**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a care plan for one of three sampled residents (Resident 1) when, Resident 1 did not continue to walk in the corridor out of fear of falling and no care plan was developed to address Resident 1's fear of falling and refusal to walk. This failure placed Resident 1 at risk of not receiving the appropriate care and services to include interventions which could result in a physical decline.Findings: Review of Resident 1's Activities of Daily Living (ADL) care plan, initiated on 10/4/21 and last revised on 9/9/25, in the section Focus, indicated, .the resident has an ADL self-care performance deficit. In the section titled Goal, indicated, .Resident will remain current level of physical function through review date. Review of Resident 1's fall risk care plan, initiated on 10/4/21 and revised last on 9/9/25, in the section titled Focus, indicated, .The resident is at risk for falls.6/23/25: Resident had unwitnessed fall in bathroom [ROOM NUMBER]/28/25 - Resident had unwitnessed fall in the bathroom [ROOM NUMBER]/5/25 - Resident had an unwitnessed fall in room next to her bed. In the section titled Interventions, indicated, .7/5/2025-PT [physical therapy] consult ordered 6/30/2025, performed on 7/5/2025. Per PT, resident unsafe with independent ambulation with FWW [front wheeled walker] and wheelchair. Needs staff assist at all times. During a review of Resident 1's Activities of Daily Living (ADL) Documentation Flow Sheets, dated July, August, and September of 2025, the ADL documentation for WALK IN CORRIDOR: SELF-PERFORMACE - How resident walks in corridor or unit and documented every shift (AM, PM, and Night Shift) was reviewed. Resident 1's record showed that in July of 2025, staff marked that Resident 1 had walked 10 times that month and was provided with staff assistance via supervision to limited assistance three times total. Resident 1's record showed that in August of 2025, staff marked that Resident 1 had walked 7 times that month and was provided with staff assistance via supervision two times total. Resident 1's record showed that from 9/1/25 through the AM shift on the 18th of the month, staff marked that Resident 1 had walked 7 times during that time frame and was provided with staff assistance via supervision to limited assistance three times total. During a review of Resident 1's Physical Therapy's (PT) Progress Notes, dated 7/4/25, the progress notes indicated that Resident 1 could not safely walk alone with an assistive device (refers to any item, such as a cane, wheelchair, or walker, used to help a resident move safely and function better) unless a staff member was supervising. During an interview on 9/19/25 at 2:47 PM, Certified Nurse Assistant (CNA 1) stated that Resident 1 stopped walking because Resident 1 had a fear of falling after having a fall on 7/5/25 which resulted in an injury. CNA 1 explained that she provided encouragement and assurance to Resident 1 to walk, however it has not been effective because Resident 1 continued to refuse to walk. CNA 1 stated that Resident 1's mobility had the potential to decline. During a concurrent interview and record review on 9/19/25 at 2:15 PM, Resident 1's Nurse's Notes, dated 7/9/25, and care plans were reviewed with the Director of Nursing (DON). Resident 1's nurses note indicated that when the physical therapist tried to get Resident 1 to walk, Resident 1 was too scared and would not cooperate. The DON confirmed that Resident 1 had a fear of falling and refusal to walk. The DON confirmed that there was no care plan to help Resident 1 who was afraid of falling and refused to walk with assistance. During an interview on 9/22/25 at 12:06 PM, the Director of Staff Development (DSD) stated that CNAs should inform the nurses if a resident refused help with an ADL care and if Resident 1 showed fear of falling when walking. The DSD further explained that the nurse needs to create a care plan, so the staff know how to properly take care of the residents. The DSD stated that a care plan was important because it informed the staff what to do to help the residents. The DSD stated, if staff did not assist a resident with exercise or walking when needed, it could lead to a loss of mobility. Review of facility's policy and procedure (P&P) titled, Care Planning, dated 10/28/17 indicated, Policy: A person-centered care plan to meet the individual needs of residents/clients is prepared by an Interdisciplinary Team. 9. Care planning shall include measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs.10. Develop care plans to be consistent with the resident rights, including review of clinical issues,.coordination of care,.to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 11. Include resident refusals of treatment, the right to refuse treatment, alternate treatments attempted, resident education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided services to maintain the ability to carry out an activity of daily living (ADL's), specifically mobility (walking) when, staff did not consistently document an attempt to walk Resident 1 or a refusal, staff did not always walk with Resident 1 with supervision as recommended according to the documentation, and a care plan with interventions (actions nursing staff and others take to help