Based on observation, interview, and record review, the facility failed to ensure one out of 23 sampled residents (Resident 365) was assisted with nail care as part of her Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when Resident 365 had long fingernails with blackish substance underneath the fingernails. This failure had the potential for Resident 365 to sustain injury and/or for Resident 365 to acquire an infection. Findings: A review of Resident 365's clinical record indicated Resident 365 was admitted November of 2024 and had diagnoses that included muscle weakness, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hearing loss. A review of Resident 365's Minimum Data Set (MDS - a federally mandated resident assessment tool) Cognitive Patterns, dated 11/11/24, indicated Resident 365 had a Brief Interview for Mental Status (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 out of 15 which indicated Resident 365 had an intact cognition. A review of Resident 365's MDS Functional Abilities and Goals, dated 11/11/24, indicated Resident 365 required substantial/maximal assistance with toileting hygiene, shower/bathing, upper and lower body dressing, and setup or clean-up assistance with personal hygiene and eating. During a concurrent observation and interview on 11/19/24 at 10:28 a.m. with Resident 365, in Resident 365's room, Resident 365 had fingernails that were long and with blackish substance underneath the fingernails. Resident 365 stated she wanted her fingernails to be cleaned and trimmed and already told a staff about it. During a concurrent observation and interview on 11/19/24 at 10:31 a.m. with Certified Nurse Assistant (CNA) 5, in Resident 365's room, CNA 5 confirmed that Resident 365 had long fingernails and with blackish substance underneath the fingernails. CNA 5 stated she would expect that Resident 365's fingernails to be properly trimmed and cleaned because it would be a risk for infection and Resident 365 might scratch her skin. During a concurrent interview and record review on 11/21/24 at 9:52 a.m. with the Infection Preventionist/Director of Staff Development (IP/DSD), Resident 365's clinical records were reviewed. The IP/DSD confirmed that Resident 365 had no documentation that she was refusing personal hygiene assistance and nail care. The IP/DSD stated residents should have a clean and well-trimmed fingernails because it is a component of personal hygiene and a part of infection control. During an interview on 11/22/24 at 9:44 a.m. with the Director of Nursing (DON), the DON stated if the patient has diabetes, the CNA should notify the Licensed Nurse to clean and trim the resident's fingernails. The DON further stated she would expect residents' fingernails to be clean and trimmed because long fingernails could cause infection and skin injury. A review of Resident 365's care plan, dated 11/6/24, indicated, Resident Is at risk for altered ADL's .Needs ext [sic] assistance with all ADL's. A review of Resident 365's care plan intervention, dated 11/6/24, indicated, Provide assistance with ADLs as indicated. A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, revised 3/2018, indicated, .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care, including appropriate support and assistance with: a. hygiene ( .grooming .).underneath the fingernails. CNA 5 stated she would expect that Resident 365's fingernails to be properly trimmed and cleaned because it would be risk for infection and Resident 365 might scratch her skin. During a concurrent interview and record review on 11/21/24 at 9:52 a.m. with the Infection Preventionist (IP), Resident 365's clinical records were reviewed. The IP confirmed that Resident 365 had no documentation that she was refusing personal hygiene assistance and nail care. The IP stated residents should have a clean and well-trimmed fingernails because it is a component of personal hygiene and a part of infection control. During an interview on 11/22/24 at 9:44 a.m. with the Director of Nursing (DON), the DON stated if the patient has diabetes, the CNA should notify the Licensed Nurse to clean and trim the resident's fingernails. The DON further stated she would expect residents' fingernails to be clean and trimmed because long fingernails could cause infection and skin injury. A review of Resident 365's care plan, dated 11/6/24, indicated, Resident Is at risk for altered ADL's .Needs ext [sic] assistance with all ADL's. A review of Resident 365's care plan intervention, dated 11/6/24, indicated, Provide assistance with ADLs as indicated. A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, revised 3/2018, indicated, .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care, including appropriate support and assistance with: a. hygiene ( .grooming .).

Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 259) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 259's antidepressant was given without appropriate documented diagnosis. This failure decreased the facility's potential to monitor Resident 259's for target behaviors and had the potential to result in Resident 259's increased risk and exposure to side effects associated with psychotropic medications. Findings: During a review of Resident 259's admission records, the records indicated Resident 259 was admitted in November 2024 with diagnoses which included anxiety, restless legs syndrome (a very strong urge to move the legs), and abnormal involuntary movements. There was no diagnosis of depression on Resident 259's records. Resident 259's Minimum Data Set (MDS – a federally mandated resident assessment tool) indicated Resident 259 had intact cognition. During a review of Resident 259's physician order, dated 11/13/24, the order indicated, Sertraline KCl [Zoloft, medication to treat depression] Oral [by mouth] Tablet 50MG [milligrams, a unit of measurement] .Give 1 tablet by mouth in the morning for Depression m/b [manifested by] verbalized sadness. During a review of Resident 259's document titled Psychotropic Informed Consent and Verification, dated 11/13/24, the document indicated, 1. List Medication, Dose, Frequency, Diagnosis and Behavior manifestation: Sertraline HCl Oral Tablet 50 MG .1 tablet by mouth in the morning for Depression m/b verbalized sadness. During a review of Resident 259's Admission-Nursing Assessment, dated 11/13/24, the assessment indicated, Is the Resident currently taking psychotropic medication? .5ca. Antidepressant .The resident uses antidepressant medication Zoloft r/t Depression .Monitor for behaviors of depression .and notify MD [medical doctor] .if behavior worsens. During a review of Resident 259's IDT [Interdisciplinary Team]: admission Notes, dated 11/18/24, the notes indicated, Psychotrophic Drug Use: [Resident] is on Sertraline HCl 50MG in the morning for depression m/b verbalized sadness & current dose is well tolerated with no side effects reported. During an interview on 11/21/24 at 12:46 p.m. with Resident 259, Resident 259 stated, I was taking medication for depression, and I still take them here. I've been taking it for a while. I'm actually feeling good now. During an interview on 11/21/24 at 12:48 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, She eats a lot, not really sad, prefers to be in the bed and wait for family .No behaviors that would indicate sadness or depression, not at all. During an interview on 11/21/24 at 12:53 p.m. with Licensed Nurse 6 (LN 6), LN 6 stated, When I go to the room, she's alright especially when family comes .I don't think she shows any signs of sadness or depression .When the family leaves, she feels sad but that's natural. During a concurrent interview and record review on 11/21/24 1:39 p.m. with LN 5, LN 5 stated, If it's antidepressant, we can get consent from resident to administer that, we get the consent and we let the MD sign it .We also monitor the target behavior and side effects .If we can't found a diagnosis related to the medication, that's going to the doctor to get clarified .if they are not in the list of diagnosis, it can be a problem. LN 5 verified Resident 259 was receiving Sertraline for depression m/b verbalized sadness and had no depression diagnosis based on the hospital discharge documents and stated, She doesn't have diagnosis of depression .The indication was wrong, it should have been for anxiety. During an interview on 11/21/24 at 2:12 p.m. with the Director of Social Services (DSS), the DSS stated, She's usually pretty calm, haven't had any complaints that something's off .She was a little down upon admission .No concerns with roommate .Her facial expressions are not always smiley, but she doesn't verbalize sadness or depression . During an interview on 11/21/24 at 3:46 p.m. with the Director of Nursing (DON), the DON stated, I found that sertraline was given for anxiety in the hospital so I changed it and called [doctor] .They put that one as depression, and there was no diagnosis for depression .The hospital wrote it for anxiety .It's important when we are getting the consent and also the [resident] doesn't have depression .We put the wrong target behavior. During a telephone interview on 11/21/24 at 4:15 p.m. with the Consultant Pharmacist (CP), the CP stated, It is important to have the diagnosis .to make sure to get the right dose and make sure there's a benefit .I expect that there's a diagnosis for the medication .when I check if the psychotropic is necessary, I look for the diagnosis, and from discharge documents from the hospital. During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, dated 7/2022, the P&P indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition .

Based on observation, interview, and record review, the facility failed to ensure call light system was accessible for one out of 23 sampled residents (Resident 24), when Resident 24's call light was observed under the bed and not within reach. This failure had the potential to negatively affect Resident 24's safety by preventing the resident from communicating a request for assistance when needed. Findings: During a review of Resident 24's admission records, the records indicated Resident 24 was admitted in August 2024 with diagnoses which included fracture of shaft of left tibia and fibula (broken bones in the lower leg), muscle weakness, and history of falling. Resident 24's Minimum Data Set (MDS – a federally mandated resident assessment tool) indicated Resident 24 was cognitively intact. During a review of Resident 24's MDS Section GG - Functional Abilities and Goals, dated 9/3/24, the MDS indicated Resident 24 required substantial/maximal assistance with toileting, shower, lower body dressing, putting in/taking off footwear, and personal hygiene. During a review of Resident 24's care plan, revised on 9/10/24, the care plan indicated, Resident is at risk for falls r/t [related to] impaired mobility, history of falling, muscle weakness .Ensure call light is within reach when in room . During an observation on 11/19/24 at 9:57 a.m. in Resident 24's room, Resident 24 was observed lying in bed, eyes closed, respirations unlabored. Resident 24's call light was observed under the bed and not within reach. During a follow-up observation on 11/19/24 at 12:02 p.m. in Resident 24's room, Resident 24's call light was still observed under the bed and not within reach. During a concurrent observation and interview on 11/19/24 at 12:05 p.m. with Licensed Nurse 3 (LN 3) in Resident 24's room, LN 3 confirmed the observation and took the call light from the floor under the bed. LN 3 stated, He uses call light if needs assistance. During an interview on 11/20/24 at 11:40 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, For call lights, I place it within residents reach, if I put [a resident] in a chair, I put it where he can reach it .If he needs help, it's always with him, for safety .I broke safety if it's not within reach. During an interview on 11/20/24 at 11:48 a.m. with LN 1, LN 1 stated, It should be on the side where resident can reach it .CNAs are supposed to make sure .it's accessible and reorient the resident .They are supposed to be checking regular rounds, do random checks and do visual checks .That would be a problem if they can't reach the call light .There's a possibility their needs will not be met .Make sure call light is accessible . During an interview on 11/21/24 at 3:35 p.m. with the Director of Nursing (DON), the DON stated, If the resident is alert, they will let the staff know about their preference .Either we put it on their hand or within their reach .The staff are informed that if the resident is in bed, they have to give the call light and should be reachable at all times . During a review of the facility's policy and procedure (P&P) titled, Call System, Resident, dated 9/2022, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station .

