**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete medication self-administration assessment for one resident out of four residents (Resident 15) observed during medication administration of inhaler and nasal spray, when no documentation that Resident 15 can self-administer medication. This failure resulted in Resident 15 given the wrong dose of nasal spray. FINDINGS: During the medication administration observation on 11/19/24 at 9:20 a.m.,, for Resident 15, Licensed Nurse (LVN) 2 was observed preparing and administering (6) oral medications. LVN 2 pulled out Fluticasone propionate 50 mcg/ actuation nasal spray 1 spray both nares twice a day for postnasal drip, Trelegy Ellipta 100 mcg-62.5 mcg-25 powder for inhalation I puff inhalation once a day for Emphysema. LVN 2 handed Fluticasone bottle to resident, per LVN 2, resident does it herself. Resident shook the bottle and sprayed 2 sprays on the right nose and 2 sprays on the left nose. LVN 2 came out of the washroom and asked resident, how many sprays did you do Resident stated, 2 they don't work anyway. LVN 2 handed the inhaler to resident, reminded to take deep breath, resident pushed the inhaler button once, handed the inhaler back to LVN 2. Resident rinsed her mouth with water provided by LVN 2. A review of Resident 15's clinical record indicated, admitted on [DATE] with diagnoses including: Emphysema(a lung disease that makes it difficult to breathe), Atrial Fibrillation(irregular heartbeats). During an interview on 11/19/24 at 10: 30 a.m., with Resident 15, per Resident 14, I give it to myself, I gave 2 sprays they don't even work, maybe I don't need it. Resident stated she used to give this spray to herself. During an interview on 11/19/24 at 11 a.m.,, with LVN 2, per LVN 2, resident has been giving herself the inhaler and nasal spray since she has been admitted to the SNF. She came from the Independent Living floor. Don't remember completing the self-administration assessment form. During a concurrent interview and record review with on 11/20/24 at 10:15 AM, NM, per NM, there is a process for self- administration of medication. Resident request to self administer and IDT will meet and document result from the assessment form, if the resident is capable of doing her own medication. MD will have to be involved and IDT will need to care plan. needs pharmacy approval. Per NM, there is no documentation in the record about self -administration, no care plan and no MD order. Review of BIMS (Brief Interview for Mental Status) score is 10, mild cognitive impairment. A review of facility Policy and Procedure, Medication: Self Administration dated 4/24, indicated: Policy: An individual resident may self-administer medications if the interdisciplinary team (IDT) had determined that this practice is safe, and the physician writes an order for self -administration of the specific medications. 2. If a resident wants to self-administer medications, the IDT shall assess the resident's cognitive, physical, and visual ability to carry out this responsibility. 3. A licensed nurse will perform an assessment of the resident's ability to self-administer medications and submit the results to the IDT .5. Residents requesting to self-administer handheld nebulizers shall be required to demonstrate the capability of safely and effectively using the hand-held nebulizers without assistance or oversight of a licensed nurse. 6. The self-administration assessment and any other information will be presented to the physician and the IDT for final determination of the resident's ability to self-administer medications. The assessment shall be documented in the resident's chart. 7. The resident may not begin self-administration prior to approval by the IDT and the resident's physician .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility had a medication error rate of 7.41 % when two medication errors occurred out of 27 opportunities during the medication administration for two of four (Resident 8) and (Resident 19). The failure resulted in the nursing staff not following the facility's policy and procedures (P&P) and had the potential for the resident not receiving full therapeutic effects or causing side effects for the residents. FINDINGS: 1.During the medication administration observation on 11/19/24 at 8:03 AM, for Resident 19, Licensed Vocational Nurse (LVN) 1 was observed preparing and administering (5) oral medications and Thera Tears eyedrop eye 0.25% droperette, 1 drop both eyes, 4x a day for dry eyes. Resident pulled right lower eyelid down, LVN instilled one drop, Resident pulled the left lower eyelid down, LVN instilled one drop. Resident closed eyes and LVN handed a tissue, resident wiped her eyes. 2. During the medication administration observation on 11/19/24 at 8:59 AM for Resident 8, LVN 1 was observed preparing and administering six oral medications and one eyedrop, Timolol ophthalmic 0.5% one drop both eyes once a day. Resident pulled down lower lid of right eye, LVN instilled one drop and did the same for the left eye. Resident closed eyes and wiped her eyes right after. A review of Resident 19's clinical record indicated, admitted on [DATE] with diagnoses including: Anxiety Disorder( condition causing excessive fear feeling of fear that affects daily life),History of Falling. A review of Physician Order, indicated TheraTears 0.25% eye drops one drop both eyes 4times a day for dry eyes. A review of Resident 8's clinical record indicated admitted on [DATE] with diagnoses including Acute Kidney Failure(condition when kidney is not working properly),Type 2 Diabetes Mellitus (condition with high blood sugar). Review of Physician's Order, indicated, an order for Timolol maleate 0.5% eye drops-0.5% both eyes once daily for Glaucoma, (eye disease that can lead to blindness). During an interview on 11/19/24 at 10AM, with LVN1, per LVN1, how to give eyedrops, ask the permission of the resident, follow five R's of medication administration, read orders, wash hands before and after, tissue to wipe, let resident close eyes and hold it, some residents do what they want. LVN or resident did not hold the eyes. During an interview on 11/19/24 at 10:15AM, with Nurse Manager, per NM, there is a process we follow when administering eye drops. Handwashing for infection control. Follow the policy and procedure. Looking at the P&P, per NM, the LVN did not press thumb over inner canthus to prevent systemic absorption. Per NM, inservices are given by DSD (director of Staff Development) on medication administration yearly. Per NM, will check with Pharmacist for inservices on medication administration. A review of facility Policy and Procedure, Medication Administration through Certain Routes of Administration, dated 4/1/22, indicated, Opthalmic Drops: Eye drops, ointments are applied to the eye for diagnostic and therapeutic purposes .Procedure: Eyedrops: 13. Gently press thumb over inner canthus for 1 to 2 minutes after instilling Drops while resident closes eyes gently to prevent systemic absorption and allow medicine to distribute over surface of eye. Wipe off excess solution with tissue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standards of quality for Resident 13 when the licensed nurse failed to sign the medication as given on the electronic Medication Administration Record (eMAR - a tool used by nurses to keep track of the medications given to patients) as ordered by the physician (person qualified to practice medicine). This deficient practice could potentially compromise the health and safety of the resident. Findings: Resident 13 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). During a medication administration observation on 5/9/23 at 10:08 AM, Registered Nurse (RN) 1 administered Albuterol sulfate 2.5 milligram (mg)/3 milliliter (ml) via nebulizer to Resident 13. Review of Resident 13's Physician's Orders for 5/11/2023 indicated, Resident 13 had an order for Albuterol sulfate 2.5 mg/3 ml (0.083%) solution for nebulization - 1 vial inhalation via nebulizer every 4 hours as needed for COPD/SOB (shortness of breath). During a concurrent interview and record review, on 5/10/23 at 12:42 PM, with RN 1, Resident 13's eMAR dated May 2023 was reviewed. The eMAR indicated, on 5/9/23, for the 10:08 AM administration time, there was no licensed staff initials in the box for Resident 13's Albuterol sulfate (medication used to prevent and treat difficulty breathing, shortness of breath) 2.5 mg/3 ml, to demonstrate the medication was administered. RN 1 acknowledged that there was no documentation on the eMAR dated May 2023 that indicated Resident 13 received the Albuterol sulfate 2.5 mg/3 ml on 5/9/23 at 10:08 AM. RN 1 stated, It should have been signed. If not signed, it will show as not given. Review of facility policy titled, Medication Administration last revision date of 2/18, indicated, .Administration of Medications .5. The licensed nurse shall chart the date and time of each administered medication by putting his/her initial in the corresponding box for that date and time on the eMAR .If the medication is given on a per need (PRN) basis, the time shall be noted on the eMAR .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that irregularities in the Pharmacy Medication Regimen Review (MRR-a systematic evaluation of medication therapy) for one of three sampled residents (Resident 23) were acted upon when there was no evidence the attending physician reviewed and documented if actions had been taken to address the identified irregularities (includes use of medications without adequate monitoring, in excessive doses, and/or in presence of adverse consequences) for MRR dated April 2023 in response to the pharmacist's recommendations. This deficient practice had the potential risk for harm by causing adverse consequences related to medication therapy. Findings: Resident 23 was admitted on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, Alzheimer's disease (a progressive disease beginning with mild memory loss), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Review of Resident 23's Minimum Data Set (MDS- an assessment tool) dated 4/13/23 indicated, Resident 23's cognition is moderately impaired. Review of Resident 23's Physician Orders for 5/11/23 indicated, Resident 23 was on Mirtazapine (antidepressant) 15 milligram (mg) at bedtime for depression manifested by (m/b) inability to sleep/insomnia, Lorazepam (medication used to treat anxiety) 0.5 mg every 8 hours as needed for anxiety m/b agitation and/or verbalization of belief that staff may be taking things from her room, Seroquel 25 mg twice daily and Quetiapine [generic] 50 mg daily at 2:00 PM (an antipsychotic medication that treats several kinds of mental health conditions) for vascular dementia with behavioral disturbance m/b agitation, paranoia and hallucinations. Review of MRR dated 4/1/23 indicated, no response from the physician. In a concurrent interview on 5/11/23 at 10:54 AM, Registered Nurse (RN) 2 said, the pharmacist comes to do the medication review, and has a binder of the monthly individualized report. RN 2 stated, If the physician responds, he makes a note and signs it. During an interview on 5/12/23 at 9:54 AM, the