine, vomit, or sputum V. Bleeding of gums, eyes, or nose VI. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. New DVT (acute, usually unilateral, edema [swelling] with or without pain) V. New PE (chest pain, shortness of breath, tachycardia [heart rate that exceeds the normal resting rate], cough, fever) VI. Stroke (facial drooping, arm weakness, speech difficulties) e. A review of Resident 137's Face Sheet indicated the facility admitted the resident on 11/26/2019 and readmitted the resident on 10/24/2022 and 11/29/2022 with diagnoses including pulmonary edema (a condition caused by too much fluid in the lungs), end stage renal disease (ESRD - a condition in which a person's kidneys stops working permanently leading to the need for dialysis [a treatment for kidney failure that rids the body of unwanted toxins, waste products and excess fluids by filtering the blood] or a kidney transplant to maintain life), and atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications). A review of Resident 137's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/9/2022, indicated the resident had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated the resident required supervision with eating, limited assistance with personal hygiene, one-person extensive assistance with dressing and toileting, and two-person extensive assistance with bed mobility and transfers. During an interview on 1/5/2023 at 11:11 a.m., Licensed Vocational Nurse 9 (LVN 9) stated that nurses just visually monitor residents who are on anticoagulants but there was no task in the Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) to monitor the residents for bruising or bleeding. LVN 9 verified that there was no documented evidence that Resident 137 was being monitored for bleeding. LVN 9 stated it was important to monitor the resident for bruising or bleeding so the physician would know if the medication needed to be discontinued. During a concurrent interview and record review on 1/5/2023 at 11:42 a.m., Registered Nurse 3 (RN 3) stated Resident 137 had a physician's order for apixaban (anticoagulant - medication that helps prevent blood clots) 2.5 milligrams (mg - a unit of measurement) oral (by mouth) twice a day for atrial fibrillation. Upon review of Resident 137's MAR dated 1/3/2023, the resident received apixaban 20 times from 12/24/2022 to 1/3/2023. When asked if the nurses are monitoring the resident for bruising or bleeding, RN 3 stated that monitoring was not part of the physician's order and there was no documented evidence indicating licensed nurses were monitoring the resident for bruising or bleeding. RN 3 stated it was important to know if the resident had any bruising or bleeding so the physician would know if the medication needed to be discontinued. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits in order to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: I. Severe or unexplained bruising II. Signs of active bleeding III. Severe decrease in plasma hemoglobin IV. Blood in stool, urine, vomit, or sputum V. Bleeding of gums, eyes, or nose VI. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. New DVT (acute, usually unilateral, edema [swelling] with or without pain) V. New PE (chest pain, shortness of breath, tachycardia [heart rate that exceeds the normal resting rate], cough, fever) VI. Stroke (facial drooping, arm weakness, speech difficulties) f. A review of Resident 204's Face Sheet indicated the facility admitted the resident on 9/2/2022 and readmitted the resident on 9/16/2022 with diagnoses including cerebral atherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque [a fatty, waxy substance that forms deposits in the artery wall] in the inner lining of arteries [the blood vessels that bring oxygen-rich blood from the heart to the body]) in the brain, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications. A review of Resident 204's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/10/2022, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required one-person extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and one-person total assistance with bathing. During an interview on 1/5/2023 at 11:11 a.m., Licensed Vocational Nurse 9 (LVN 9) stated that nurses just visually monitor residents who are on anticoagulants but there was no task in the Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) to monitor the residents for bruising or bleeding. LVN 9 verified that there was no documented evidence that Resident 204 was being monitored for bleeding. LVN 9 stated it was important to monitor the resident for bruising or bleeding so the physician would know if the medication needed to be discontinued. During a concurrent interview and record review on 1/5/2023 at 11:42 a.m., Registered Nurse 3 (RN 3) stated Resident 137 had a physician's order for apixaban (anticoagulant - medication that helps prevent blood clots) 2.5 milligrams (mg - a unit of measurement) oral (by mouth) twice a day for atrial fibrillation. Upon review of Resident 204's MAR dated 1/3/2023, the resident received apixaban 28 times from 12/22/2022 to 1/4/2023. When asked if the nurses are monitoring the resident for bruising or bleeding, RN 3 stated that monitoring was not part of the physician's order and there was no documented evidence indicating licensed nurses were monitoring the resident for bruising or bleeding. RN 3 stated it was important to know if the resident had any bruising or bleeding so the physician would know if the medication needed to be discontinued. During an interview on 1/6/2023 at 10:40 a.m., the Director of Nursing (DON) stated it was important to ensure monitoring for the side effects of anticoagulant usage was done including monitoring for bruising, bleeding of the gums, hematuria, and nose bleeding, etc. The DON stated the facility policy and procedure indicated to monitor for the side effects of anticoagulant use. The DON stated documentation was important because if it was not documented, then it was not done. A r[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Discard discontinued bubble packs (a package that contains multiple sealed compartments with medication) for two sampled residents (Resident 7 and Resident 164) from one of five medication carts (1st Floor Medication Cart B) investigated during the facility task Medication Storage and Labeling. This deficient practice had the potential for residents to receive medications that were not ordered for them or medications that were already expired and ineffective. 