a resident reach their health goals and improve outcomes) was not created regarding Resident 1's fear of falling. This failure had the potential to result in the decline in Resident 1's ability to ambulate, from Resident 1 being able to ambulate independently for 10 to 50 feet on 6/11/25 according to Resident 1's quarterly MDS (Minimum Data Set, an assessment tool), to the activity of ambulation not occurring on Resident 1's next quarterly MDS, dated [DATE]. Findings:Review of Resident 1's fall risk care plan, initiated on 10/4/21 and revised last on 9/9/25, in the section titled Focus, indicated, .The resident is at risk for falls.6/23/25: Resident had unwitnessed fall in bathroom [ROOM NUMBER]/28/25 - Resident had unwitnessed fall in the bathroom [ROOM NUMBER]/5/25 - Resident had an unwitnessed fall in room next to her bed. In the section titled Interventions, indicated, .7/5/2025-PT [physical therapy] consult ordered 6/30/2025, performed on 7/5/2025. Per PT, resident unsafe with independent ambulation with FWW [front wheeled walker] and wheelchair. Needs staff assist at all times.During a review of Resident 1's Nurses Note, dated 7/4/25, the record indicated, .Resident was seen by.PT [physical therapist] today for a PT Evaluation. Per [name of PT], resident is not safe for independent transfers or walking with an assistive device unless supervision is present with staff. Review of Resident 1's Physical Therapy Initial Evaluation., dated 7/4/25, the record indicated, .Findings.[Resident 1] was hesitant with the evaluation process but was cooperative.Walking attempts were not done as the patient was too fearful and became uncooperative. There is no need for the rehab aide to attempts [sic] working with this patient at this time because of her behavior and fear of falling.During an interview on 9/22/25, at 1:20 PM, with the Physical Therapist (PT), the PT stated, before he could start a rehabilitation program (designed to meet the needs of the individual, such as assistance with activities of daily living), the facility needed to address Resident 1's behavior because it was not safe for Resident 1 to walk, and it was risky for the Rehab Aide to work with Resident 1. The PT stated that Resident 1's behavior needed to be evaluated by the Psychiatrist to control the behaviors before he could start a rehabilitation program for Resident 1. The PT stated that he informed the staff about his evaluation and concerns but could not recall who specifically as the consultation for Resident 1 happened a few months ago, nor did he document this communication with staff. The PT stated that the facility has had other residents whose behaviors were assessed by a psychiatrist before beginning a rehabilitation program. During an interview on 9/18/25, at 2:10 PM, Resident 1 stated she did not remember the fall incident in July of this year (2025) but mentioned that she had experienced multiple falls in the past. Resident 1 stated she remembered falling many times but was unsure why. Resident 1 explained that she believed she was falling because she was not watching where she was going. Resident 1 stated that she could still walk using a walker but primarily used the wheelchair.During an interview on 9/18/25 at 1:50 PM, Licensed Nurse (LN) 1 stated that Resident 1 used to walk with a walker but now uses a wheelchair.During an interview on 9/19/25 at 2:47 PM, Certified Nurse Assistant (CNA) 1 stated that Resident 1 did not have a walker in the room. CNA 1 further stated that Resident 1 stopped walking because Resident 1 was scared of falling. During a concurrent interview and record review on 9/19/25 at 3:10 PM, with the Director of Nursing (DON), Resident 1's Activities of Daily Living (ADL) Documentation Flow Sheets, dated July, August, and September of 2025, the ADL documentation for WALK IN CORRIDOR: SELF-PERFORMACE - How resident walks in corridor or unit and documented every shift (AM, PM, and Night Shift) was reviewed. Resident 1's record showed that in July of 2025, staff marked that Resident 1 had walked 10 times that month and was provided with staff assistance via supervision to limited assistance three of the ten times. Resident 1's record showed that in August of 2025, staff marked that Resident 1 had walked 7 times that month and was provided with staff assistance via supervision two of the seven times. Resident 1's record showed that from 9/1/25 through the AM shift on the 18th of the month, staff marked that Resident 1 had walked 7 times during that time frame and was provided with staff assistance via supervision to limited assistance three of seven times. The DON confirmed the above documentation and stated that the CNAs might have charted the information incorrectly.During a concurrent interview and record review on 9/19/25 at 3:10 PM, with the DON, Resident 1's Minimum Data Set Assessment (MDS: an assessment tool) Section GG - Functional Abilities, dated 6/11/25 and 9/3/25, were reviewed. The DON confirmed Resident 1's MDS assessment documentation showed that Resident 1 had walked independently for 10 to 50 feet on 6/11/25 and Resident 1's MDS assessment documentation on 9/3/25, indicated that Resident 1 did not walk at all. Resident 1's MDS, dated [DATE], indicated Resident 1 did not use a wheelchair, compared to Resident 1's most recent