Director of Nursing stated, We don't have it, when asked for the physician's response to the pharmacist-reported irregularities on Resident 23's MRR dated 4/1/23. During an interview on 5/12/23 at 10:46 AM, the Consultant Pharmacist (CP) said, MRR is done monthly and a formal note to the physician is written for recommendations that are appropriate at the time of review. The CP stated, Yes, it is expected the physician needs to see it (MRR) and elect what to do. Review of Resident 23's physician notes dated 4/11/23 and 5/5/23, did not indicate identified irregularities in the MRR dated 4/1/23 has been reviewed and what action has been taken to address it. Review of facility policy titled, Medication Regimen Review with effective date of 11/28/16, indicated, .7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 23) reviewed were free from unnecessary psychotropic medication (drugs that affect brain activities associated with mental processes and behavior) when: 1. Resident 23 received Seroquel (Quetiapine [generic] - an antipsychotic medication to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) without appropriate indication, patient centered non-pharmacological approaches, and adequate behavior monitoring; 2. There was no evidence Gradual Dose Reduction (GDR - a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Seroquel use was attempted; 3. Care plan did not reflect specific target behavior to be monitored for the use of Seroquel; 4. There was no rationale indicated when Lorazepam (medication used to treat anxiety) PRN was used for more than 14 days, and there was no duration of therapy indicated in the physician's order. These deficient practices had the potential to result Resident 23 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis. For short-term adjunctive use while addressing underlying cause(s) of severe symptoms. In patients without a clinically significant response after an adequate trial (e.g., up to 4 weeks), taper and withdraw therapy. Only continue in patients with demonstrated benefit; attempt to taper and withdraw at regular intervals (e.g., within 4 months of initiation). [https://online.[NAME].com/lco/action/doc/retrieve/docid/patch_f/7598 accessed on 5/22/23]. According to the American Geriatrics Society (AGS) based on the Beers Criteria® (AGS Beers Criteria - Guidelines for Healthcare Professionals to help improve the safety of prescribing medications for older adult) for Potentially Inappropriate Medication (PIM) Use in Older Adults 2023, .Quetiapine .Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. The recommendation is to strongly avoid the use of this medication . Findings: Resident 23 was admitted on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, Alzheimer's disease (a progressive disease beginning with mild memory loss), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels of the brain) with agitation. Review of Resident 23's Minimum Data Set (MDS- a care area assessment and screening tool), dated 4/13/23, indicated, Resident 23's cognition was moderately impaired. 1. During an observation and concurrent interview on 5/8/23 at 9:39 AM, Resident 23 was in her wheelchair watching television, smiling and in good spirits. Resident 23 said she loved staying in the facility, it felt like being home. Resident 23 was also observed on multiple occasions: on 5/8/23 at 12:30 PM, and on 5/9/23 at 10:22 AM, during which she did not exhibit any types of behaviors. During an interview on 5/8/23 at 12:36 PM, Certified Nursing Assistant (CNA) 1 said, Resident 23 was combative but usually nice, when asked what behavioral disturbance Resident 23 manifested. During an interview on 5/11/23 at 2:17 PM, CNA 2 said, at times Resident 23 would say, My mom was here earlier. CNA 2 stated, I think that's her hallucination. During an interview on 5/11/23 at 2:29 PM, Registered Nurse (RN) 1 said, behaviors manifested by Resident 23 were: sometimes she's in the hallway and wants to go out or would say that she doesn't want the medications. RN 1 further said, hallucinations as manifestation of behavioral disturbance was generalized because different people have different manifestations of hallucination (auditory or visual). RN 1 stated, Monitoring of hallucination should be specific to see if medication is effective. Review of current physician's orders included: Seroquel 25 milligram (mg) by mouth twice daily (BID) with a start date of 1/8/23, and Quetiapine 50 mg daily at 2:00 PM with a start date of 4/9/23, both for vascular dementia with behavioral disturbance manifested by (m/b) agitation, paranoia, and hallucinations. The orders did not indicate what specific target behaviors were to be monitored. 2. Review of Resident 23's medication administration record (MAR) indicated: - Seroquel 25 mg three times a day was administered from 1/1/23 to 1/7/23 - Seroquel 25 mg BID was administered from 1/8/23 to 5/11/23 - Quetiapine 50 mg daily was administered from 1/8/23 to 5/10/23 During a concurrent interview and record review on 5/12/23 at 9:54 AM, with the Director of Nursing (DON), the Pharmacy Services Report April 2023 with an attachment titled Note to Attending Physician/Prescriber printed 4/1/23 was reviewed. The Note to Attending Physician/Prescriber indicated, .If appropriate, please consider a GDR at this time. If not appropriate, please document rationale for contraindication . The DON said, there was no documentation the physician acted upon the pharmacist's recommendation for GDR and stated, We don't have it. During an interview on 5/12/23 at 10:46 AM, the Consultant Pharmacist (CP) said, MRR