1c. During an observation in the room of Resident 414 on 11/19/24 at 8:55 a.m., observed a metal power strip was not anchored and had another electrical cord plugged into it. During an observation and interview on 11/20/24 at 09:21 a.m. with CNA 7, CNA 7 confirmed the metal power strip was not attached properly and normally was attached to the wall. CNA 7 indicated the power strip was a safety hazard for the staff and residents as someone could fall if they tripped over it. During an in interview on 11/20/24 at 1:26 p.m. with the DM, the DM stated that the metal power strip should be attached to the wall and not hanging. The DM stated that if the power strip was not attached properly, it could be a fall hazard for resident, staff, or visitors. During an interview on 11/22/24 at 8:44 a.m. with the DON, the DON stated that the power strip should be anchored to the wall and not freely hanging. She further stated that it was a risk for someone to fall if the power strip cord was not attached to the wall. A review of the facility's policy and procedure (P&P), Safety Precautions, Electrical, dated 2011, the P&P indicated, Report any and all unsafe electrical hazards to your supervisor immediately. Based on observation, interview and record review, the facility failed to provide an environment free from potential accident hazard for three of 23 sampled residents (Resident 259, Resident 261, and Resident 414), when electrical extension cords were observed laying on the floor inside the rooms of Resident 259 and Resident 261, and hanging unsecured in Resident 414's room. This failure had the potential to result in accidents and falls for Residents 259, 261, and 414. Findings: 1a. During a review of Resident 259's admission records, the records indicated Resident 259 was admitted in November 2024 with diagnoses which included anxiety, restless legs syndrome (a very strong urge to move the legs), and muscle weakness. Resident 259's Minimum Data Set (MDS - a federally mandated resident assessment tool) indicated Resident 259 had intact cognition. During a review of Resident 259's care plan, undated, the care plan indicated, Resident is at risk for falls r/t [related to] impaired balance. During a review of Resident 259's IDT [Interdisciplinary Team] Clinical Review, dated 11/17/24, the evaluation indicated resident 259 had an unwitnessed fall on 11/15/24. The evaluation indicated, 1. Fall prevention measure in place .2. Environment free of clutter . During a concurrent observation and interview on 11/19/24 10:29 a.m. with Resident 259 in her room, an electrical extension cord with wires connected was noted on the floor beside Resident 259's bed. Resident 259 stated, That can be dangerous. 1b. During a review of Resident 261's admission records, the records indicated Resident 261 was admitted in November 2024 with diagnoses which included fracture of fifth metatarsal bone (broken bone in the smallest toe) of right foot, muscle weakness, and history of falling. Resident 261's MDS indicated Resident 261 had moderate cognitive impairment. During an observation on 11/19/24 at 9:27 a.m. in Resident 261's room, an electrical extension cord with multiple wires connected was noted on the floor beside the bed. During a concurrent observation and interview on 11/20/24 at 11:40 a.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 261's room, CNA 1 confirmed the extension cord was on the floor beside the bed and stated, It's not supposed to be there, they can trip and fall .it's supposed to be on the wall, for resident safety. During a concurrent observation and interview on 11/20/24 at 12:04 p.m. with Licensed Nurse 1 (LN 1) in Resident 261's room, LN 1 confirmed the extension cord was on the floor and stated that it's a trip hazard and safety issue. During an interview on 11/20/24 at 2:37 p.m. with the Maintenance Director (DM), the DM stated, Power strips [extension cords] should be up on the wall .I just wish there was a better design .The DM confirmed there were safety issues on the power strips on the floor and stated, I hope there's a better way. During a concurrent observation and interview on 11/21/24 3:42 p.m. with the Director of Nursing (DON), the DON confirmed the extension cord was still on the floor on the side of the bed and stated, Some [extension cords] are already put in, but it comes off .They put it on the wall for safety .They could possibly trip on these wires .That's a safety hazard. During a concurrent observation and interview on 11/19/24 10:29 a.m. with Resident 259 in her room, an electrical extension cord with wires connected was noted on the floor beside Resident 259's bed. Resident 259 stated, That can be dangerous. 1b. During a review of Resident 261's admission records, the records indicated Resident 261 was admitted in November 2024 with diagnoses which included fracture of fifth metatarsal bone (broken bone in the smallest toe) of right foot, muscle weakness, and history of falling. Resident 261's Minimum Data Set (MDS, an assessment tool) indicated Resident 261 had moderate cognitive impairment. During an observation on 11/19/24 at 9:27 a.m. in Resident 261's room, an electrical extension cord with multiple wires connected was noted on the floor beside the bed. During a concurrent observation and interview on 11/20/24 at 11:40 a.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 261's room, CNA 1 confirmed the extension cord was on the floor beside the bed and stated, It's not supposed to be there, they can trip and fall .it's supposed to be on the wall, for resident safety. During a concurrent observation and interview on 11/20/24 at 12:04 p.m. with Licensed Nurse 1 (LN 1) in Resident 261's room, LN 1 confirmed the extension cord was on the floor and stated that it's a trip hazard and safety issue. During an interview on 11/20/24 at 2:37 p.m. with the Maintenance Director (DM), the DM stated, Powerstrips [extension cords] should be up on the wall .I just wish there was a better design .The DM confirmed there were safety issues on the powerstrips on the floor and stated, I hope there's a better way. During a concurrent observation and interview on 11/21/24 3:42 p.m. with the Director of Nursing (DON), the DON confirmed the extension cord was still on the floor on the side of the bed and stated, stated, Some [extension cords] are already put in, but it comes off .They put it on the wall for safety .They could possibly trip on these wires .That's a safety hazard.

Based on observation, interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 55 residents when: 1. Resident 35's controlled drug (medications that the use and possession of are controlled by the federal government) use and removal from Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) was not accurately documented in Resident 35's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and Resident 12's controlled drug use documented in the MAR was not accurately signed out in Resident 12's CDR; and, 2. Resident 16 received expired eye medication for 27 days. These failed practices may contribute to unsafe medication use and risk of controlled drug diversion. Findings: 1a. A review of Resident 35's clinical record indicated Resident 35 was admitted October of 2024 and had diagnoses that included encounter for other orthopedic aftercare (a care provided after a surgery that involves bones, muscles, and joints) following surgical amputation (a procedure to remove a limb or other body part), low back pain, chronic (long-lasting) pain, and spinal stenosis (narrowing of the spaces inside the backbone, putting pressure on the spinal cord and nerve roots leading to pain, numbness, or weakness in the arms or legs). A review of Resident 35's Minimum Data Set (MDS – a federally mandated resident assessment tool) Cognitive Patterns, dated 11/3/24, indicated Resident 35 had a Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 35 had an intact cognition. A review of Resident 35's MDS Health Conditions, dated 11/3/24, indicated Resident 35 had received scheduled and as needed pain medication regimen. A review of Resident 35's physician's order, dated 10/28/24, indicated, oxyCODONE HCl [a controlled pain medication] Oral Tablet 5 MG [milligrams- unit of measurement] .Give 1 tablet by mouth every 6 hours as needed for moderate-severe pain. A random audit of Resident 35's MAR and the CDR for oxycodone, for the month of November 2024, indicated nursing staff did not document oxycodone administration on the MAR when signed out from CDR on 11/1/24 at 9:38 p.m. 1b. A review of Resident 12's clinical record indicated Resident 12 was admitted August of 2014 and had diagnoses that included osteoarthritis (a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet), severe obesity (a disorder that involves having too much body fat), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) A review of Resident 12's MDS Cognitive Patterns, dated 10/15/24, indicated Resident 12 had a BIMS score of 15 out of 15 which indicated Resident 12 had an intact cognition. A review of Resident 12's MDS Health Conditions, dated 10/15/24, indicated Resident 12 had received scheduled and as needed pain medication regimen. A review of Resident 12's physician's order, dated 4/15/22, indicated, Norco [a medication for pain which contains a combination of Hydrocodone; a controlled pain medication, and Acetaminophen; a potent pain reliever that increases the effects of hydrocodone] Tablet 5-325 MG .Give 1 tablet by mouth two times a day for PAIN MANAGEMENT. A random audit of Resident 12's MAR and the CDR for oxycodone, for the month of November 2024, indicated the Norco administration documented in the MAR of Resident 12 on 11/12/24 at 9 a.m. was not documeted on Resident 12's CDR. During a concurrent interview and record review on 11/21/24 at 10:18 a.m. with the Infection Preventionist/Director of Staff Development (IP/DSD), Resident 35's and Resident 12's CDR and MAR for November 2024 were reviewed. The IP/DSD confirmed the finding of Resident 35's oxycodone being signed out of the CDR but was not accurately documented on the MAR on 11/1/24 at 9:38 p.m. The IP/DSD also confirmed the finding of Resident 12's Norco administration being documented in the MAR but was not accurately signed out in the CDR on 11/12/24 at 9 a.m. The IP/DSD stated the process should be when the nurse pulls out controlled drug in the bubble pack (a form of packaging where an individual pushes individually sealed tablets through the foil to remove the medication), the nurse should sign out the CDR, then administer the medication, and then sign the administration in the MAR. The IP/DSD further stated nurses should follow the process as part of controlled drug accountability. During an interview on 11/21/24 at 3:56 p.m. with the Consultant Pharmacist (CP), the CP stated, The process [of controlled drug administration], you [facility staff] must be signing both [CDR and MAR] .The risk [if CDR and MAR are not both signed] .off-count [uneven count] of the [controlled] medication and possible [controlled drug] diversion . During an interview on 11/22/24 at 9:44 a.m. with the Director of Nursing (DON), the DON stated when staff takes out controlled drug medication from the bubble pack, the staff should sign it out in the CDR, the staff would then administer the medication to the resident, and then after administration, the staff should sign the MAR. The DON further stated the risk if staff are not signing both CDR and MAR for controlled drug administration are possible controlled drug diversion. A review of the facility's policies and procedures (P&P) titled, Controlled Substances, revised 12/2012, indicated, Nursing staff must count controlled medications at the end of each shift. The nurses coming on duty and the going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. A review of the facility's P&P titled, Administering Medications, revised 04/2019, indicated, .22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 2. A review of Resident 16's clinical record indicated Resident 16 was admitted January of 2022 and had diagnoses that included glaucoma (an eye condition that can cause vision loss), dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), and communication deficit (difficulty with communication). A review of Resident 16's physician's order, dated 3/3/24, indicated, Latanoprost [a prescription medication used to treat glaucoma] Ophthalmic [eye] Solution 0.005 % [percent- measurement of one part in every hundred] (Latanoprost) Instill 1 drop in both eyes at bedtime for Glaucoma. During a concurrent observation and interview on 11/19/24 at 4:15 p.m. with Licensed Nurse (LN) 4 of medication cart 2- south station, an opened bottle of Latanoprost for Resident 16 was found stored in medication cart 2- south station labeled, EXP DT [expiration date] -10/22/24 . [Dispense date] 9/10/24 . No other bottle of Latanoprost for Resident 16 was found in medication cart 2- south station. LN 4 confirmed the observation. LN 4 stated the expired medication would not work anymore if it was administered to Resident 16. A review of Resident 16's MAR for October 2024 and November 2024 indicated Resident 16 received one drop in both eyes of Latanoprost Ophthalmic Solution 0.005 % from 10/23/24 to 11/18/24 which was a total of 27 days. Requested a copy of the pharmacy receipt of another Latanoprost Ophthalmic Solution 0.005 % between 9/11/24 to 11/18/24 to Medical Records (MR) on 11/21/24 at 3:50 p.m. but none was provided. During an interview on 11/22/24 at 9:40 a.m. with the Nurse Consultant (NC), the NC confirmed that they could not provide receipt of Latanoprost Ophthalmic Solution 0.005 % before the expiration of the found Latanoprost bottle. The NC agreed that this would mean that Resident 16 received expired Latanoprost Ophthalmic Solution 0.005 % from 10/23/24 to 11/18/24 which was a total of 27 days. During an interview on 11/22/24 at 9:44 a.m. with the DON, the DON agreed that Resident 16 most likely received expired Latanoprost Ophthalmic Solution 0.005 % from 10/23/24 to 11/18/24 which was a total of 27 days. The DON stated expired medications should not be administered to residents because the efficacy of the treatment is affected. A review of the facility's P&P titled, Administering Medications, revised 04/2019, indicated, .12. The expiration/beyond use date on the medication label is checked prior to administering.