MDS, dated [DATE], which indicated that Resident 1 did use a wheelchair. The DON stated that if a resident who used to walk stopped walking and did not get help from the staff to keep walking, residents would decline. During an interview on 9/19/25, at 2:15 PM, the DON confirmed there was no care plan developed to address Resident 1's fear of falling.During an interview on 9/22/25, at 12:06 PM, the Director of Staff Development (DSD) stated if CNAs encounter challenges in providing ADLs, such as refusals, specifically in the case of Resident 1, who exhibits behaviors like fear of falling while walking, the staff were expected to notify the Licensed Nurses. The DSD explained that the LNs could assist and collaborate to determine the most effective approach for the residents. The DSD stated the LNs were expected to create a care plan to guide the staff in caring for residents. The DSD stated that the purpose of the care plan is to determine how care will be provided for the residents. The DSD stated if a resident required assistance with exercise or walking and it is not provided, their muscles may deteriorate, potentially resulting in a loss of mobility.During an interview on 10/13/25, at 8:45 AM, the DON stated Resident 1 was last seen by the psychiatrist on 7/7/25 and Resident 1's medication was adjusted. The DON stated the nurses documented that the psychiatrist was informed by the nursing staff that Resident 1 had recent falls, but the nurses note did not indicate that the psychiatrist was informed of Resident 1's fear of falling. The DON confirmed Resident 1's fear of falling was first noted when Resident 1 worked with the PT on 7/4/25. The DON stated nursing staff should attempt to offer ambulation assistance at any given opportunity and provide such assistance if Resident 1 was able and wanted to. The DON stated that she did not see on the ADL task that CNAs had documented an attempt to walk Resident 1, nor the documentation of a refusal if they had attempted to walk Resident 1 and Resident 1 refused. The DON stated it would be important to note if Resident 1 refused cares so the facility could address why Resident 1 was refusing and to provide reassurance. The DON stated the CNAs would know how often to walk with a resident by the direction in the care plan, however, the DON confirmed that Resident 1's care plans did not contain this information. Review of Resident 1's PSYCHIATRIC PHYSICIAN'S PROGRESS NOTES, dated 7/7/25, the record indicated Resident 1 was seen for recent falls (x4) and Resident 1 complained of weakness. The record further indicated to decrease a dosage of medication and to monitor. There was no mention regarding Resident 1's fear of falling. Review of a facility policy and procedure (P&P) titled Ambulation, dated 9/1/13, the P&P indicated, .A resident/client ability to ambulate will not diminish unless the clinical condition demonstrates diminished ability is unavoidable.Document ambulation activity on the ADL record.Review of a facility P&P titled RESIDENT / CLIENT CARE, ROUTINE, dated 9/1/13, the P&P indicated, .Assist residents as needed with ambulation. Encourage residents to ambulate with the help of the nursing assistant and/or the restorative nursing assistant.

Based on interview and record review, the facility failed to ensure services provided met professional standards when facility did not provide drug information resources as reference for nursing staff. This failure could contribute to unsafe use of medication and nursing ability to provide quality care to the residents. Findings: During an interview and concurrent record review on 4/24/25, at 1:54 p.m., Licensed Nurse (LN) 2 stated they did not have drug information resources (a drug book or in computer) to look up how to administer Linzess medication (a prescription medication used to treat complicated constipation). LN 2 further stated she was not aware of manufacturer specification to give Linzess on empty stomach 30 minutes before meals. LN 2 stated she was not aware of a drug information book or online drug information via internet that was used in the facility. During an interview on 4/24/25, at 2:03 p.m., Licensed Psychiatric Technician (LPT) 1 stated it would have been nice if MAR (Medication Administration Record, a record that listed drugs to be administered) had information for Linzess to be taken on an empty stomach. LPT 1 further stated there was no drug information book for reference in the medication cart or medication room. During an interview on 4/24/25, at 2:12 p.m., Registered Nurse Supervisor (RN) 1 stated she could not locate a drug information book for nurses to use if needed. RN 1 further stated she was not aware of any online drug reference guide for the nurses. During an interview on 4/25/25, at 12:04 p.m., the Director of Nursing (DON) confirmed that the facility did not have printed and online drug resources for nursing staff and she was working on getting the resources for use by the staff. Review of the facility policy titled, 1.4 Medication Reference Sources and Texts, dated 10/31/16, indicated, .This Policy 1.4 sets forth procedures relating to medication reference sources and texts that should be maintained at Facility and accessible to staff .Facility should obtain medication reference sources for each nursing station .