is done monthly and a formal note to the physician is written for recommendations that are appropriate at the time of review. CP stated, Yes, it is expected the physician needs to see it (MRR) and elect what to do. Review of Resident 23's physician notes dated 4/11/23 and 5/5/23, did not indicate pharmacist's recommendation for GDR, identified in the MRR printed 4/1/23, has been reviewed and what action has been taken to address it. 3. During a concurrent interview and record review on 5/11/23 at 10:54 AM, with RN 2, Resident 23's care plan for psychotropic drugs was reviewed. The care plan did not indicate behaviors to be monitored for the use of Seroquel. RN 2 said, the care plan should reflect the overall care provided to the resident. RN 2 stated, Resident 23's care plan was not individualized, there was no behavior monitoring indicated, only observe for side effects for the use of Seroquel. 4. During a review of Resident 23's clinical record, the following were found: - The Physician Orders for 5/11/23 indicated, .Lorazepam 0.5 mg (milligram) 1 tab (tablet) by mouth every 8 hours as needed (PRN) for anxiety . with a start date of 10/4/22 and no stop date indicated. - The MAR for 1/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on January 3 and 15, 2023. - The MAR for 2/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on February 22, 2023. - The MAR for 3/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on March 22, 2023. - The MAR for 4/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on April 16 and 19, 2023. - The MAR for 5/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on May 3 and 8, 2023. During an interview on 5/12/23 at 10:46 AM, CP said, for PRN psychotropic medications, he goes through the resident's medications twice or three times to evaluate, and for the medication to not stay on the resident's profile, only 10-14 days. The CP then writes a formal note to the physician for recommendations that are appropriate at the time of review. Review of facility policy titled, Psychotherapeutic Medication Management Program last revised on 6/21, indicated, .A. Physician Responsibilities .2. The psychotherapeutic medication order shall include the following information: Manifestations of the disorder and/or specific behavioral targets treated i.e., auditory hallucinations, hitting others, refusing to eat, etc. 4. The physician shall review the monthly psychotherapeutic summary and determine if the resident should remain on the same dose, or an adjustment should be made .G. Interdisciplinary Team .1. The resident's interdisciplinary care plan shall include the reason for the drug and describe the behaviors the drug was prescribed to treat .

Based on observation, interview, and record review, the facility had a 7.69% error rate when two medication errors out of 29 opportunities were observed during a medication pass when: 1. Resident 10 received Symbicort (medication used to treat asthma and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) was not in accordance with the manufacturer's instructions for use. 2. Resident 42 received Metoprolol (medication used to treat high blood pressure, chest pain, and heart failure) not in accordance with the physician's order. These failures resulted in medications given not in accordance with the physician's order and manufacturer's instructions for use that may affect the residents' clinical conditions. Findings: 1. During a medication pass observation on 5/9/23 at 9:28 AM, Registered Nurse (RN) 1 prepared Resident 10's Symbicort 160 microgram (mcg)-4.5 mcg/actuation HFA aerosol inhaler. RN 1 did not shake the inhaler prior to administering two puffs by mouth. During an interview on 5/9/23 at 9:31 AM, RN 1 acknowledged that he did not shake the inhaler before administering the medication, and stated, Yeah, I should shake before giving. Review of Symbicort instructions for use indicated, .Shake your Symbicort inhaler well for 5 seconds right before each use . 2. During a medication pass observation on 5/9/23 at 9:41 AM, RN 1 was observed preparing eight medications for Resident 42. Included in the medications was Metoprolol Succinate ER (Extended Release) 25 milligram (mg). RN 1 checked Resident 42's vital signs (clinical measurements, specifically heart rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and had a heart rate of 59 beats per minute. Then, RN 1 proceeded to give the eight medications to Resident 42. During an interview on 5/9/23 at 9:46 AM, RN 1 read Resident 42's heart rate on the monitor as 59 and acknowledged that the resident took all medications. RN 1 stated, Yes, all eight. During a concurrent interview and record review on 5/10/23 at 12:35 PM, with RN 1, Resident 42's electronic medication administration record (eMAR) dated 5/9/23 was reviewed. The eMAR indicated, a physician's order for Metoprolol Succinate ER 25 mg tablet once daily for hypertension, hold for SBP (systolic blood pressure - measures the pressure in the arteries when the heart beats) less than 100 or HR (heart rate) less than 60. RN 1 read the physician's established parameters and acknowledged that the medication was administered on 5/9/23 with Resident 42's HR at 59. RN 1 stated, I should have held the medication. RN 1 said, Resident 42's heart rate might go down and can cause loss of consciousness. Review of facility policy titled, Medication Administration revised on 2/18, indicated, .B. Holding Medications .2. The following criterion must be met in order to hold ordered medications .For cardiovascular drugs, BP or pulse outside MD established parameters .