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 55. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of four errors out of 33 opportunities which resulted in a facility wide medication error rate of 12.12 % in three out of 11 residents (Resident 261, Resident 359, and Resident 360) observed for medication administration. These failures had the potential for unsafe and ineffective medication use of Resident 261, Resident 359, and Resident 360 and potential to affect the residents' medical conditions. Findings: 1. During a medication administration observation which started on 11/19/24 at 3:24 p.m. with Licensed Nurse (LN) 2 at North Station, LN 2 administered one tablet of Famotidine (a medication that works by decreasing the amount of acid the stomach produces) 20 mg (milligrams- unit of measurement) to Resident 261. A review of Resident 261's active physician's order, dated 11/5/24, indicated, Famotidine Oral Tablet 20 MG(Famotidine) Give 1 tablet by mouth two times a day for GERD [Gastroesophageal reflux disease- a condition in which stomach acid and/or other contents leak back and irritates the food pipe lining] Take with food. 2. During a medication administration observation which started on 11/19/24 at 3:35 p.m. with LN 2 at North Station, LN 2 administered one tablet of Pantoprazole (a medication that reduces the amount of acid the stomach makes) 40 mg to Resident 359. A review of Resident 359's active physician's order, dated 11/11/24, indicated, Pantoprazole .Oral Tablet .40 MG .Give 1 tablet by mouth two times a day for GI [Gastrointestinal- refers to the digestive system, which includes the organs and passageways that food and liquids travel through as they are digested, absorbed, and leave the body] protection Take 30 minutes before a meal. The administration time on the Medication Administration Record (MAR-a document that listed administered drugs) indicated the medication was scheduled to be administered at 4:30 p.m. 3. During a medication administration observation which started on 11/19/24 at 3:35 p.m. with LN 2 at North Station, LN 2 administered a total of two tablet medications which included one tablet of Pantoprazole 40 mg to Resident 360. A review of Resident 360's active physician's order, dated 11/11/24, indicated, Pantoprazole .Oral Tablet .40 MG .Give 1 tablet by mouth two times a day for GI protection Take 30 minutes before a meal. The administration time on the MAR indicated the medication was scheduled to be administered at 4:30 p.m. During a concurrent interview and medication order review on 11/19/24 at 3:45 p.m. with LN 2 at North Station, LN 2 acknowledged the observed medication administration of Famotidine to Resident 261, and Pantoprazole to Resident 359 and Resident 360. LN 2 stated the dinner mealtime for residents would start at 5 p.m. which was about an hour and 30 minutes after the medications were administered. LN 2 further stated the physician's order should be followed when administering Famotidine and Pantoprazole because the residents could get heart burn (a burning pain in the chest or throat that occurs when stomach acid flows back into the food pipe lining) and the medications would not be effective anymore when residents eat. A review of the facility's document titled, Woodside Healthcare Center Meal Times, undated, indicated, .Dinner: 5:00-6:00 PM. 4. During a medication administration observation which started on 11/20/24 at 8:32 a.m. with LN 3 at North Station, LN 3 administered a total of 12 medications to resident 360 which included one inhaler capsule of Spiriva (a medication that relaxes muscles in the airways and increases air flow to the lungs) 18 mcg (micrograms- unit of measurement). LN 3 placed 1 capsule of Spiriva 18 mcg in the handihaler device (a breath-activated device that delivers dry powder medication directly to the lung), pressed the green button on the handihaler to release the medication, held the handihaler up to Resident 360's mouth, and instructed Resident 360 to inhale (breath-in) through the mouth slowly one time. After administering the other medications, LN 3 went to clean the handihaler and stored it in the medication cart. A review of Resident 360's active physician's order, dated 11/14/24, indicated, Spiriva HandiHaler Inhalation Capsule 18 MCG .1 capsule inhale orally one time a day for COPD [Chronic obstructive pulmonary disease- a group of diseases that causes airflow blockage and breathing-related problems] Rinse mouth with water after each use *repeat inhalation process a 2nd time to ensure entire contents of capsule inspired*. During a concurrent interview and medication order review on 11/20/24 at 2:06 p.m. with LN 3 at North Station, LN 3 acknowledged the observed medication administration of Spiriva to Resident 360. LN 3 stated she should have given two inhalations of the medication to Resident 360 so the resident could get the whole dose of the medication. LN 3 further stated that not repeating inhalation process for the second time may cause Resident 360 to not get the whole dose of the medication and the treatment will be less effective. During a concurrent interview and medication order review on 11/21/24 at 3:56 p.m. with the Consultant Pharmacist (CP), the CP stated the physician's order should be followed when administering medications. During a concurrent interview and medication order review on 11/22/24 at 9:44 a.m. with the Director of Nursing (DON), the DON stated that nurses should follow physician's order when administering medications, if not, the residents would not get the full benefits of the medication. A review of the facility's policy and procedure titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber's orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .10. The individual administering the medication checks the label THREE (3) times to verify the .right dosage .of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 55 residents when: 1. A total of 3 loose pills were found in medication cart 1- north station and medication cart 2- south station; and, 2. An expired bottle of an opened Latanoprost (a prescription eye drop medication used to treat increased pressure in the eye) for Resident 16 was found stored in medication cart 2- south station. These failures resulted in Resident 16 receiving expired medication with unsafe and/or reduced potency and had the potential for diversion (illegal distribution) of the loose medications. Findings: During a concurrent observation and interview on 11/19/24 at 1:40 p.m. with Licensed Nurse (LN) 1, of medication cart 1- north station, two loose pills were found inside the second-right drawer of the medication cart. LN 1 confirmed the observation. LN 1 stated there should not be loose pills inside a medication cart because staff would not know what medication those were anymore. During a concurrent observation and interview on 11/19/24 at 4:15 p.m. with LN 4, of medication cart 2- south station, one loose pill was found inside the third-right drawer of the medication cart and an expired bottle of an opened Latanoprost for Resident 16 was found stored in the first-left drawer of the medication cart. LN 4 confirmed the observations. LN 4 stated the risk of having loose pill in the medication cart was that staff would not know what medication it is and who the medication if for. LN 4 further stated expired medication should not be stored inside the medication cart. During an interview on 11/21/24 at 3:56 p.m. with the Consultant Pharmacist (CP), the CP stated there should not be any loose pills inside the cart because those pills are lost dose, and the medication cart should be kept clean. The CP further stated expired medications should not be stored in medication carts because of the health consequences it could give if administered to a resident. During an interview on 11/22/24 at 9:44 a.m. with the Director of Nursing (DON), the DON stated the risk of having loose pills is that it could fall on the floor and a resident can pick it up and take it. The DON also stated that staff would not know what medication the loose pills were anymore. The DON further stated that there should be no expired medication stored in medication carts to prevent administering expired medications to residents. A review of the facility's P&P titled, Storage of Medications, revised 04/2007, indicated, 1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing system in which they are received .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to store food and maintain equipment in accordance with the professional standards for food service safety for a 54 residents out of 54 residents eating facility prepared meals, when: 1. The fruit and vegetable wash sink did not have an air gap (a gap in the draining pipe of a sink to prevent backflow); and 2. Food was expired in the residents' refrigerator. These failures had the potential to result in residents acquiring food-borne illnesses. Findings: 1. During an observation and interview on 11/19/24 at 8:25 a.m. with the Dietary Supervisor (DS), the DS confirmed that the sink that was used to wash fresh produce did not have an air gap. During an observation and interview on 11/20/24 1:55 p.m. with the Director of Maintenance (DM), the DM confirmed that there was no air gap for the sink in the kitchen where fresh produce was washed. The DM stated the purpose of the airgap was to prevent the possibility of backflow of contaminated water to the sink. During an interview on 11/21/24 1:47 p.m. with Registered Dietician (RD), the RD stated she remembers there was some problem with the air gap but did not remember the issue. The RD stated that if the sink did not have an air gap there was the potential that contaminated water could back up to clean produce and may result in a resident catching a food-borne illness. During a review of the 2022 FDA [Food and Drug Administration] Food Code, Section 5-202.13 Backflow Prevention, Air Gap, the Food Code indicated, During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system .Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. 2. During an observation and interview on 11/19/24 at 3:30 p.m. with Licensed Nurse (LN) 6, LN 6 found a seafood salad and crackers in a plastic container and a bag of lettuce labeled for Resident 43 in the residents' refrigerator. The lettuce appeared brownish, with a small amount of discolored water in the bag. LN 6 confirmed that the food was dated 11/8/24 and was expired and stated that the food items should have been thrown out. During an observation and interview on 11/19/24 at 3:45 p.m. with the DS, the DS stated that it was the responsibility of the nursing staff to throw away expired foods. The DS stated the lettuce should be thrown out based on the looks of the lettuce, and the seafood salad with crackers would only be good for 3-4 days. The DS further stated that the potential harm would be food-borne illness. During an interview on 11/21/24 at 8:58 am with the DON, the DON stated the process for food from home was the family will bring food from home and it was labeled with the resident's name and dated. The DON stated the LN was responsible for throwing out expired food. The DON further stated that food would be thrown out 72 hours after it had been brought in. The DON indicated if expired food was left in the refrigerator, residents were at risk for upset stomach and risk for food-borne illness. During a review of the facility's policy and procedure (P&P) titled, Bringing in Food for a Resident, dated 2023, the P&P indicated, Any suspicious or obviously contaminated food or beverages will be thrown away immediately.