2. Maintain the refrigeration log with the correct safe temperature range, according to the facility's policy and procedures, for refrigerated stored medications for one of five medication rooms (Third Floor Medication Room) investigated during the facility task Medication Storage and Labeling. This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. Findings: 1a. During a medication cart observation (inspection) of 1st Floor Medication Cart B on [DATE] at 10:48 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 7's lisinopril (a medication to lower blood pressure) 10 milligrams (mg, a unit of measure) bubble pack stored in the medication cart. LVN 2 verified Resident 7 did not have an active order for the use of lisinopril 10 mg. LVN 2 stated the discontinued bubble pack should have been taken out of the medication cart and been put in the medication room for destruction. A review of Resident 7's Face Sheet (admission record) indicated the facility originally admitted the resident on [DATE] with diagnoses that included hypertensive chronic kidney disease (a medical condition referring to damage to the kidney due to chronic high blood pressure). A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated Resident 7 was cognitively intact (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 7 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, and personal hygiene. A review of Resident 7's Physician's Orders indicated the following orders: 1. Lisinopril 10 mg by mouth every day for hypertension (HTN - elevated blood pressure), ordered on [DATE] and discontinued on [DATE]. 2. Lisinopril 10 mg by mouth twice a day for hypertension, ordered [DATE] and discontinued [DATE]. 3. Lisinopril 15 mg (strength of each tablet is 5 mg) by mouth twice a day for hypertension, ordered [DATE]. A review of Resident 7's Care Plan for Alteration in Cardiac Status, initiated [DATE], indicated a goal that signs and symptoms of hypertension will be managed daily. The care plan indicated an intervention to monitor blood pressure as ordered. During an interview and concurrent record review on [DATE] at 3:03 p.m., reviewed the policy and procedure titled, Disposition of Controlled and Non-Controlled Medication, reviewed in 10/2022. The Director of Nursing (DON) stated discontinued medications should be taken out of the medication cart and placed in the medication room the day the medication order was discontinued even though the time frame was not specified in the policy. The DON verified Resident 7 did not have an active order for the use of lisinopril 10 mg and stated the last order would have been discontinued on [DATE]. 1 b. During a medication cart observation (inspection) of 1st Floor Medication Cart B on [DATE] at 10:48 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 164's medication and medication bubble pack stored in the medication cart. LVN 2 verified Resident 164 did not have an active order for the use of buspirone 5 mg tablets or lithium carbonate 150 mg tablets. LVN 2 stated the discontinued bubble pack should have been taken out of the medication cart and been put in the medication room for destruction. A review of Resident 164's Face Sheet indicated the facility originally admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses that included anxiety (feelings of uneasiness) and major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). A review of Resident 164's MDS, dated [DATE], indicated Resident 164 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 164 required one-person extensive assistance. A review of Resident 164's Physician's Orders indicated the following orders: 1. Buspirone 5 mg by mouth three times a day for anxiety, ordered [DATE] and discontinued on [DATE]. 2. Lithium carbonate 150 mg by mouth twice a day for major depressive disorder, ordered [DATE] and discontinued on [DATE]. During an interview on [DATE] at 3:03 p.m., with the Director of Nursing (DON), the DON stated discontinued medications should be taken out of the medication cart and placed in the medication room. The DON verified Resident 164 did not have an active order for the use of buspirone 5 mg or lithium carbonate 150 mg. During an interview and concurrent record review on [DATE] at 3:03 p.m., reviewed the policy and procedure titled, Disposition of Controlled and Non-Controlled Medication, reviewed in 10/2022. The Director of Nursing (DON) stated discontinued medications should be taken out of the medication cart and placed in the medication room the day the medication order was discontinued even though the time frame was not specified in the policy. The DON verified Resident 164 did not have an active order for the use of buspirone 5 mg or lithium carbonate 150 mg. 2. During medication room observation on the third floor (Third Floor Medication Room) and a concurrent interview with Registered Nurse 1 (RN 1) on [DATE] at 10:28 a.m., observed the refrigerator log for that medication room. The log indicated refrigerator containing drugs shall be maintained between 2 degrees Celsius (°C, a unit of measure for temperature) (68 degrees Fahrenheit [°F, a