Based on interview and record review, the facility failed to ensure one resident (Resident 39), in a sample of 39 residents, received accurate post fall and comprehensive fall assessments. This failure potentially resulted in Resident 39's subsequent fall 14 days later, negatively impacting Resident 39's health and well-being. Findings: A review of Resident 39's clinical record titled, admission RECORD, indicated Resident 39 was admitted to the facility with diagnoses which included convulsions (a sudden, involuntary contraction or series of contractions of the muscles, often involving shaking or jerking movements). During a concurrent interview and record review of Resident 39's clinical record, with Licensed Nurse (LN) 3, on 4/25/25, at 9:30 AM, LN 3 confirmed the following clinical documents were filled out incorrectly for Resident 39: Fall Risk Assessment, dated 11/8/24, indicted, in Section H, . PREDISPOSING FACTORS . Seizures . NONE PRESENT . contrary to Resident 39's admission RECORD, which indicated Resident 39 did have a history of seizures. Fall Risk Assessment, dated 11/22/24, indicated, in Section H, . PREDISPOSING FACTORS . Seizures . NONE PRESENT . Fall Risk Assessment, dated 12/30/24, indicated, in Section G, . MEDICATIONS . Antiseizure . Psychotropics (drugs that affect mental processes and behavior) . NONE of these medications were taken within the last 7 days, Section H, . PREDISPOSING FACTORS . Seizures . NONE PRESENT . A review of Resident 39's clinical document titled, Medication Administration Record, (MAR - contains physicians order with start dates and times of administration), dated 4/1/25 through 4/30/25, indicated Resident 39 was taking the following medications for the following diagnoses: Keppra (a seizure medication) to treat convulsions, with a start date of 8/15/16; Olanzapine (a medication used to treat metal health condition) for delusions (a disease characterized with a false belief or judgment about external reality), with a start date of 12/11/24. LN 3 confirmed the above Fall Risk Assessment, inaccuracies. LN 3 stated the importance of the above documents was to determine Resident 39's fall risk. LN 3 explained it was important for nursing to be able to review the fall assessments and know what medications the resident was taking that may contribute to their fall risk. LN 3 further explained the fall assessments contained relevant diagnoses which could contribute to residents fall risk. LN 3 stated if the fall risk assessments were not filled out accurately there was a risk the resident may fall and sustain an injury. During an interview with the Director of Nursing (DON), on 4/25/25, at 10:03 AM, the DON stated the importance of the fall assessment was to have an accurate picture of the resident's fall risk and interventions that were in place for the resident's plan of care. The DON explained it would affect the resident's safety if the fall risk assessment was not accurate and the facility would not be able to develop a personalized fall prevention plan for the resident. During a follow-up interview with the DON, on 4/25/25, at 12 PM, the DON explained the risk of having inaccurate post fall assessments, reflected in the Fall Assessment[s], dated 11/8/24, 11/22/24, and 12/30/24, would be subsequent falls for that resident. A review of the facility policy titled, FALL PREVENTION & MANAGEMENT, revised 4/3/20, indicated, . It is the goal of this facility to prevent or reduce the occurrence of falls and severity of fall-related injuries while improving the quality of life for our residents and clients . Upon admission, each resident is assessed using a Fall Risk Assessment tool to determine possible risk for sustaining a fall . Fall details, assessment findings, interventions, & notifications are to be documented in resident's clinical record & care plan updated accordingly .