Based on observation, interview, and record review, the facility failed to ensure medications and/or medical supplies were properly labeled and stored. There were four expired nasal swabs, two packets of expired supplement powder, six packets of expired food thickener in Atrium medication cart. Also, there were boxes of expired insulin syringes, 18 expired electrocardiogram (ECG/EKG - records the electrical signal from the heart to check for different heart conditions) electrodes (sticky patches placed on the chest to record the heart's electrical signals), one canister of expired Sani-Cloth Purple Wipes, six expired intravenous (IV) catheters (a flexible tube inserted to a vein to administer fluids or medications), two expired IV start kit, two expired CADD (Continuous Ambulatory Delivery Device -a small, battery-operated pump that can be used to send fluids, medication, and chemotherapy as an intravenous infusion) administration sets, five dressing change trays, five expired foam dressings, 21 expired syringe tip caps, 12 expired needleless connectors (device that allow quick access to the infusion line, ensuring a secure connection), 41 expired female luer lock caps (connect to all syringe tips in place of a dispensing tip), 18 expired duoderm dressings (indicated for the management of lightly exuding wounds), one expired IV connecting tubing, two expired hypodermic safety needles (medical tool which enters the skin, a very thin, hollow tube with one sharp tip), two expired angiocaths (thin hollow tubes that allow the introduction of contrast dyes into various areas of the body for diagnostic purposes) and an expired vacutainer safety lok blood collection set (a sterile closed system for drawing blood from difficult veins) found in the medication storage room. This deficient practice had the potential to cause unsafe and/or inappropriate storage and administration of medications to residents. Findings: 1. During an observation on 5/9/23 at 10:35 AM, with Registered Nurse (RN) 3, there were four nasal swabs in the third drawer from the top, on the left side of the Atrium Medication Cart. The swabs indicated an expiration date of 1/31/22. During a concurrent interview, RN 3 said, the swabs were used for respiratory pathogen panel (checks for virus, bacteria, or other organism that causes an illness in the respiratory tract). RN 3 stated, It should not be there, should be discarded. During an observation on 5/9/23 at 10:35 AM, with RN3, there were two JUVEN (brand name) supplement powder with an expiration of 12/1/21 and six packets of SIMPLY THICK (brand name) food thickener with an expiration of 8/4/22, in the fourth drawer from the top, on the left side of the Atrium Medication Cart. During a concurrent interview, RN 3 said, the food thickener is used to thicken thin liquids for residents on nectar thick diet. RN 3 stated, It should not be in the cart. 2. During an observation of the Medication Storage Room on 5/9/23 at 10:52 AM, with RN 3, the following were found: A box of insulin syringes (110 pieces) with an expiration date of 12/31/22; 18 ECG/EKG electrodes with an expiration date of July 2017; A canister of Sani-Cloth purple wipes with an expiration date of April 2023; IV catheters with different expiration dates: one on 11/30/21, four on 2022, and one on 1/31/23; Two IV start kit with an expiration date of 2022 Two CADD administration sets with an expiration date of 2022 Dressing change trays with different expiration dates: two on 2022, and three on 2/19/23; Five Allevyn (brand name) dressing with an expiration date of July 2022; Syringe tip caps with different expiration dates: 14 on 12/2021 and 7 on 2/2023; 12 Needleless connectors with different expiration dates: 6/2022, 8/2022, and 11/2022; Female Luer Lock caps with different expiration dates: three on 2020, 19 on 2/2021, and 19 on 11/2022; Duoderm dressings with different expiration dates: three on 9/2021, seven on 5/2022, and eight on 11/2022; One IV connecting tubing with an expiration date of 11/2022; Two hypodermic safety needles with an expiration date of 6/2020; Two angiocaths with an expiration date of 3/2021; and A vacutainer safety lok with an expiration date of 12/31/22. During a concurrent interview, RN 3 acknowledged the above findings. During an interview on 5/9/23 at 1:03 PM, with RN 2 and the Director of Nursing (DON), RN 2 confirmed the above findings. The DON said, the expired supplies should not be in the medication storage room and should be discarded. Review of facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles last revised on 4/1/22, indicated, .3. General Storage Procedures .3.4 Facility should ensure that infusion therapy products and supplies are stored .according to the manufacturer's or supplier's recommendations .3.7 Facility should ensure that .disinfectants and other household substances are stored separately from medications .19. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2b. Resident 42 was admitted on [DATE] with diagnoses including multiple fracture (breaking) of ribs, pleural effusion (water on the lungs). During the initial tour observation on 5/8/23, at 10:35 AM, Resident 42 was in her room sitting up on her wheelchair with oxygen concentrator (a medical device) on at one liter per minute via nasal cannula. The nasal cannula was not labeled. During a concurrent observation and interview on 5/8/23, at 10:38 AM, RN 1 checked the oxygen concentrator and the nasal cannula tubing, stated, I don't see any label. Further stated, There should be a label and change tubing every 72 hours. During an interview on 5/8/23, at 10:40 AM, DON acknowledged by stating, Yeah, we are supposed to label tubing when we put it together. During an interview on 5/9/23, at 4:05 PM, the IP stated, . the nasal cannula tubing should be dated and changed weekly. 3. Resident 42 was admitted on [DATE] with diagnoses including multiple fracture (breaking) of ribs, pleural effusion (water on the lungs). During the initial tour observation on 5/8/23, at 10:35 AM, Resident 42 was in her room sitting up on her wheelchair with oxygen concentrator on at one liter per minute via nasal cannula. The humidifier (a medical device used to humidify supplemental oxygen) attached to the oxygen concentrator was not labeled. During a concurrent observation and interview on 5/8/23, at 10:38 AM, RN 1 checked the oxygen concentrator and the humidifier, stated, I don't see any label. Further stated, There should be a label and change the humidifier when it's empty. During an interview on 5/8/23, at 10:40 AM, DON acknowledged by stating, Yeah, we are supposed to label when we put it together . looking at how often we have to change it. During an interview on 5/9/23, at 4:05 PM, the IP stated, humidifier should be dated and changed daily. Review of Physician's Orders (PO) for 5/11/23 on 5/11/23, at 3:00 PM, PO indicated, .Date and change humidifier bottle - every week or when water level is low. Review of facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Oxygen Administration . 