2. During a review of Resident 41's admission records, the records indicated Resident 41 was admitted in October 2024 with diagnoses that included obstructive sleep apnea (breathing pauses during sleep), chronic obstructive pulmonary disease (COPD, chronic lung disease causing difficulty in breathing), asthma (airways narrow and swell), and dependence on supplemental oxygen. Resident 41's Minimum Data Set (MDS, an assessment tool) indicated Resident 41 had intact cognition. During a review of Resident 41's physician order dated 10/13/24, the order indicated, Supplemental oxygen 2-4L [Liter, a unit of measurement] via NC [nasal cannula] or oxymask [oxygen mask] to keep SpO2 [oxygen saturation, a measurement of how much oxygen the blood is carrying as a percentage] > or = 92% [percent, a unit of measurement] .as needed for SOB/Dyspnea [shortness of breath]. During an observation on 11/19/24 at 10:39 a.m. in Resident 41's room, Resident 1 was not in the room and nasal cannula was observed connected to oxygen concentrator and hanging on bed side rail, uncovered. During an observation on 11/19/24 at 11:59 a.m. in Resident 41's room, Resident 1 was still not in the room and the nasal cannula was still hanging, uncovered, on the side rails of the bed. During a concurrent observation and interview on 11/19/24 at 12 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 confirmed the nasal cannula was hanging on the bed side rail uncovered. CNA 2 stated, It's not supposed to be hanging and should be in a bag. During an interview on 11/20/24 at 12:08 a.m. with Licensed Nurse 1 (LN 1), LN 1 stated, There should be a black bag where we put it every time it's not in use .We don't want germs in it, people could walk on it. During an observation on 11/21/24 at 8:48 a.m. in Resident 41's room, Resident 41 was observed going out of the room via wheelchair assisted by CNA 2. Nasal cannula was observed connected to oxygen concentrator and placed on top of the bed, uncovered, while not in use. During a concurrent observation and interview on 11/21/24 at 8:57 a.m. with the Infection Preventionist/irector of Staff Development (IP/DSD) in Resident 41's room, the IP/DSD confirmed the nasal cannula was place on top of the bed, uncovered, when not in use and stated, Looks like he left and I don't know why he is not using oxygen tubing .it's not supposed to be lying on the bed, it should be in a bag .by touching the linen, it will be contaminated and will not be clean, if resident use it again, might introduce bacteria . During an interview on 11/21/24 at 3:34pm with the Director of Nursing (DON), the DON stated, [For nasal cannula storage] We have the black bags, if not being used they [staff] have to store it in the bag. When asked about the possible outcome if the nasal cannula was not stored properly, the DON stated, It's already contaminated. During a review of the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, the P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Infection Control Considerations Related to Oxygen Administration .5. Keep the oxygen cannula and tubing used PRN [as needed] in an antimicrobial bag when not in use. Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 55 when: 1. A shared glucometer (a device which measures blood sugar using blood from the fingertip) was not cleaned and sanitized properly after use of three residents (Resident 261, Resident 24, and Resident 359); and, 2. Resident 41's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not properly stored when not in use. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), and potential exposure of Resident 261, Resident 24, Resident 359, and Resident 41 to germs. Findings: 1. During a medication administration observation on 11/19/24 at 3:24 p.m., Licensed Nurse (LN) 2 took a shared glucometer ([Brand Name] G3 blood glucose monitoring system) and supplies in Resident 261's room to measure the blood sugar of Resident 261. LN 2 used a lancet (a sharp piercing device) to pierce the Resident 261's finger to get blood and then applied the blood to the test strip that was attached to the glucometer. After reading the result, LN 2 went out of Resident 261's room, discarded the used lancet and test strip, and wiped the shared glucometer using one wipe of [Brand Name] micro-kill one Germicidal Alcohol wipes (wipe with chemicals the facility is using to disinfect surfaces) quickly (less than 5 seconds), which dried-up immediately, to clean the glucometer's outer surface, then placed it on top of the medication cart. During a subsequent medication administration observation on 11/19/24 at 3:30 p.m., LN 2 again took the same shared glucometer and supplies in Resident 24's room to measure the blood sugar of Resident 24. LN 2 pierced Resident 24's finger using a new lancet to get blood and then applied the blood to the new test strip that was attached to the glucometer. After reading the result, LN 2 went out of Resident 24's room, discarded the used lancet and test strip, and again wiped the shared glucometer using one wipe of [Brand Name] micro-kill one Germicidal Alcohol wipes quickly (less than 5 seconds), which dried-up immediately, to clean the glucometer's outer surface, then placed it on top of the medication cart. During another subsequent medication administration observation on 11/19/24 at 3:35 p.m., LN 2 again took the same shared glucometer and supplies in Resident 359's room to measure the blood sugar of Resident 359. LN 2 pierced Resident 359's finger using a new lancet to get blood and then applied the blood to the new test strip that was attached to the glucometer. After reading the result, LN 2 went out of Resident 359's room, discarded the used lancet and test strip, and again wiped the shared glucometer using one wipe of [Brand Name] micro-kill one Germicidal Alcohol wipes quickly (less than 5 seconds), which dried-up immediately, to clean the glucometer's outer surface, then placed it on top of the medication cart. During an interview on 11/19/24 at 3:45 p.m. with LN 2, LN 2 confirmed the three observations of her cleaning the shared glucometer quickly (less than 5 seconds) in between use of three residents. LN 2 stated the shared glucometer needed to be cleaned for one (1) minute to kill the germs and to sanitize it properly. During an interview on 11/21/24 at 10:33 a.m. with the Infection Preventionist/Director of Staff Development (IP/DSD), the IP/DSD stated that the facility's shared glucometer should be disinfected properly after each resident's use using the [Brand Name] Micro-Kill Germicidal Wipes. The IP/DSD further stated, .The glucometer should be cleaned for one minute .[it] should remain wet for one minute .You have to see it visibly wet .Disinfection should be done properly. During an interview on 11/22/24 at 9:44 a.m. with the Director of Nursing (DON), the DON stated staff should wipe the shared glucometer thoroughly. The DON also stated she would expect staff to follow the manufacturer's instruction in cleaning the shared glucometer. The DON further stated that there would be a risk of spreading infection to the residents if the shared glucometer was not sanitized properly. A review of the facility's policy and procedures (P&P) titled, Cleaning and Disinfecting .Resident-Care Items, dated 06/2011, indicated, .d. Reusable Items are cleaned and disinfected or sterilized between residents .5. Manufacturers' instructions will be followed for proper use of disinfecting products . A review of the manufacturer's instructions for [Brand Name] G3 blood glucose monitoring system titled, CLEANING AND DISINFECTING, undated, indicated, .The [Brand Name] G3 Meter should be cleaned and disinfected between each patient .The following products have been approved for cleaning and disinfecting the [Brand Name] G3 Meter: .[Brand Name] Micro-Kill .Germicidal .Wipes . A review of the label of [Brand Name] micro-kill one Germicidal Alcohol wipes, undated, indicated, .1 MINUTE KILL TIME .DIRECTIONS FOR USE .DISINFECTING: To disinfect hard, non-porous surfaces, use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on this label .