unit of measure for temperature] and 25 (°C (77 [°F). When asked if 2 °C was equivalent to 68 °F, RN 1 stated she did not know and would have to check. When asked if 25 °C was the higher range limit to store refrigerated medications, RN 1 stated she did not know and would have to check. During an interview and concurrent record review with the Director of Nurses (DON) on [DATE] at 3:03 p.m., reviewed the refrigerator logs for all five medication rooms. Reviewed the facility's policy and procedure titled, Medication Refrigerator Storage for Nursing Floor Medication Room, reviewed 10/2022. The policy indicated the refrigerator temperature range was to be between 36 degrees to 46 °F which corresponds to 2 to 8 °C. The DON stated the log medication refrigerator temperature parameters (limit or boundary) were incorrect on the medication logs for all five refrigerator logs and would be corrected. The DON stated he was not sure how long this medication refrigerator log was being used by licensed nursing staff. The DON stated there was a potential to cause confusion among licensed nursing staff about what the actual parameters were and had the potential for the refrigerator to be maintained at incorrect temperatures thus making medications ineffective for their intended use.

d. On 01/03/23 at 10:36 a.m., during a kitchen tour observation and interview, accompanied by DS 1 and DS 2, observed a partially used bag of sliced bread with no label as to when it was opened and no label as to when to discard. According to DS 2, the sliced bread had to be discarded since it had no open date label and there was no way to determine if it was past the best by date or discard date. Per DS 2, the sliced bread was no longer safe for consumption as it might already be spoiled. A review of the facility`s policy and procedures dated 10/2022, titled Storing Dry Foods, indicated that dry foods will be stored in a safe and sanitary manner. Breads removed from the freezer are dated upon thawing and are used within 7 days. Based on observation, interview, and record review, the facility failed to: 1. Follow the practice of proper personal hygiene when one dietary aide (DA 1) out of seven sampled dietary staff was observed not wearing a hair restraint while in the kitchen. 2. Ensure the kitchen's ice machine (Kitchen 2) was free from red spots on the inside of the ice machine. 3. Ensure that raw chicken was not placed on a rack in the refrigerator above a pan of onions. 4. Follow safe food handling practices by failing to label with open date and best by date a partially used bag of sliced bread. These deficient practices had placed the residents at risk for foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) with common symptoms such as nausea, vomiting, stomach cramps, and diarrhea for 218 residents on oral feeding. Findings: a. During a kitchen observation and interview on 1/03/2023 at 8:13 a.m., observed DA 1 not wearing a hair net after entering the kitchen area. DA 1 stated she should have been wearing a hair net. The Dietary Supervisor (DS 1) stated DA 1 should have gotten a hair net in the hair net holder just inside the kitchen door entrance. During an interview with DS 1 on 1/03/2023 at 8:14 a.m., DS 1 stated all staff should wear a hair net while working in the kitchen. DS 1 stated DA1 should have been wearing a hair net so that food would not become contaminated. A review of the facility's policy and procedure titled, Hair Restrains/Jewelry/Nail Polish, reviewed 10/2022, indicated hair restraints (hair nets) shall be worn by all dietary services employees while on duty in the dietary department. b. During a kitchen observation and interview with DS 1 and DA 2 on 1/03/2023 at 8:16 a.m., observed the two ice machines. Wiped the top inside portion of Kitchen 2 ice machine with a clean napkin with gloved hand and saw red specks on the paper towel. DS 1 stated DA 2 cleans the ice machine monthly. DS 1 presented the facility's Ice Machine Cleaning Log which indicated the last time staff documented the ice machines were cleaned was on 6/14/2022. DA 2 stated the last time the ice machines were cleaned was 11/19/2022. During an interview with the Lead Dietary Supervisor (DS 2) on 1/03/2023 at 9:10 a.m., he stated the ice machine should be cleaned monthly according to their policy. DS 2 stated there is a potential for causing a food borne illness if ice machines are not cleaned each month. A review of the facilities policy and procedure titled, General Sanitation, reviewed 10/2022, indicated at least monthly ice making machines are to be turned off, emptied, cleaned with a soap solution, rinsed with a sanitizer solution and air dried before the machines are turned back on. c. During a kitchen observation and interview with DS 1 and DS 2 on 1/03/2023 at 8:30 a.m., observed a pan of raw chicken in the walk-in refrigerator placed on a shelf directly above a pan of raw onions. DS 1 and DS 2 stated the raw chicken pan should be placed on the bottom shelf so that it does not leak any liquid into any food pans in the shelf below. DS 2 stated this could potentially cause Salmonella infection (bacterial infection caused from eating raw chicken) in those eating the onions. A review of the facilities policy and procedure titled, Storing Refrigerated/Frozen Foods, reviewed 10/2022, indicated raw foods are to be stored on bottom shelves in case of leakage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** h. A review of Resident 74's Face Sheet indicated the facility originally admitted the resident on 6/1/2018 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar) and allergic rhinitis (a diagnosis associated with a group of symptoms affecting the nose; these symptoms occur when you breathe in something you are allergic to, such as dust and pollen). A review of Resident 