3. [NAME] bottle with date and initials upon opening and discard after twenty-four (24) hours. 6. Change the oxygen cannula and tubing every seven (7) days, or as needed . Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment when: 1. Residents 13 and 23's handheld nebulizer masks were unlabeled and uncovered while not in use. 2. Residents 23 and 42's oxygen tubing were unlabeled. 3. Resident 42's humidifier was unlabeled. These deficient practices could potentially result in the transmission and spread of infection causing harm to the residents. Findings: 1a. Resident 13 was admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD- A group of lung diseases that block airflow and make it difficult to breathe). During an observation on 5/10/23 at 12:59 PM, Resident 13 was in bed, asleep. There was a nebulizer with an attached handheld mask that was uncovered and unlabeled on the bedside table. During an interview on 5/10/23 at 1:11 PM, Registered Nurse (RN) 1 acknowledged that the nebulizer mask was unlabeled and uncovered. RN 1 stated, The mask should be covered when not in use, so bacteria won't get in. For infection control. 1b. Resident 23 was admitted on [DATE] with diagnosis that included COPD. During the initial tour observation on 5/8/23 at 9:39 AM, Resident 23 was sitting on her wheelchair while watching television. There was a nebulizer with an attached handheld mask that was uncovered and unlabeled on the bedside table During an interview on 5/8/23 at 12:41 PM, the Licensed Vocational Nurse (LVN) 1 acknowledged that the nebulizer mask was unlabeled and uncovered. LVN 1 stated, When not in use, we have to cover so dust won't contaminate it. During an interview on 5/9/23 at 4:05 PM, the Infection Preventionist (IP) said, the nebulizer should be covered when not in use and should have the resident's name on it. Review of facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol .7. Store the circuit in designated bag, marked with date and resident's name, between uses .9. Discard the administration set-up every seven (7) days . 2a. During the dining observation on 5/8/23 at 12:30 PM, Resident 23 was sitting on her wheelchair, watching television while eating her lunch. Resident 23 was on oxygen via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) attached to a small oxygen cylinder tank. The nasal cannula was unlabeled. During an interview on 5/8/23 at 12:36 PM, the Certified Nursing Assistant (CNA) 1 stated, She's (Resident 23) always on oxygen, 24/7. During an interview on 5/8/23 at 12:41 PM, the Licensed Vocational Nurse (LVN) 1 said, Resident 23 is on oxygen at 1 liter/minute when out of bed. LVN 1 acknowledged that the oxygen tubing was not dated, and stated, Not labeled. During an interview on 5/9/23 at 4:05 PM, the Infection Preventionist (IP) said, the nasal cannula should be dated and changed weekly. Review of facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Oxygen Administration .6. Change the oxygen cannulae and tubing every seven (7) days, or as needed .

Based on observation, interview and record review, the facility failed to ensure food sanitation when: 1. Two expired 1.86 liters of chocolate caramel were found on the shelf of the canned food storage area, 2. A kitchen equipment and stove/warmer were found unclean in the plating area of the kitchen. These failures have the potential to place the residents at risk for food borne illness. Findings: 1. During the initial tour of the facility's kitchen on 5/8/23 at 9:20 am, it was observed that two 1.86 liters can of Chocolate Caramel were stored on the front of the second layer of the canned food storage shelf. During a concurrent interview with the Executive Chef (EC), Director of Dining Services and Registered Dietitian (RD), they stated that it was a mistake and an omission. They said that the cans of chocolate caramel were not supposed to be on that shelf and these were supposed to be discarded. The facility's undated policy and procedure titled the Food and Supply on page 1, indicated, Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. 2. During observation on 5/8/23 at 9:21 am, the oven/warmer in the kitchen area was found to be dirty. When asked, the EC stated that they must order supplies to clean the equipment while the RD said they have to contact the company that made the equipment to come and loosen the parts so they can clean it. During observation on 5/11/23 at 11:00 am, the oven warmer was still not cleaned up. In a concurrent interview, the EC and RD stated that they called the company to come loosen the stove before they can clean it. The EC and RD could not say when is the appointment date/time. During a review of Area and Equipment Cleaning Policy on 5/11/23 at 2:00 pm, it indicated in the procedure: Director develops a reference manual on cleaning areas and equipments in the Food and Nutrition Services/Dinning Services, Assigns daily cleaning responsibilities in each position workflow .Management and Supervisory Personnel. Assigns weekly and special cleaning to be completed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to maintain an account of all controlled drugs when the facility was not able to provide evidence of documentation of accounting of receipt and disposition of discontinued controlled substance (is generally a drug or chemical whose manufacture, possession, or use is regulated by a government; a prescription from a licensed physician [medical doctor] is needed to acquire these medications). This deficient practice had the potential for drug diversion. Findings: During medication room observation and concurrent interview with the Nurse Manager 1 (NM 1) on [DATE] at 1:40 PM, the storage for discontinued controlled substance medications contained the following: 14 Temazepam capsules - medication to treat sleep problem; 17 Clonazepam tablets - medication to treat anxiety (excessive fear and worrying); eight Triazolam tablets - medication to treat sleep problem; nine Zoldipem tablets - medication to treat sleep problem. NM 1 stated, when the controlled substance medications are discontinued the nurses give them to me. We do not have any kind of form to log the controlled substance medication that was given to me. During an interview with the Director of Nursing (DON) on [DATE] at 1:30 PM, the DON stated, No, I don't deal with that [discontinued controlled substance medications], you have to talk to the Nurse Manager [NM 1]. During a review of the facility policy and procedure titled, Disposal/Destruction of Expired or Discontinued Medications, Effective Date [DATE], indicated, Disposal of Controlled Substance Medications, 13. The facility should record destruction of controlled substances on: 13.1 Medication Disposition/Destruction Form; . 13.3 Medication Destruction Log Book.