Based on observation, interview, and record review, the facility failed to ensure professional standards of quality were met when Rybelsus (medication that lowers blood sugar in adults) was not administered in accordance with the manufacturer's specifications for one of five sampled residents (Resident 40). This failure had the potential to result in ineffective management of Resident 40's diabetes mellitus (DM, a disease where blood sugar is too high). Findings: A review of Resident 40's admission record indicated she was admitted to the facility in April 2023 with multiple diagnoses which included aphasia (difficulty communicating) and Type 2 DM (adult onset of diabetes mellitus). A review of Resident 40's medical record indicated a physician's order, dated 8/4/23, for Rybelsus 3 milligrams (mg, a unit of measurement) 1 tablet one time a day for Type 2 diabetes. During an observation on 10/30/23, at 9:06 a.m., with Licensed Nurse 1 (LN 1), LN 1 administered Rybelsus 3 mg along with six other medications to Resident 40. During an interview on 10/30/23, at 12:09 p.m., with LN 1, LN 1 stated she was not aware Rybelsus was to be taken on an empty stomach 30 minutes before breakfast. She stated breakfast was delivered to Resident 40 between 7 a.m. and 7:30 a.m. daily. LN 1 confirmed she had access to online resources to look up medication information. During a review of Resident 40's Medication Administration Record (MAR), dated 8/1/23 to 10/31/23, the MAR indicated, Resident 40 was administered Rybelsus 3 mg daily at 9 a.m. (after breakfast) from 8/5/23 to 10/30/23. During an interview on 10/31/23, at 9:37 a.m., with the Director of Nursing (DON), the DON stated nursing staff were expected to call the pharmacy or pharmacy consultant to educate themselves if not familiar with a medication. The DON confirmed nurses had access to online resources and books to learn about medications if a pharmacy consultant was not available. The DON stated Rybelsus was a medication for diabetes and was best taken on an empty stomach for proper absorption. The DON confirmed Resident 40 had Rybelsus scheduled to be administered at 9 a.m. and Resident 40's breakfast was served between 7 a.m. and 7:30 a.m. daily. During an interview on 10/31/23, at 10:13 a.m., with the Pharmacy Consultant (PC), the PC stated nurses were expected to call or email the pharmacy if they were not familiar with a medication. The PC stated the manufacturer for Rybelsus indicated the medication was to be taken on an empty stomach 30 minutes before the first meal of the day and not with other medications. During a review of the product labeling for Rybelsus, the labeling indicated, Instruct patients to take Rybelsus at least 30 minutes before the first food, beverage, or other oral medications of the day with no more than 4 ounces of plain water only . taking with food . or other oral medications will lessen the effect of Rybelsus. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 2023, the P&P indicated, Medications shall be administered in a safe and timely matter . including any required time frame . believed to be inappropriate . the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure the continuous positive airway pressure (CPAP- machine used in the treatment of sleep apnea) device was cleaned, labeled, and stored properly for one of 13 sampled residents (Resident 17). This failure had the potential to result in an infection for Resident 17. Findings: A review of the Skilled Nursing Facility admission Record indicated, Resident 17 was admitted to the facility on [DATE] with diagnoses that included dementia and obstructive sleep apnea (a condition that occurs when the throat muscles relax and block the airway). During a concurrent observation and interview with Licensed Nurse 5 (LN 5) on 10/30/23 at 9:30 a.m., the CPAP humidifier, tubing, and mask were unlabeled. The mask was left uncovered on top the CPAP device. LN 5 stated, the mask should have been stored in a bag and labeled with the date it was last cleaned. During a concurrent interview and record review with the Director of Nursing (DON) on 10/31/23 at 11 a.m., the DON verified the mask should have been stored in a dated bag. A review of the Medication Administration Record (MAR) contained no documentation indicating the last date the mask was cleaned. The DON further stated, it is her expectation for the mask to be cleaned daily and be placed in a bag with the date it was last cleaned. Additionally, the cleaning of the mask should have been documented in the MAR as well. During an interview and record review with LN 4 on 11/1/23 at 2 p.m., LN 4 stated, the CPAP tubing, mask, and humidifier are changed weekly and as needed. LN 4 verified the cleaning of the CPAP was not documented in Resident 17's MAR. A review of the facility's policy titled, CPAP/BiPAP Support revised March 2015 under, General Guidelines for cleaning #7 indicated, Masks, nasal pillows, and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes .

Based on observation, interview, and record review, the facility failed to ensure accurate accountability and reconciliation of controlled medications (those with high potential for abuse or addiction) for two out of two medication carts when controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications) were not completed. This failure had the potential for abuse or misuse of these medications. Findings: During a concurrent interview and record review on 10/30/23, at 12:45 p.m., with Licensed Nurse 3 (LN 3), the narcotic binder for Medication Cart South was reviewed. LN 3 confirmed there was no controlled drug sign-in/sign-out sheet in the binder. LN 3 stated the incoming nurse counted the controlled drugs with the outgoing nurse, but it was not documented. During a concurrent interview and record review on 10/30/23, at 2:07 p.m., with the Director of Nursing (DON), the narcotic binders for the North and South medication carts were reviewed. The DON looked in the binders and stated, It's [the sign-in/sign-out sheet] not here. DON stated the expectation for the incoming nurse was to count the controlled drugs in the medication cart with the outgoing nurse to confirm there were no discrepancies. She stated both nurses were to sign the controlled drug sign-in/sign-out sheet to document this step was completed. During a review of the facility's policy and procedure (P&P) titled, Controlled Medication Storage, dated 6/2016, the P&P indicated, At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented .

Based on observation, interview, and record review the facility failed to store food and maintain equipment per professional standards for food service safety when: 1. The bananas were stored less than the standard of 6 (inches, a unit of measurement) off the floor; 2. The chest freezer had a brown substance on the inside lid and ice buildup on all four sides inside the freezer extending down approximately 8, and ice buildup on the back ledges that created a poor seal; 3. A large blender with the lid on was stored and ready to use, with noticeable clear liquid dripping down the inside walls and with liquid pooled at the bottom; 4. The can opener was found with a chipped metal tip covered with a brown sticky substance; 5. Two out of four cutting boards were found with deep gouges and discolored; 6. The fruit and vegetable wash sink did not have an air gap (a gap in the draining pipe of a sink to prevent backflow); 7. The stainless-steel food preparation area had a missing metal section, measuring 5x 24. These failures had the potential to result in food borne illness for a census of 49 residents eating facility prepared meals. Findings: 1. During a concurrent observation and interview on 10/30/2023, at 9:15 a.m. with the Dietary Services Supervisor (DSS) in the dry storage area, a box of bananas was stored on a platform approximately 4 from the ground. The DSS acknowledged the box of bananas needed to be 6 off the floor. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2020, stipulated in bullet 4, .All food and food containers are to be stored 6 off the floor and on clean surfaces in a manner that protects it from contamination. 2. A chest freezer was observed with ice buildup on all four sides, inside the freezer extending down approximately 8, and ice buildup on the back ledges which created a poor seal. During a concurrent observation and interview on 11/01/2023 at 9:17 a.m. with the DSS and the Maintenance Supervisor (MS) in the dry storage area, the MS and DSS acknowledged the buildup of ice within the chest freezer. The MS stated, This definitely needs to be watched, when the seal goes bad it can let air in. The DSS stated, The [ice] buildup and lack of a complete seal is a food quality and safety issue. If the food thaws, we can't use it and have to throw it away. The same chest freezer was observed with a brown substance on the inside of the lid. During an interview on 11/01/2023 at 9:17 a.m. with the DSS, the DSS acknowledged the inside of the chest freezer lid was dirty. According to the 2022 Food and Drug Administration (FDA) Food Code, Section 4-602.13 Nonfood-Contact Surfaces: The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During a concurrent observation and interview on 10/30/2023, at 9:25 a.m. with the DSS in the main kitchen, a large blender was found stored with the lid on but had a clear liquid dripping down the internal sides and pooling at the bottom. The DSS acknowledged the blender had been stored without being properly dried. During a review of the facility's P&P titled, Dish Washing, dated 2018, the P&P stipulated, Dishes are to be air dried in racks before stacking and storing. 4. During a concurrent observation and interview on 10/30/2023, at 9:33 a.m. with the DSS in the main kitchen, the can opener was found with a chipped metal tip covered with a brown sticky substance. The DSS acknowledged the can opener tip was chipped and dirty. According to the 2022 FDA Food Code, Section 4-501.11 Good Repair and Proper Adjustment: (C) cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened .the cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and possibly result in consumer injury. Section 4-202.15 Cleanability: Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. 5. During a concurrent observation and interview on 10/30/2023, at 9:36 a.m. with the DSS in the main kitchen, two out of four colored cutting boards were found with deep gouges and discoloration. The DSS stated the red cutting board was used for raw meat and the blue cutting board was used for raw fish. She further indicated the cutting boards needed to be replaced. According to the 2022 FDA Food Code, Section 4-501.12 Cutting Surfaces: Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. 6. During an observation on 10/30/2023, at 9:42 a.m. with the DSS in the main kitchen, the fruit and vegetable wash sink did not have an air gap. During a concurrent observation and interview on 10/30/2023, at 1:37 p.m. in the main kitchen, with the MS and DSS, the MS verified the center sink (by the steam table) did not have an air gap. The DSS indicated this sink was used to wash the fruits and vegetables. According to the 2022 FDA Food Code, Section 5-202.13 Backflow Prevention, Air Gap: During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system . Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. 7. During an observation on 10/31/2023, at 11:52 a.m., a stainless-steel food preparation surface had a missing metal section, measuring approximately 5x 24, exposing a soft wood material. During a concurrent observation and interview on 10/31/2023, at 11:55 a.m. in the main kitchen with the MS and DSS, the MS and DSS acknowledged the missing piece of stainless steel on the food preparation area and concurred that it could not be sanitized. According to the 2022 FDA Food Code Section 4-202.11 Food-Contact Surfaces: The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Multi-use food contact surfaces shall be smooth; free of breaks .cracks .crevices .