74's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/2/22 indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 74 required two-person extensive assistance with bed mobility and toilet use; required two-person total assistance with transfer; and required one-person extensive assistance with dressing and personal hygiene. A review of Resident 74's Physician Orders dated 1/2023 indicated oxygen at two liters per minute (LPM - a measurement of the flow rate at which air flows into the nostrils [openings to your nose] over a period of one minute) via nasal cannula as needed for blood oxygen level less than 93%. A review of Resident 74's Care Plan last revised on 12/2/2022 indicated respiratory system (the network of organs and tissues that help you breathe) problem related to allergic rhinitis. The Care Plan indicated monitor blood oxygen level, give oxygen through nasal cannula as ordered, and store mask or cannula in a bag when not in use. During a concurrent observation and interview on 1/3/2023 at 10:43 a.m., in Resident 74's room, observed with Licensed Vocational Nurse 1 (LVN 1) Resident 74's nasal cannula was on the floor. LVN 1 stated Resident 74's nasal cannula was on the floor but should have been inside a bag. LVN 1 stated the nasal cannula had been contaminated because the floor was dirty. LVN 1 stated had the resident used the nasal cannula that had already been on the floor, the resident could get an infection. During an interview on 1/5/2023 at 10:29 a.m., Registered Nurse 3 (RN 3) stated Resident 74's nasal cannula should not have been on the floor but should have been stored in a bag when not in use. RN 3 stated the resident's nasal cannula that was on the floor was an infection control problem because the floor was considered dirty. RN 3 stated if the nasal cannula was used after it had already been on the floor, this placed the resident at risk for respiratory problem such as a trigger of allergy because the resident had a diagnosis of allergic rhinitis. RN 3 stated it was the facility's responsibility to monitor Resident 74's nasal cannula to ensure it was not on the floor especially because the resident tends to remove the nasal cannula. During an interview on 1/5/2023 at 3:15 p.m., Infection Preventionist (IP) stated Resident 74's nasal cannula should not have been on the floor but should have been stored in a bag when not in use. IP stated the nasal cannula could have picked up organisms (livings things capable of growing such as bacteria) on the floor and if the resident were to use the nasal cannula, it could cause infection. A review of the facility's policy and procedure (P&P), titled, Oxygen Management, dated 10/2022, indicated, Infection Control . The oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The cannula, mask, and tubing will be stored in a plastic bag when not in use . i. A review of Resident 48's Face Sheet indicated the facility originally admitted the resident on 9/20/2021 and readmitted the resident on 4/16/2022 with diagnosis including chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 48's MDS dated [DATE] indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 48 required one-person extensive assistance with bed mobility, transfer, dressing, and toilet use; required one-person limited assistance with personal hygiene; and required setup and supervision with eating. A review of Resident 48's Physician Orders dated 1/2023 indicated oxygen at two LPM via nasal cannula as needed to keep blood oxygen level above 92%. A review of Resident 48's Care Plan dated 9/21/2022 last revised on 1/4/2023 indicated the resident had respiratory system problem related to COPD and smoking. During a concurrent observation and interview on 1/3/2023 at 12:09 p.m., in Resident 48's room, observed with RN 2 Resident 48's nasal cannula hanging on an oxygen tank and dolly (a cart with wheels used to transport objects) without a bag. RN 2 stated Resident 48's nasal cannula was hanging over the dolly of an oxygen tank without a bag and part of the tubing was touching the floor. RN 2 stated leaving the nasal cannula without storing in a bag hanging on a dolly was not a correct procedure; RN 2 stated the nasal cannula should have been stored in a bag when not in use. RN 2 stated Resident 48 had respiratory issues and required oxygen as needed. RN stated storing the nasal cannula without a bag could potentially place the resident at risk for infection if the resident were to use the nasal cannula. During an interview on 1/5/2023 at 3:15 p.m., IP stated Resident 48's nasal cannula should not have been hanging over an oxygen tank or dolly but should have been stored in a bag when not in use. IP stated the nasal cannula had been contaminated because the surface of the oxygen tank might have had organism causing infection. IP stated a nasal cannula is used through the nose and if the resident were to use a contaminated nasal cannula, it could cause the resident respiratory infection. A review of the P&P, titled, Oxygen Management, dated, 10/2022, indicated, Infection Control . The oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The cannula, mask, and tubing will be stored in a plastic bag when not in use . j. A review of Resident 141's Face Sheet indicated the facility admitted the resident on 3/2/2021 with diagnosis including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 141's MDS dated [DATE] indicated the resident had a severe cognitive (relating to thinking, reasoning, or remembering) impairment (loss or damage). The MDS indicated Resident 141 required one-person extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene; and required two-person extensive assistance with transfer. During an observation on 1/3/2023 at 10:52 a.m., in Resident 141's room, observed two blue wedge cushion pillows on the floor with