Based on observation, interview and record review, the facility failed to ensure medications were properly labeled and stored when: 1. 75 suppositories used to treat nausea (feeling of an urge to vomit) and vomiting were found without labeling. 2. The temperature of the refrigerator containing vaccines was not monitored. This failure had the potential to dispense medication without a physician order and decrease the effectiveness of the vaccines. Findings: 1. During the medication room observation and concurrent interview with Nurse Manager 1 (NM 1) on 8/26/19, at 2:10 PM, 48 unlabeled promethazine suppositories, and 27 unlabeled prochlorperazine suppositories were found in one of one medication refrigerator in one of one medication room. NM 1 acknowledged the suppositories were not labeled and stated, Those are house supplies, we don't label them. During an interview with the Director of Nursing (DON) on 8/28/19 at 2:10 PM, DON stated, we do not have a specific policy for labeling. That's all we have, 2. During the medication room observation and concurrent interview with NM 1 on 8/27/19 at 2:15 PM, the temperature of the refrigerator containing 12 Prevnar 13 vaccine (used for prevention of pneumonia [a potentially serious lung disease]) and two Purified Protein Derivative (PPD, used for skin testing to determine if a person has tuberculosis [TB]) was not monitored. NM 1 acknowledged the finding and stated, I didn't know the temperature of the refrigerator containing vaccines has to be monitored twice a day. Review of the facility policy and procedure titled, Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, dated 10/2016, indicated, .Facility should ensure that medications and biological's were stored at their appropriate temperature according to the United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor of vaccines twice a day .

Based on observation, interview and record review, the facility failed to ensure manufacturers guidelines for safety and maintenance were implemented for bed rails (adjustable metal or rigid bars that attach to the bed and come in a variety of types, shapes and sizes. Examples of bed rails include grab bars and assist bars) when: 1) 35 out of 35 beds did not have routine scheduled maintenance in place for the use of bed rails, 2) 15 out of 35 residents (Residents 1, 2, 3, 4, 10, 12, 13, 16, 18, 19, 21, 23, 24, 25, 28) did not have reassessments for the use of bed rails, and 3) 28 out of 35 residents (Residents 1, 3, 4, 5, 6, 7, 8, 10, 11, 12, 20, 13, 14, 15, 16, 17, 18, 19, 21, 23, 24, 25, 27, 139, 138, 140, 141 and 142) did not have bed rail care plans implemented. A substandard quality of care deficiency was identified regarding the use of bed rails. Failure to implement a comprehensive approach for the use of bed rails had the potential to place residents at risk for entrapment or physical injury. Findings: 1) During observation on 8/26/19 at 9:45 AM, 16 resident occupied beds in the following rooms had bed rails in their up position: Rooms 201, 202, 204, 205, 206, 207, 208, 209, 211, 213, 224, 226, 230, 233, 234, 237. During observation on 8/29/19 at 11:23 AM, 25 resident occupied beds in the following rooms had bed rails in their up position: Rooms 202,206, 208, 210, 212, 214, 217, 219, 221, 223, 220, 225, 222, 224, 226A, 226B, 227, 229, 235, 237, 238, 234, 228, 230, 233. During an interview on 8/27/19 at 3:46 PM, Resident 28 stated she was concerned about the grab bars (bed rails) because the bed control attached to it keeps sliding down to the mattress and is very difficult to get to. Resident 28 stated this has been brought up to staff several times during the resident council meetings but nothing has been done about it so she sticks a pillow between the bars under the bed control to try and keep it from slipping down. During record review of Resident Council minutes dated 6/20/19 indicated, Another difficulty with the new rails (bed rails) is that the call light and the bed raising buttons keep falling to the floor. Clips will be attached to these (the call lights) and clipped to the bed clothes to keep them within reach. There was no documentation of the facilities response to the concern regarding the bed raising buttons. During record review of the Resident Council minutes dated 7/18/19 indicated the clips for the bed controls were discussed. There was no documentation of the facilities response to the sliding bed raising button control bar concern. During record review of the Resident Council minutes dated 8/15/19 indicated no documentation for follow-up from the facility to residents regarding concerns about the sliding bed raising button control bars on beds. During an interview on 8/27/19 at 3:40 PM in hallway after the Resident Council meeting, the Director of Nursing (DON) stated they had not completed any work regarding the issue with the bed raising control bars sliding down and would put in a request order that day. During review of a Work Order 122847 dated 8/27/19 at 4:38 PM, indicated initiation of work to secure the remote control holders to the assist bars for all rooms. During record review on 8/30/19 at 10:51 AM, the Administrator