Based on observation, interview, and record review, the facility failed to ensure that one of 14 sampled residents (Resident 33) maintained acceptable parameters of nutritional status. This failure resulted in Resident 33's sustaining severe weight loss (10% unplanned weight loss) in less than two months. Findings: A review of the admission Record indicated Resident 33 was admitted to the facility in August of 2021 with diagnoses of dementia with behavioral disturbance (a progressive brain disorder that destroys memory and thinking skills), bipolar disorder (mood disorder), and depression. A review of Resident 33's Minimum Data Set (MDS, an assessment and care planning tool), dated 11/1/21, indicated resident scored 14 out of 15 on a Brief Interview for Mental Status, where score of 13 -15 indicated intact cognitive status. According to the MDS, Resident 33 was able to eat with limited assistance from staff. A review of the physician order, dated 8/27/21, indicated Resident 33 was on a regular diet, mechanical soft texture (a diet for someone who has difficulties with chewing and/or swallowing) and thin liquids. A review of Resident 33's admission Registered Dietician (RD) evaluation dated 9/2/21, indicated resident weighed 110 lbs (pounds, unit of measurement) and was below the IBW (Ideal Body Weight) of 130 lbs. The RD documented that resident was underweight and at nutritional risk. The RD recommended to add a nutritional supplement, Med Pass 120 milliliters (ml, unit of measurement), to give resident three times a day between meals. The RD documented, Will monitor weights .PO [oral] intake .and follow up as needed. A review of Resident 33's weekly weights summary record indicated the following: - On August 23, 2021, Resident 33 weighed 110 lbs (admission weight). - On August 28, 2021, weighed 109 lbs - On August 30, 2021, weighed 110 lbs - On September 3, 2021, weighed 112 lbs - On September 6, 2021, weighed 114 lbs - On October 6, 2021, weighed 114 lbs - On October 9, 2021, weighed 114 lbs - On October 14, 2021, weighed 99 lbs A total of 15-pounds weight loss (13.2 %) in less than two months. A review of Resident 33's clinical records revealed a document titled, Weight Discrepancy Notification (a form of physician notification), dated 10/14/21, which indicated resident's physician was notified of 15 lb weight loss. The nurse communicated to the physician the following: Last weight 114 on 10/6/21. Reweighed pt [patient] @ 99 lbs. Pt eat [sic] 50% of meals at most times. Drink [sic] Med Pass 25% most times. The notification had pre-printed message, Resident (s) with SIGNIFICANT weight .LOSS will be referred to RD for review. Resident (s) with SIGNIFICANT weight LOSS will be on weekly weights x 4; or as ordered. The document was reviewed and signed by resident's physician on 10/15/21, at 11:55 a.m. A review of the Weight Discrepancy Notification form, dated 10/28/21, indicated resident's physician was notified of 3 lb weight gain. The weight was not entered into resident's electronic clinical records. A review of Resident 33's care plan titled, The Resident has nutritional problem or potential nutritional problem, initiated by RD on 9/2/21, indicated resident's goal was to maintain adequate nutritional status as evidenced by maintaining weight within (10)% of 125# [lbs]. The care plan's one intervention indicated Provide and serve diet as ordered. The care plan did not contain resident's food preferences, did not address Resident 33's weight loss, and did not contain any nutritional interventions. The care plan was not revised and updated since it was initiated. A review of Resident 33's clinical record failed to contain any further documentation of resident's weights after 10/28/21. There was no documented evidence if resident's physician was contacted for further instructions and if resident was referred and assessed by RD as noted in the communication form dated 10/14/21. Review of the physician's progress notes for October and November 2021 did not contain any documentation regarding resident's weight loss. During an observation on 12/1/21, at 12:35 p.m., Resident 33 was sitting in bed with her lunch meal tray in front of her. Resident 33 ate approximately 40% of her meal. Resident did not reply when asked why she stopped eating and if she liked her food. Resident 33 had no dentures and stated she did not have difficulties with chewing. During a concurrent interview and record review on 12/2/21, at 2:40 p.m., the Dietary Services Supervisor (DSS) stated she was familiar with resident. The DSS stated she reviewed residents' clinical records and if observed any concerns with weight loss or resident not eating, she would re-assess the resident. The DSS stated, Once I identify that resident has weight loss, I assess resident to find out the reason for weight loss, ask if resident wants any food or snacks added to her tray, update preferences and notify RD. The DSS stated she was not aware of resident's severe weight loss and did not inform the RD. The DSS stated Resident 33 was due for quarterly assessment and review, but it was not done yet. During a concurrent interview and record review on 12/2/21, at 4:25 p.m., the Administrator (ADM) acknowledged that Resident 33 lost 15 lbs of weight in less than two months. The ADM stated Resident 33 was on weekly weights since admission, but she refused the weekly weights frequently. Upon reviewing resident's clinical records, the ADM was not able to find any documented weights refusals. On 12/2/21, at 4:35 p.m., the ADM provided spreadsheets with facility's residents' weekly weights recorded. The ADM stated the facility had a contracted Restorative Nurse Assistant (RNA), who was responsible for obtaining residents weights. The ADM stated that after the RNA weighed residents, she would give her list with weights to nurses. Nurses were responsible to enter residents weights in the electronic chart and inform the physician and RD if any concerns with weight loss were identified. Review of the spreadsheet indicated on 9/30/21 Resident 33's weight was 103 lbs and on 10/28/21 resident's weight was 102 lbs. The ADM acknowledged resident's weights for 9/30 and 10/28/21 were not recorded in resident's electronic chart and not available for physician and other clinicians for review. According to the spreadsheet, Resident 33 refused weight on 9/13, 9/20, 9/27, 10/7 and 10/20/21, but the refusals were not documented in resident's electronic chart. The ADM stated that if resident refused to be weighed, it should be documented in the records and the physician should be notified. The ADM explained that from 10/30/21 Resident 33 was on isolation precautions and her weights were not obtained during that period of time. The ADM stated resident's weights were not obtained after 11/2/21 until the present. The ADM stated the RD should be seeing the resident, but was not able to find any documentation if RD was contacted regarding resident's weight loss. The ADM stated, Not done, we dropped the ball. During a concurrent interview and record review on 12/3/21, at 2:05 p.m., the Director of Nursing (DON) stated Resident 33 had a severe weight loss. The DON stated she could not recall if resident's weight loss was discussed during one of the Interdisciplinary Team Meetings. The DON stated if resident was identified to have weight loss, resident's care plan should be revised and updated. The DON stated the interventions should include weekly weight monitoring, identifying food preferences, and encouraging oral intake, including supplemental nourishment. During a review of Resident 33's care plan, the DON acknowledged the care plan had one intervention, was not adequate, and was never revised and/or updated. A review of the facility's policy titled, Weight Assessment and Intervention, revised 2021, indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Weights will be recorded .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietitian .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .3 months - 7.5% weight loss is significant; greater than 7.5% is severe .Assessment information shall be analyzed by the multidisciplinary team .Care planning for weight loss will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian .Individualized care plans shall address .the identified causes of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment.