bed linens on top of wedge cushion pillows. During a concurrent observation and interview on 1/3/2023 at 10:58 a.m., in Resident 141's room, observed with Certified Nursing Assistant 5 (CNA 5) two blue wedge cushion pillows were on the floor with bed linens on top. CNA 5 stated he was not sure if the wedge cushion pillows and linens were clean or dirty because he was only covering for the assigned CNA for the resident. CNA 5 stated if it were him, he would not leave bed linens and wedge cushion pillows the way they were left because this was not a professional practice. During an interview on 1/5/2023 at 11:33 a.m., RN 3 stated Resident 141's wedge cushion pillows should not have been on the floor. RN stated the wedge cushion pillows left on the floor was an infection control violation because the floor was dirty. During an interview on 1/5/2023 at 4:28 p.m., the Director of Nursing (DON) stated Resident 141's wedge cushion pillows should have been left on the floor because the floor was considered dirty and if the resident were to use the wedge cushion pillows, this could potentially cause infection issues to the resident. A review of the facility's P&P, titled, Infection Control Program, dated 5/2022, indicated, Priority #5: Reduce healthcare-associated infections (HAIs) . Strategies and interventions include: Provide education and training to the staff to ensure that all individuals understand the elements of the prevention strategies related to transmission of infections . Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to: 1. Ensure six of seven surveyors were screened for Coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) upon entering the facility. 2. Ensure Certified Nursing Assistant 7 (CNA 7) did not pull down her N95 respirator (a respiratory [related to breathing] protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) to speak to a resident for one (Resident 173) out of 10 sampled residents investigated for infection control. 3. Ensure Certified Nursing Assistant 8 (CNA 8) wore a gown while feeding a resident inside a contact/droplet isolation room (an isolated room used to prevent the spread of germs that are spread either by touching the resident or items in the room or germs that are spread through respiratory secretions [fluid from the lungs]) for one (Resident 119) out of 10 sampled residents investigated for infection control. 4. Ensure that a resident's oxygen tubing (device used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory help) was not on the floor for one (Resident 39) out of 10 sampled residents investigated for infection control. 5. Ensure the nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) was labeled with the date it was changed for one of four sampled residents (Resident 12) investigated for infection control. 6. Ensure the residents' nasal cannulas were not touching the floor and were stored properly inside a plastic storage bag when not in use for four of four sampled residents (Resident 12 , 74, 48, and 74) investigated for infection control. 7. Ensure the nebulizer (a small machine that turns liquid medicine into a mist) tubing was placed properly inside the plastic storage bag when not in use and not touching the floor for one (Resident 204) of two sampled residents investigated under infection control. 8. Ensure the Yankauer suction catheter (a rigid, bent, plastic catheter used to suction oropharyngeal [part of the throat at the back of the mouth] secretions) was dated when last changed and placed properly inside a storage bag for one of two sampled residents (Resident 121) investigated under infection control. 9. Ensure wedge cushion pillows were not on the floor for one of one sampled resident (Resident 141) investigated for infection control. These deficient practices had the potential to transmit infectious microorganisms and placed residents and staff at risk for infection. Findings: a. During an observation on 1/3/2023 at 7:40 a.m., with the Executive Administrative Assistant (AADM), six surveyors entered the first-floor lobby, facility staff members walked past surveyors without speaking to them. The AADM met six surveyors shortly after entering the facility. The AADM was notified that the surveyors were at the facility to conduct the recertification survey. The AADM proceeded to escort the surveyors to the fourth floor, past the nursing station and resident rooms, to the fourth-floor conference room. During an observation and interview on 1/3/2023 at 9:13 a.m., Certified Nursing Assistant 2 (CNA 2) stated she was stationed at the front lobby desk and was the COVID-19 designated screener. CNA 2 stated she works weekdays from 8 a.m. to 4 p.m. and nobody was assigned to be the designated screener prior to her arrival. CNA 2 stated all visitors should be screened for signs and symptoms of, and exposure, to COVID-19 prior to entry to the facility. CNA 2 stated the facility's Visitor/Vendor Screening Log should be completed for all visitors when they are screened. CNA 2 stated if a visitor did not screen, had a positive test, or showed signs and symptoms of COVID-19, then they are not allowed entry to the facility. CNA 2 was notified of six surveyors that were not screened prior to entry. CNA 2 stated the surveyors should have been screened and requested surveyors return to the lobby to be screened. During an interview on 1/3/2023 at 9:25 a.m., the AADM stated there is usually a designated screener from the medical records department at the front lobby desk starting at 5:30 a.m., but she was off today. The AADM stated the surveyors were not asked if they were screened for COVID-19 prior to entering the facility. During an interview on 1/4/2023 at 7:45 a.m., [NAME] Clerk 1 (WC 1) stated she begins work at 5:30 a.m. in the medical records department and screens visitors until 8 