provided a copy of a maintenance log titled, Completed Work Order 121227 for HC [Health Center] quarterly beds inspection dated 8/2/19 indicating, Ensure all the BC beds are safe and working in good conditions, report all the issues to supervisor. Preventative maintenance is a schedule of planned maintenance actions including equipment inspection, lubrication, calibration, etc. aimed at the prevention of breakdowns and failures before they occur. Ensure the thickness is at (left blank). Ensure no cracks, holes, slits, openings, stains etc. - need to replace mattress. The administrator also provided a copy of section 8 of the bed rails Transfer Assist User Manual, undated, which indicated a Mechanical Inspection and Maintenance Checklist that should include: Inspect rail latches; Ensure that all rails engage and lock as specified; Lubricate rail pivot points and all mechanical hinge points, bushings, and surface contact points as needed with white lithium grease; Inspect bed, rails, assist rails, or assist bars for the presence of tubing end caps and replace as required; Inspect all bed components (i.e. rails, clevis pins, hitch pins, etc .) for damage or excessive wear and replaced as necessary; Visually examine all welds for cracks; Inspect the head and foot sections for bending, warping or damage; Inspect all bolts and rivets to ensure that they are securely tightened and functioning properly. Check sleep surfaces to ensure all slats are intact; Check casters to ensure they lock if applicable and roll properly. In a concurrent interview, after reviewing the work order and user manual checklist, the Administrator stated, I do not have anything to support specific notes for routine maintenance of the assist bars. This work order does not specify the checklist was completed and should be more detailed. 2) During a tour of the facility on 8/26/19 at 10:47 AM, the beds in rooms 215, 219 and 221 were observed to have bed rails in an up locked position regardless of whether or not a resident was in the bed. During a concurrent interview, Registered Nurse (RN) 2 stated, It is our normal practice to have bedrails up at all times and to have an assessment and consent on file. During an interview on 8/26/19 at 11:10 AM, the Director of Nursing (DON) stated, We got rid of all bed rails and switched to transfer assist bars due to changes in the regulation so we wouldn't have to do assessments and consents. During an interview on 8/26/19 at 3:40 PM, the DON stated, Grab bars are an opt out system. They are placed on almost all beds except one or two that said they didn't want them. During an interview on 8/27/19 at 12:14 PM, Resident 3 stated, Side bars were put on bed a few months ago. I was told the government wanted them there. They never asked me if I wanted them. During an interview on 8/29/19 at 11 AM, Registered Nurse (RN) 1 stated, no, we didn't perform resident assessments on use of the bed transfer assist bars. They are not restraints. During review of the clinical records on 8/30/19, there was no documented evidence to support quarterly reassessment of bed rails for 15 of 35 residents (Residents 1, 2, 3, 4, 10,12, 13, 16, 18, 19, 21, 23, 24, 25 and 28). During an interview on 8/30/19 at 11:22 AM, the DON stated, The current assist bars were installed the end of June 2019. Quarterly care conferences are held to determine updated consent status. The DON further stated, There is a lapse of timely assist bar consent reassessments for Residents 5, 7 and 11. 3. During review of the clinical records on 8/30/19, there was no documented evidence to support implementation of bed rail care plans for 28 of 35 residents (Residents 1, 3, 4, 5, 6, 7, 8, 10, 11, 12, 20, 13, 14, 15, 16, 17, 18, 19, 21, 23, 24, 25, 27, 139, 138, 140, 141 and 142). During review of the facility's user manual for the Assist Bar, undated, it indicated under section 2 Safety, 2.1 General Guidelines .Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment .To avoid injury . always maintain and inspect equipment per the instructions in this manual. Under section 2.2 Intended use, it indicated, The purpose of the Assist Bar is to provide the resident a grab bar in which they can use to assist themselves from a sitting position to standing while exiting a long-term care bed. Clinical staff must decide whether a resident would benefit from the use of this aid. Under section 5 Usage, indicated, To avoid patient entrapment from use of assist bar .only use the assist (up) position while attending to the resident. Return the assist bar to the storage (down) position when unattended. Under section 7 Maintenance, it indicated, 7.1 Cleaning and Care .maintenance and cleaning procedures should be conducted initially, between users, on a regular schedule and as needed. During review of the Policy and Procedure titled, Side Rails/Assist Bars dated 06/19 indicated, Procedure .3. Nursing staff .shall assess the need for assist bar upon admission, quarterly and when indicated . An assessment form and informed consent will be completed by nursing staff. 4. Nursing staff shall document initial assessment in the medical record and develop a care plan