Based on observation, interview, and record review, the facility failed to ensure the drug regimen was free of unnecessary psychotropic medications (medications which are intended to have a therapeutic effect on mood and behavior) for one of 14 sampled residents (Resident 25), when resident received two medications from the same pharmacological class without specific target behaviors. This failure had the potential for Resident 25 to experience adverse effects (unwanted, uncomfortable, or dangerous effects), related to the use of psychotropic medications, which may impair resident's psychosocial well-being. Findings: According to the admission Record, Resident 25 was admitted to the facility in 2017 with diagnoses which included dementia without behavioral disturbance (a disorder affecting mind, emotions, and intellect), bipolar disorder without psychotic features (a brain disorder that causes changes in a person's mood), anxiety disorder (excessive and persistent worry and fear about everyday situation), and glaucoma (damage to the optic nerve in the eye resulting in impaired vision). A review of Resident 25's Minimum Data Set (MDS, an assessment and care planning tool), dated 9/8/21, indicated resident scored 13 out of 15 on a Brief Interview for Mental Status, where score of 13 -15 indicated intact cognitive status. According to the MDS, Resident 25 required extensive staff assistance with dressing and toileting. A review of Resident 25's clinical records indicated the following medication orders: 1. Olanzapine (Zyprexa, atypical psychotropic medication to treat severe mental disorders) 10 milligram (mg, unit of measurement) at bedtime for Bipolar Disorder with psychotic features manifested by yelling out related to self-hatred. The physician directed the staff to monitor resident's episodes of yelling out and document each occurrence every shift. 2. Quetiapine (Seroquel, atypical psychotropic medication) 50 mg at bedtime for bipolar disorder with psychotic features manifested by mood swings. The physician directed the staff to monitor resident's episodes of mood swings and document each occurrence every shift. According to National Alliance of Mental Illness (NAMI), retrieved on 12/8/21 from https://www.nami.org > About-Mental-Illness >,Psychosis is characterized as disruptions to a person's thoughts and perceptions that make it difficult for them to recognize what is real and what isn't. These disruptions are often experienced as seeing, hearing and believing things that aren't real or having strange, persistent thoughts, behaviors and emotions. A review of Resident 25's psychiatric consultation visit note, dated 9/30/21, indicated resident exhibited anxiety, however, had no depression, delusions, hallucinations, and violence. The physician documented that resident behavior included frequent requests throughout the day where he'll yell out for staff, but then does not have any needs and apologizes for yelling .requires reassurance Patient reports feeling nervous and sad .about not being able to see wife .appear to have an anxious affect. The physician noted that Resident 25 continued to have BUE [bilateral upper extremities] hand tremor (excessive shaking) due to his diagnosis of Parkinson's and two antipsychotic medications which required him to need assistance with eating. The progress note did not contain any documentation of Resident 25 exhibiting severe mental disorder and clinical insight or rationale to support the diagnostic criteria for which the resident was prescribed multiple psychotropic medications. A review of Resident 25's psychosocial visit note, dated 11/2/21, indicated resident was alert, pleasant, and conversant. The Nurse Practitioner (NP) documented that resident reported having depression and anxiety as he wants to go home, missing his wife. He claims to have hallucinations seeing shadows of animals. He is blind .Staff reports that he is cooperative with care. A review of weekly nursing summaries, dated 9/28, 10/11, 10/25, 11/1, and 11/29/21, indicated Resident 25 was noisy, yelling, easily upset, and cooperative. The weekly summaries and nursing progress notes did not contain any documentation indicating Resident 25 exhibited behaviors specific to psychosis, including anger, aggression, being a danger to himself and/or others. A review of social services (SS) notes, dated 9/24/21 and 12/1/21, indicated Resident 25 exhibited anxiety about most everything. The SS documented that resident does yell out for help due to his anxiety .if the aids don't [sic] come help him right away .will start yelling for his medications at times, up to an hour before it is due . The SS noted that calling resident's wife and sister often was effective and helped to calm the resident down. During a concurrent observation and interview on 11/30/21, at 10:15 a.m., Resident 25 was in his wheelchair in the room. Resident was neatly dressed and groomed and was alert and pleasant. Resident 25's hands were visibly shaking when he attempted to drink water from a plastic cup. Resident 25 stated he had trouble seeing and would get anxious if he was not able to find his call light or other personal items. During an observation on 11/30/21, at 12:45 p.m., Resident 25 was sitting in his wheelchair praying with rosaries. Resident was quiet and no yelling out or screaming was noted. During an observation on 12/1/21, at 2:30 p.m., resident's call light outside the room was on. Resident was not yelling out. When attempted to talk to him, he stated he was waiting for his CNA (Certified Nursing Assistant) to help him. During an observation on 12/2/21, at 3:40 p.m., Resident 25 was conversing with staff in a normal tone of voice while the staff was assisting the resident with activities of daily living (ADLs). During an interview on 12/2/21, at 9:50 a.m., the Licensed Nurse 4 (LN 4) stated Resident 25 was anxious frequently, but not aggressive. LN 4 stated, [I have] never seen him aggressive. Always apologetic, multiple times a day keeps apologizing. LN 4 stated resident's yelling out was not because of aggression, but mostly like calling out for help. During an interview on 12/2/21, at 10:10 a.m., LN 2 stated he was familiar with Resident 25. LN 2 stated resident was anxious a lot, but not psychotic and not dangerous to self or others. LN 2 stated Resident 25's episodes of yelling out and mood swings were manifested by calling out for assistance, calling out staff's names repeatedly or asking who will be his CNA the next shift. LN 2 stated nurses documented on medication administration record how many times the resident had episodes of yelling out. When the LN 2 was asked about the documentation for behaviors of mood swings, the LN 2 stated the nurses documented how many times the resident became restless or agitated. During an interview on 12/2/21, at 11 a.m., the Activity Director (AD) described Resident 25 as very nice, sweet, occasionally inpatient. The AD stated Resident 25 was not dangerous and not aggressive. The AD stated she was not aware if resident ever exhibited aggression toward the staff or his roommate. The AD added, Not that type to fight. No harm from him . Yelling out - mostly for needing help . He can't see .Then he starts apologizing. During a concurrent interview and record review on 12/2/21, at 12:43 p.m., the Director of Nursing (DON) stated she was aware Resident 25 received two antipsychotic medications of the same pharmacological class, both before sleep. The DON stated, Yelling out .not dangerous to staff .not aggressive .not rejecting care .He always yelling out for help. He needs assistance with ADL's, feeding, toileting and has impaired vision due to glaucoma. When the DON was asked if yelling out was for help was considered a psychotic feature, the DON stated, no. The DON stated Resident 25 had frequent episodes of yelling out when he was not able to contact his wife and then he would become restless and anxious. The DON searched the resident's clinical records and was unable to find any physician's progress notes supporting resident's target behavior of yelling out related to self-hatred. The DON stated she could not find the physician's justification on why Resident 25 was receiving two antipsychotic medications of the same pharmacological class. The DON confirmed the indication for use and the targeted behaviors for yelling out related to self-hatred and psychotic features manifested by mood swings were too general and not descriptive of resident's behaviors. The DON stated it was important to offer and document non-pharmacological interventions to address and manage resident's behaviors. The DON acknowledged that Resident 25's clinical records, including 'Impaired psychosocial well-being' care plan dated 2/28/19, did not contain documented non-pharmacological interventions attempting to prevent or remove resident's yelling out or mood swings. During a telephone interview on 12/2/21, at 3:35 p.m., the Nurse Practitioner stated she provided psychologic and psychiatric services in the facility. The NP stated when she visited Resident 25 on two occasions, he did not seem dangerous or aggressive. The NP stated resident reported to her that his behaviors of yelling out were calling for help. The NP stated, [Resident 25] told me he's anxious and worrying a lot. During a telephone interview with the Pharmacy Consultant (PC) on 12/2/21, at 3:45 p.m., the PC stated that to .justify for antipsychotics, resident has to have behaviors or to be a danger to himself or others. When the PC was asked if Resident 25's behaviors of yelling out calling for assistance and mood swings were adequate indications for the use of psychotropic medications, the PC did not provide any answer. The PC was asked if he identified any potential issues with resident's duplicate drug therapy during his medication regiment review for October and November 2021, and he stated, No. Review of the facility's policy titled, Antipsychotic Medication Use, revised 2021, indicated. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The policy stipulated that the physician and other staff will gather and document information to clarify a resident's behavior, mood, medical condition, specific symptoms .will identify, evaluate and document, with input from other disciplines and consultants .symptoms that may warrant the use of antipsychotic medications .The antipsychotic medications will .only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) The symptoms are identified as being due to mania or psychosis .(2) Behavioral interventions have been attempted and included in the plan of care.

Based on observation, interview and policy review, the facility failed to ensure the garbage storage area was maintained in a sanitary manner when garbage and refuse was observed on the ground next to the dumpsters for a census of 52 residents. This failure had the risk potential for harborage and feeding of pests. Findings: During an observation of the dumpsters area located near the kitchen on 12/1/21, at 12:45 p.m., accompanied by a Dietary Aide (DA), two empty garbage bags and a bag containing refuse was noted laying on the ground next to the dumpsters and partially covered with dry leafs. The garbage bag was transparent and contained among other refuse, used briefs, empty ice-cream cups and disposable cups. In a concurrent interview with the DA on 12/1/21, at 12:45 p.m., she stated, don't know when it fell off. A review of the facility's 'Miscellaneous Areas' policy dated 2020 indicated, Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and the lids are closed . The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. During a concurrent observation of the dumpsters area and interview with the Dietary Services Supervisor (DSS) on 12/1/21, at 3 p.m., the DSS stated the trash should not have been on the ground.