a.m. WC 1 stated she was off on 1/3/2023 and did not know who screened visitors when she was off. During an interview on 1/4/2023 at 9:37 a.m., the Infection Preventionist (IP) stated there is an assigned designated screener for visitor entry starting at 5:30 a.m. The IP stated prior to 5:30 am and as needed, the first-floor staff provide screening of visitors. The IP stated the first-floor staff was responsible for symptom and exposure screening of the surveyors prior to entry because there was no designated screener at that time. The IP stated the importance of COVID-19 screening was to identify if anyone had symptoms in order to prevent the spread of disease to residents and staff. During an interview and record review on 1/5/2023 at 9:37 a.m., the Director of Nursing (DON) reviewed the facility Mitigation Plan policy and procedures and stated all visitors should be COVID-19 screened prior to entering the facility. The DON stated the importance of screening was to catch anyone with symptoms of COVID-19 and prevent them from entering the facility and spreading infection. A review of the COVID-19 Facility Mitigation Plan (identifies policies and procedures taken to reduce risk and minimize loss in the event of disasters/emergencies) policy and procedures, last reviewed 10/2022, indicated it was the policy of the facility to address and mitigate elements of the COVID-19 Pandemic in accordance with the California Department of Public Health (CDPH) requirement that all skilled nursing facilities develop and implement a CDPH approved COVID-19 mitigation plan. The purpose of the policy was to state the facilities understanding of how to manage and conduct actions under emergency conditions to mitigate the impact of a potential outbreak of COVID-19 in the facility. The MP indicated the facility would screen and document individuals entering the facility for COVID-19 symptoms. Visitors to the facility would complete their Visitor /Vendor Screening Log and be screened for questions regarding COVID-19 symptoms and for close contact with confirmed or suspected cases. Visitors permitted entry would record their name and contact information for possible contact tracing. Visitors known to be positive for COVID-19 or with symptoms of a respiratory infection (i.e. cough, shortness of breath, etc) would not be permitted to enter the facility at any time. The facility would have designated staff to perform screening for healthcare personnel and visitors. f. A review of Resident 204's Face Sheet indicated the facility admitted the resident on 9/2/2022 and readmitted the resident on 9/16/2022 with diagnoses including cerebral atherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque [a fatty, waxy substance that forms deposits in the artery wall] in the inner lining of arteries [the blood vessels that bring oxygen-rich blood from the heart to the body]) in the brain, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and diabetes mellitus type 2 (a chronic disease characterized by how the body processes sugar in the blood). A review of Resident 204's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/10/2022, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required one-person extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and one-person total assistance with bathing. A review of Resident 204's Physician Order Report indicated the following orders: 1. Albuterol sulfate solution (a medication used to treat wheezing [a high-pitched whistling sound when the airway is partially blocked] and shortness of breath caused by breathing problems) for nebulization; 2.5 milligrams (mg - a unit of measurement) per 3 milliliters (ml - a unit of measurement) (0.083 percent [%]); amount: 1 unit dose (a unit of measurement); inhalation special instructions: dx: coughing give with ipratropium (a medication used to control and prevent symptoms of wheezing and shortness of breath caused by ongoing lung disease) via hand held nebulizer (HHN - a small machine that turns liquid medicine into a mist) every 6 hours 2. Ipratropium bromide solution; 0.02%; amount: unit dose; inhalation special instructions: cough every 6 hours A review of Resident 204's Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) indicated albuterol sulfate and ipratropium bromide were last administered on 1/3/2023 at 8:30 a.m. During an observation on 1/3/2023 at 11:15 a.m. in Resident 204's room, observed the nebulizer machine on top of the bedside table with the tubing hanging on the side, not properly placed inside the storage bag, and touching the floor. During a concurrent observation and interview on 1/3/2023 at 11:21 a.m., Registered Nurse 3 (RN 3) confirmed that the nebulizer tubing was hanging on the side of the table, not properly placed inside the storage bag, and touching the floor. RN 3 stated that the tubing should be properly placed inside the bag and not touching the floor. RN 3 stated it is an infection control issue and had the potential for contamination of the tubing. During an interview on 1/6/2022 at 10:40 a.m., the Director of Nursing (DON) stated that the tubing should have been placed properly in the storage bag and not touching the floor to prevent contamination of resident equipment and spread of infection. A review of the facility's policy and procedure titled, Oxygen Equipment, last reviewed 10/2022 indicated the purpose to prevent respiratory infection from oxygen equipment. A review of the facility's policy and procedure titled, Oxygen Management, last reviewed 10/2022 indicated that tubing will be stored in a plastic bag when not in use. g. A review of Resident 121's Face Sheet indicated the facility admitted the resident on 3/1/2016 and readmitted the resident on 7/1/2022 with diagnoses including dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), seizures (a medical condition when there is a temporary, unstoppable surge of electrical activity in the brain), gastrostomy (a medical procedure in which a tube is placed into the stomach for nutritional support). A review of the physician's Skilled Nursing Facility (SNF - an inpatient facility type that provides short- or long-term rehabilitation services to senior patients) Visit Note dated 12/6/2022 indicated Resident 121 was unable to make their own medical decision. A review of Resident 121's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 12/2/2022, indicated that the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required one-person total assistance with eating; one-person extensive assistance with locomotion on and off unit, dressing, and person hygiene; and two-person extensive assistance with bed mobility, transfers, toileting, and bathing. A review of Resident 121's Physician's Order Report indicated an order dated 12/4/2021 to suction secretions as needed. A review of Resident 121's care plan on risk for aspiration (refers to the drawing in of a foreign substance into the lungs) or respiratory complications related to over secretion of saliva initiated on 3/13/2020 and last edited on 12/6/2022 with a goal of no signs and symptoms of aspiration, indicated to suction secretions as needed every shift. During an observation on 1/3/2023 at 12:38 p.m., observed the Yankauer suction catheter on top of the suction machine. There was no date indicated when the catheter was last changed and it was not stored properly in a plastic storage bag. During a concurrent observation and interview on 1/3/2023 at 12:43 p.m., Registered Nurse 3 (RN 3) confirmed that the suction catheter did not indicate when it was last changed and was not stored properly in a plastic storage bag. RN 3 stated that suction catheters are changed every shift or as needed. RN 3 stated that the catheter should have been dated when it was last changed and should be stored in a plastic storage bag when not in use to prevent contamination of the equipment and for staff to know when the catheter is due to be changed. During an interview on 1/6/2022 at 10:40 a.m., the Director of Nursing (DON) stated that the suction catheter should have been dated when it was last changed and placed in a plastic bag to prevent contamination of the catheter and potential spread of infection. A review of the facility's policy and procedure titled, Suctioning, last reviewed on 10/2022, indicated the purpose of the policy to help prevent nosocomial infections (a type of infection acquired during the process of receiving health care that was not present during admission) associated with suctioning and to prevent transmission of infections to residents/patients/staff. The policy indicated to date, time and initial the new suction catheter every shift or as needed. The policy indicated to place the suction catheter in a clean plastic bag and change every seven days or as needed if soiled and dated, timed and initialed. e. A review of Resident 12's Face Sheet indicated the facility admitted the resident on 6/2/2022, and most recently readmitted the resident on 8/10/2022, with diagnoses that included acute respiratory failure (a serious condition that develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low level of oxygen in the body tissues), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and asthma (chronic condition that affects the airways in the lungs). A review of Resident 12's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/22/2022, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 12 required limited assistance with bed mobility, transfers, and personal hygiene, and required extensive assistance from staff with dressing and toileting. A review of Resident 12's physician orders indicated an order for oxygen one liter via nasal cannula continuously, okay to titrate to two liters during meals and when walking, ordered on 8/10/2022. A review of Resident 12's Care Plan for respiratory system related to COPD, asthma, and cough, last revised on 12/29/2022, indicated an intervention to change oxygen tube and bag every Sunday and to label tube and bag once a day on Sundays. During an observation, on 1/3/2023 at 11:10 a.m., observed Resident 12 sitting in a wheelchair on one liter of oxygen via nasal cannula connected to a portable oxygen tank. Observed nasal cannula tubing unlabeled with no date. Observed Resident 12's second nasal cannula that was not in use touching the floor and out of the plastic storage bag at bedside. During a concurrent observation and interview, on 1/3/2023 at 11:16 a.m., Licensed Vocational Nurse 7 (LVN 7) observed and verified the nasal cannula that Resident 12 was wearing was undated and the other nasal cannula that was not in use observed at bedside was touching the floor. LVN 7 stated the nasal cannula should be off the floor at all times and should be placed inside the storage bag when not in use. LVN 7 also confirmed the nasal cannula that Resident 12 was currently wearing only had the resident's name written on the tubing. LVN 7 explained the nasal cannula is changed once every week on Sundays by the dayshift nurse and the nurse who changes the tubing should be labeling it with the resident's name and the date it was changed. LVN 7 stated the importance of labeling the nasal cannula with the date and keeping the tubing off the floor and storing it properly inside a bag when not in use for infection control and for staff to know when the tubing was last changed so they know when to replace it again. LVN 7 stated she will change both nasal cannulas for Resident 12 since the one that the resident is wearing in undated while the other has been contaminated from touching the floor. During an interview, on 1/5/2023 at 5:32 p.m., the Director of Nursing (DON) stated the nasal cannula should be changed every seven days and as needed if contaminated and confirmed the nurse should be labeling the tubing with the date every time it is changed for staff to know when it should be changed again. The DON further stated the nasal cannula should not be touching the floor and properly stored in plastic bag when not in use to prevent the tubing from being contaminated. The DON stated labeling the nasal cannula and ensuring its proper storage is important for infection control purposes. A review of the facility's policy and procedure titled, Oxygen Equipment, last reviewed on 10/2022, indicated to prevent oxygen cannula and mask from falling to the floor. A review of the facility's policy and procedure titled, Oxygen Management, last reviewed on 10/2022, indicated oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The policy and procedure further indicated the cannula, mask, and tubing will be stored in a plastic bag when not in use. b. A review of Resident 173's Face Sheet indicated the facility admitted the resident on 9/15/2020 with diagnoses that included chronic kidney disease (gradual loss of kidney function). A review of Resident 173's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/23/2022, indicated the resident had moderately impaired cognitive (thought processes) skills for daily decision making and required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, toilet use, and personal hygiene. On 1/3/2023 at 11:53 a.m., during an observation, observed CNA 7 in the hallway speaking loudly to the resident. When the resident could not understand what she was saying, observed CNA 7 pull down her N95 respirator and lean in close to the resident's face to speak to him. On 1/5/2023 at 11:21 a.m., during an interview, the Director of Staff Development (DSD) stated the CNA should not have pulled her mask down to speak to the resident, especially if they were still in a resident care area. The DSD stated it was important not to modify or remove one's mask in order to protect oneself and the resident from droplets. On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated he has seen staff pulling down their mask sometimes saying that the resident cannot hear them, and the resident read their lips. The DON stated this should not be done; however, in order to prevent the spread of infection. The DON stated that if the resident could not hear what was being said, then the staff should at least step back six feet. A review of the facility's policy and procedure titled, Transmission-Based Precautions, last reviewed on 10/2022, indicated that in addition to standard precautions (practices that protect healthcare providers from infection and prevent the spread of infection from patient to patient), use transmission-based precautions for residents/patients with documented or suspected infection or colonization (germs are in the body but do not make the person sick) with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission. Droplet transmission are respiratory droplets carrying infectious pathogens which transmits infection through coughing, sneezing, etc. c. A review of Resident 119's Face Sheet indicated the facility originally admitted the resident on 2/1/2019 and readmitted the resident on 11/29/2019 with diagnoses that included chronic kidney disease. A review of Resident 119's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 1/3/2023 at 12:43 p.m., during an observation, observed CNA 8 inside a contact/droplet isolation room assisting Resident 119 with feeding. Observed CNA 8 not wearing a gown. On 1/3/2023 at 2:23 p.m., during an interview, CNA 8 stated she was supposed to wear a gown when going into a contact/droplet isolation room. On 1/5/2023 at 10:05 a.m., during a concurrent interview and record review, Minimum Data Set Nurse 2 (MDS Nurse 2) stated that Resident 119 was currently on isolation due to exposure to COVID-19. On 1/5/2023 at 11:21 a.m., during an interview, the DSD stated that when staff are inside a contact/droplet isolation room, they have to wear proper personal protective equipment (PPE - clothing and equipment worn or used in order to protect against hazardous substances or environments), such as gowns, face shields (a form of PPE used to protect the eyes, nose and mouth from splashes and sprays of body fluids), and masks. On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated that gowns should be worn inside contact/droplet isolation rooms, even if the staff is just assisting with feeding the resident. The DON stated it was important to wear proper PPE in order to prevent the spread of COVID-19. A review of the facility's policy and procedure titled, Transmission-Based Precautions, last reviewed on 10/2022, indicated that in addition to standard precautions, use transmission-based precautions for residents/patients with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission. Use contact precautions as recommended for residents/patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. PPE are used for any room entry. PPE includes gloves, gowns, and eye wear (if potential for splash). [NAME] upon entry to the resident's room. d. A review of Resident 39's Face Sheet indicated the facility originally admitted the resident on 1/28/2017 and readmitted the resident on 10/3/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 39's MDS, dated [DATE], indicated the resident had moderately impaired cognition (thought processes). A review of Resident 39's Physician Order Report (a summary of the resident's physician's orders) indicated an order for continuous oxygen at 0.5 liters per minute (LPM - unit of measurement) via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels), dated 10/12/2022. On 1/3/2023 at 10:54 a.m., during an observation, observed Resident 39 asleep