Based on observation, interview, and record review, the facility failed to provide adequate pain management, and develop and implement a resident centered care plan (tool that outlines the plan of action that will be implemented during a resident's care) for 1 of 39 sampled residents (Resident 22) when: 1. The pain management services was not adequately provided to Resident 22; and, 2. The facility did not develop and implement a comprehensive person-centered care plan for pain for resident 22. These failures led to Resident 22 experiencing unnecessary pain that potentially affected his physical and psychosocial well-being. Findings: 1. A review of Resident 22's clinical record, admission RECORD, indicated Resident was admitted to the facility with diagnoses including, but not limited to, chronic embolism and thrombosis (long-standing blood clots in the deep veins of the legs, often causing leg pain and swelling) of unspecified deep veins of lower extremity, bilateral. During an interview in Resident 22's room, on 4/22/25 11:37 a.m., and again on 04/23/25 09:16 a.m., Resident 22 stated that had pain fluctuating from 5 to 8 out of 10 on pain scale (a common tool used to quantify the intensity of pain. It typically ranges from 0, no pain to 10, worst possible pain,) to the bilateral anterior thigh radiating to lower extremities. Resident 22 added, pain was ongoing and did not relieve with current pain medication which was acetaminophen. Resident 22 further stated that pain affected his routine activities, and he was unable to attend group activities and any social events 2 weeks ago due to pain. Resident 22 stated it was hard to wake up with pain every day. During an interview in the hallway near Resident 22's room on 4/24/25 at 10:15 a.m., Certified Nursing Assistant (CNA) 2 stated Resident 22 had pain on daily basis in the morning around breakfast time and requested pain medication. Review of Resident 22's clinical record, Order Summary Report indicated, . Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 4 hours PRN (as needed) for pain . Review of Resident 22's clinical record, MEDICATION ADMINISTRATION RECORD dated 2/1/2025-2/28/2025 in comparison to 4/1/2025-4/24/2025 were reviewed. Review of records indicated, the frequency of taking PRN acetaminophen for pain management had increased from 4 doses in the month of February to 28 doses in the month of April with the severity of pain fluctuating from 5 to 8 out of 10 on pain scale which for 11 days were administered in the mornings anytime between 5:31 a.m., to 8:10 a.m. Review of Resident 22's clinical record, Activity Participation Note dated 4/12/25 indicated, .resident said, hurting because of body pain. Resident didn't attend any group today. Resident didn't attend any special events this week . Review of Resident 22's clinical record, Interdisciplinary Team Progress Note dated 4/16/25 indicated, .Pain: The resident is at risk for pain r/t arthritis, osteopenia, and degenerative disease . During a concurrent interview and record review in the nurse station 1 on 4/24/25 at 10:27 a.m., with Licensed Nurse (LN) 8 Resident 22's clinical record, MEDICATION ADMINISTRATION RECORD dated 4/1/25-4/24/25 was reviewed. LN 8 confirmed that frequency of taking PRN (as need arises) pain medication, acetaminophen has been significantly increased. Further LN 8 confirmed that in February PRN pain medication was administered 4 doses, and from April 1, 25 to April 24,25 Resident 22 received 28 doses of PRN pain medication. LN 8 stated that review indicated, Resident 22's PRN pain medication was not effective. LN 8 added Resident 22 requested specific pain medication. However, LN 8 was not able to recall the name of the medication and the date that Resident 22 requested the medication. During a concurrent interview and record review in the Director of Nursing (DON) office on 4/24/25 at 11:57 a.m., Resident 22's clinical records, MEDICATION ADMINISTRATION RECORD dated 2/1/25-2/28/25 and 4/1/25-4/24/25, and Activity Participation Note dated 4/12/25 were reviewed with the DON. The DON confirmed that frequency of taking PRN pain medication, acetaminophen had been significantly increased from February to April 2025. The DON stated increase in frequency indicated, pain medication was not effective. The DON stated her expectation from licensed nurses was to notify the Medical Director (MD )1 about increased in frequency of PRN pain medication. Further the review of Activity Participation Note dated 4/12/25 indicated that .pain affected Resident 22's daily activity. The DON stated that Resident 22's pain affected his daily activities, and there was a risk for Resident 22's to be declined in physical and mental well-being. Review of facility policy and procedure (P&P), PAIN MANAGEMENT dated 9/1/13 with the DON indicated, .the policy of this facility to promote physical comfort and psychosocial well-being through the identification and treatment of pain, as expressed by cognitively intact, or cognitively impaired, residents. PROCEDURE .10 .when a resident's medication regimen is ineffective at alleviating pain, or if pain is frequently severe in nature, the physician is to be notified for orders. If pain is consistent and exhibits noticeable patterns, and only PRN medications are ordered, then routine pain management should be considered and pursued with the physician . The DON acknowledged that the facility P&P was not followed. During a phone interview with MD 1 on 4/24/25 at 12:48 p.m., MD 1 stated his expectation from licensed nurses was to notify him when Resident 22's pain management was not effective and affected his daily activities. MD 1 further stated licensed nurses did not follow his expectation. 