Based on observation, interview, and facility policy review, the facility failed to provide reasonable accommodation of resident's needs for one of 14 sampled residents (Resident 37). These failures placed Resident 37 at increased risk of her needs not being met. Findings: According to Resident 37's Face Sheet, the facility admitted her in mid 2018 with a diagnosis of Dementia (a group of conditions characterized by memory loss and impaired judgment). The Face Sheet further indicated Resident 37's primary language was other than English. A Minimum Data Set (MDS, an assessment and care planning tool) dated 10/29/21, indicated Resident 37 had severe memory impairment. The MDS also indicated Resident 37 required extensive assistance with her activities of daily living and needed set-up help for eating. During a telephone interview with Resident 37's Family Member (FM) on 12/1/21, at 12:46 p.m., the FM stated the biggest concern was how the staff would understand her needs or provide her care when they could not understand her language. In an observation and concurrent interview with a Certified Nursing Assistant 2 (CNA 2) on 12/1/21, at 1:13 p.m., CNA 2 pointed at the communication aide/papers with pictures and signs located on the bedside table and stated that he had never seen those before. CNA 2 confirmed that he had not used the communication aide/papers with Resident 37. CNA 2 further stated he would prefer to have something in her language so that it would be easier for her to make her needs known to staff. During an observation and interview on 12/2/21, at 10:23 a.m., LN 2 brought a medication cup with liquid medication and stated to Resident 37 that it tasted bad and brought it close to Resident 37's mouth. Resident 37 took a sip, made an unpleasant face and asked LN 2 to give her water in her native language (a language understood by the Department). LN 2 continued to give Resident 37 another sip from the medication cup. Resident 37 reacted and stated again that she wanted water. In an observation and concurrent interview on 12/2/21, at 10:50 a.m.,. with LN 5, she stated that she had never used a communication aide, pictures, picture chart or anything else with Resident 37. During an observation and concurrent interview on 12/2/21, at 12:25 p.m., CNA 1 placed a clothing protector on the Resident 37. CNA 1 neither explained to Resident 37 nor asked permission prior attempting to put on the clothing protector. The Resident reacted by waving her hands and shaking her head no. She stated in her native language that she didn't want it (Department understood her language). CNA 1 still insisted. Resident 37 got angry and threw away the clothing protector. In addition, CNA 1 bent down and positioned the resident's leg without informing her what she was going to do. Resident 37 reacted by shoving her hands in a downward motion and stated in her native language, to not touch her foot. CNA 1 again did not ask permission from Resident 37 if she would like her food to be cut into pieces and with a spoon she cut the food in the tray to small pieces. She then asked the Department to ask Resident 37 what she likes to eat as she did not understand what Resident 37 had said. CNA 1 then scooped food from main entrée, and with the same spoon scooped from the desert and attempted to feed Resident 37. Resident 37 turned her head away, and with her hand pushed the spoon away. With facial grimacing Resident 37 yelled at CNA 1 in her native language , I am not going to eat this, go away. Resident 37 sighed and was visibly upset. During an interview with the Director of Nursing (DON) on 12/2/21, at 1:50 p.m., the DON agreed the inability of the staff to communicate with Resident 37 increased the risks for her needs not being met. A review of Facility's policy titled, Quality of Life -Accommodation of Needs revised 2021, indicated, Staff shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide individualized activities for one of 14 sampled residents (Resident 37). This failure resulted in Resident 37 not being provided with activities of interest which placed Resident 37 at increased risk of psychosocial harm. Findings: According to Resident 37's Face Sheet, the facility admitted her in mid 2018 with diagnosis of Dementia (a group of conditions characterized by memory loss and impaired judgment). The Face Sheet further indicated Resident 37's primary language was other than English. Review of Activity Assessment at the time of admission, dated 8/20/2018, indicated that Resident 37's past activity interests were cooking, music and reading. According to the annual Minimum Data Set (MDS, an assessment and care planning tool) dated 7/29/21, indicated that for Resident 37 it was very important for her to listen to music that she liked. Review of Resident 37's Care Conference Notes, dated 10/28/21, indicated that Resident enjoys playing and talking to her doll baby and having refreshments. There was no documented evidence the facility was providing music or reading materials to Resident 37. Review of MDS, dated [DATE], indicated Resident 37 had severe memory impairment. The MDS also indicated Resident 37 required extensive assistance with her activities of daily living and needed set-up help for eating. In an observation on 11/30/21, at 10:29 a.m., Resident 37 laid in bed awake with the head of bed elevated. Resident 37 had a doll by her side, no communication aide was available at bed side and no calendar of activities was observed. A small statue of 'Mother Mary' was observed on the night stand and the TV in the room was off. In an observation on 11/30/21, at 12:58 p.m., Resident 37 laid in bed awake with head of bed elevated and a food tray was in front of the her untouched. The TV in her room was off. In an observation on 11/30/21, at 2:08 p.m., Resident 37 laid in bed with eyes closed, head of bed elevated, a doll by her side and the TV in the room was off. In an observation on 11/30/21 at 4:12 p.m., Resident 37 laid in bed awake, with head of bed elevated, a doll by side and the TV in the room was off. In an observation on 12/1/21, at 10:59 a.m., Resident 37 was seated in wheelchair, the TV in the room was off and a doll was by her side. In a phone interview with a Family Member (FM), on 12/1/21, at 12:46 p.m.,the FM stated they had not seen the resident involved in any activities during their visits. In an observation and concurrent interview with a Certified Nursing Assistant 2 (CNA 2) on 12/1/21, at 1:13 p.m., CNA 2 stated Resident 37 did not participate in any activities since the pandemic. In an observation on 12/1/21, at 3:13 p.m., Resident 37 laid in bed awake, with head of bed elevated, a doll by her side and the TV in her room was off. In an observation on 12/1/21, at 4:19 p.m., Resident 37 laid in bed disengaged and the TV in her room was on an English news channel and a doll by her side. In an observation on 12/2/21, at 8:30 a.m., Resident 37 laid in bed awake, with head of bed elevated, breakfast on the bedside table and a doll by her side. In an observation and concurrent interview with Licensed Nurse 5 (LN 5), on 12/2/21, at 10:50 a.m. LN 5 stated that Resident 37 looked outside the window, watched whatever was on the TV and went back to bed after lunch. In an interview with the Social Service Director (SSD) on 12/2/21, at 11:49 a.m., the SSD stated Resident 37 had a baby doll she liked to play with. In an interview with the Activity Director (AD) on 12/2/21, at 12:40 p.m., the AD stated during Resident 37's typical day she talked to her doll, had tea and cookies and looked out of the window. In an interview with the Director of Nursing (DON), on 12/2/21, at 1:50 p.m., the DON agreed that facility failed to provide appropriate and adequate activities for Resident 37. In an interview with the Administrator, on 12/3/21, at 8:50 a.m., she stated that having a doll or refreshments day after day were not stimulating activities for Resident 37. The Administrator also stated that having the television on an English news channel was not an appropriate activity for her. Review of the facility's policy and procedure, titled Activity Program revised 2021, stated, Activity programs designed to meet the needs of each resident are available on daily basis. Our activity programs are designed to encourage maximum individual participation and are geared to the resident's needs.

Based on observation, interview and record review, the facility failed to develop and implement a method to effectively dispose of controlled medications (those with high potential for abuse or addiction) in a manner that rendered them unusable, when four vials containing crushed and uncrushed tablets and capsules were identified in two out of two medication carts. This failure had the potential for diversion of controlled medications (transfer of a medication from a legal to an illegal use from the individual for whom it was prescribed, to another person for illicit use). Findings: During an inspection of Medication Cart 1 on 11/30/21 at 11:26 a.m., the cart had two amber vials with child proof caps containing crushed and uncrushed tablets and capsules were identified. The vials were labeled with a sticker that stated, Drug Destruction Container. Please crush all meds. For refused doses, loose tablets found in drawers, and contaminated tablets, solution from partially used ampules. Medication must be rendered unusable prior to placing in vial . During an interview on 11/30/21, at 11:26 a.m., Licensed Nurse 6 (LN 6) validated that vials contained denied doses of medication or any drugs found loose in the drawers of the medication cart. LN 6 verified that the drugs contained in the vials were both controlled and noncontrolled substances. LN 6 acknowledged and agreed that the contents inside the vials were not rendered unusable and could be removed and diverted by facility staff. During an inspection of Medication Cart 2 on 11/30/21 at 4:56 p.m., two amber vials with child proof caps containing crushed and uncrushed tablets and capsules were identified. During an interview on 11/30/21, at 4:56 p.m., with LN 3, LN 3 stated that denied doses of medication or drugs found loose in the drawers of the medication cart were to be crushed and placed inside the amber vials. LN 3 verified that the vials contained controlled drugs and that the contents could be diverted since the contents inside were not rendered unusable and could be removed. During an interview on 12/1/21, at 9:53 a.m., with Pharmacy Consultant (PC), PC acknowledged that the contents of the amber vials could be removed and used by staff. During an interview on 12/1/21, at 11:00 a.m., with Director of Nursing (DON), DON agreed that the medications inside the amber vials were not rendered unusable and that they could be removed and used by facility staff. DON agreed that storing crushed controlled and uncontrolled medications in vials inside the medication carts was not an appropriate method of drug destruction. During a review of the facility's policy and procedure titled, Discarding and Destroying Medications, revised 2021, the policy indicated, Destruction of a controlled substance must render it 'non-retrievable,' meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted. During a review of the facility's policy and procedure titled, Controlled Substances, revised 2021, the policy indicated, .when a resident refuses a non-unit dose medication (or it is not given) . the medication shall be destroyed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an inhaler, an insulin pen (medication used to treat high blood sugar) and blood glucose (sugar) test strips were labeled with an open date in two of two medication carts inspected. The failure had the potential for the residents to receive expired medication, be given medications beyond their effective dates, or receive inaccurate blood glucose test results. Findings: During a concurrent inspection and interview on [DATE], at 10:30 a.m., of Medication Cart 1 with Licensed Nurse 6 (LN 6), an opened packaged containing a Combivent Respimat inhaler (an inhaled medication to treat breathing problems) unmarked with an opened date was identified. LN 6 verified that the package was unmarked with an open date but should have been in order to know when the inhaler expires. A review of the labeling from the manufacturer for Combivent Respimat indicated, Discard 3 months after first actuation (inhalation) or after labeled number of actuations has been reached and locking mechanism is engaged, whichever comes first. During a concurrent inspection and interview on [DATE], at 11:26 a.m., of Medication Cart 1 with LN 6, a used and unmarked with open date Semglee insulin pen was identified. LN 6 agreed that the insulin pen should have been marked with an open date but was not. A review of the labeling from the manufacturer for Semglee insulin pens indicated, Once in use, store prefilled pens at room temperature . and use within 28 days. LN 6 acknowledged the Semglee insulin pen should have be marked with opened date so staff know when to discard it. During an inspection and concurrent interview on [DATE], at 2:45 p.m., of Medication Cart 2 with LN 3, an opened vial of EvenCare blood glucose test strips unmarked with an opened date was identified. A review of the labeling from the manufacturer for EvenCare blood glucose test strips with LN 3 indicated to Use within 6 months after first opening . LN 3 acknowledged and agreed that the vial should have been marked with an opened date and that one would not know if the test strips inside were expired or not without such date.

Based on observation, interview and record review, the facility failed to ensure food removed from the freezer and placed in the refrigerator was dated and personal items were not placed in the food storage room when: 1. Undated wrapped bacon was observed thawing in the refrigerator and 2. Personal items were observed in the dry food storage room. This failure had the potential to result in food borne illnesses for 49 residents who received food from the kitchen. Findings: During the initial brief tour of the Kitchen on 11/30/21, starting from 8:15 a.m., accompanied by the Dietary Services Supervisor (DSS): 1. An undated wrapped bacon was observed in the bottom shelf of the refrigerator located near the food services area. The DSS validated the observation and was observed as she removed the bacon from the refrigerator and stated, 'will throw it away.' 2a. Personal items which included 2 bags, 2 jackets, 3 face shields, a bunch of keys and a specimen bottle in a biohazard zip lock bag were observed in the dry food storage room. One of the jackets was noted hanging near the fire extinguisher and near the 3-door freezer. The other jacket, one of the bags and the face shields were observed hanging next to a small freezer which contained ice-cream. The DSS validated these were personal items. 2c. On 11/30/21 at 2:39 p.m., an energy drink was observed placed on the counter just above the small freezer in the dry food storage room. The DSS stated it was not for residents and took it away. A review of the facility's 'Employee Personal Items' policy, dated 2018 indicated, Personal items brought in by staff from outside will not be kept in the kitchen. A review of the facility's 'Labeling and Dating of Foods' policy, dated 2020 indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. During an interview with the DSS on 12/2/21, at 2:18 p.m., she stated personal items should not have been kept in the dry food storage room. The DSS further stated the personal items were to be kept in the staff break room. The DSS further stated the undated bacon in the refrigerator should have been dated as soon as it was removed from the freezer.