2. During a concurrent interview and record review in nurse station 1 with Licensed Nurse (LN) 8 Resident 22's care plans were reviewed. LN 8 confirmed that Resident 22 did not have a care plan for pain. LN 8 stated the risk of not having a care plan for residents on a pain medication was missing the measures to manage the pain/discomfort. LN 8 further stated that Resident 22's needs to control pain/discomfort had not been met by the facility. During a concurrent interview and record review in the Director of Nursing (DON) office on 4/24/25 at 11:57 a.m., Resident 22's care plans were reviewed. The DON confirmed that Resident 22 did not have a care plan for pain medication. The DON stated that care plans and its related interventions were tools for nursing staff to implement to eliminate Resident 22's pain/discomfort. The DON stated that not having a care plan for residents receiving pain medications would lead to not identifying and addressing residents' concerns about pain/discomfort and would affect residents' activities of daily living. The DON stated her expectation was that Resident 22 who was prescribed pain medication had a care plan for pain. The DON stated there was a risk for Resident 22 to decline in physical and mental health and his needs not being met. The facility policy and procedure (P&P) titled, PAIN MANAGEMENT dated 9/1/13 was reviewed with the DON. The facility P&P for PAIN MANAGEMENT indicated, .POLICY .the policy of this facility to promote physical comfort and psychosocial well-being through the identification and treatment of pain, as expressed by cognitively intact, or cognitively impaired, residents .PROCEDURE .4. Each resident who has active pain symptoms or are high risk for experiencing pain (diagnosis related or situational), will have a plan of care encompassing the use of medication .Plans of care should be specific to the location and type of pain the resident experiences, clinical manifestation of non-verbal or cognitively impaired residents, and measurable objectives . The DON acknowledged that the facility P&P was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure safe medication use practices in three out of 39 sampled residents (Resident 134, Resident 19 and Resident 160) when: 1. Resident 134's long term use of a medication called Protonix (or pantoprazole, belongs to a class of drugs called Proton Pump Inhibitor [PPI], a type of medication that reduces the amount of acid stomach produces) was not re-assessed or evaluated for continued use based on standards of practice and Food and Drug Administration's (FDA, a federal agency responsible for protecting the public health by assuring the safety, efficacy, and security of drugs) risk warnings on long term use of PPI's. 2. Resident 19's and 160's diabetic (a disease of unregulated blood sugar) medication including insulin (medication given as injection under skin to control high blood sugar) use did not have safe monitoring parameters for blood sugar levels changes. These failed practices had potential to contribute to unsafe medication use and affect health and safety of the residents. Findings: 1. During a review of Resident 134's electronic medical record, tilted admission Record, dated 4/25/25, the record indicated Resident 134 was admitted into the facility on 9/30/21 with diagnosis including mental health issues, allergies, heartburn and GERD (stands for Gastro-Esophageal Reflux Disease, a condition where stomach acid frequently flows back up into the esophagus, the tube that carries food from your mouth to your stomach, and this backflow, called acid reflux, can irritate the lining of the esophagus and cause symptoms like heartburn) among others. The record did not indicate any history of recent or current intestinal (stomach) bleeding. During a review of Resident 134's electronic medical record, titled Medication Administration Record (or MAR, a record that listed doctor's order and medications nurses give on daily basis), dated 4/2025, the record indicated Resident 134 had been receiving Protonix on daily basis since 9/30/21 for GERD. During a review of Resident 134's electronic medical record, under nursing plan of care, dated 10/4/21, the care plan which was updated on 3/25/25, indicated Resident will be free from discomfort or complication related to alteration in gastrointestinal through review date . The resident should avoid overeating. Provide small frequent meals rather than 3 large ones. Encourage the resident to take time eating and to alternate food with sips of fluids. Date Initiated: 10/04/2021 Review of Resident 134's medical record, titled Physician Progress Notes, for year 2025, the record written by Medical Doctor 1 (MD 1), did not address continued need for use of Protonix or any issues related to resident's GERD diagnosis. In a concurrent telephone interview with facility's Consultant Pharmacist (CP) and the record review of Resident 134's medication list, on 4/24/25, at 11:49 AM, the CP's monthly Drug Regimen Review (DRR, it's the monthly review of drugs resident was taking and assess for risks and appropriateness by a pharmacist) was reviewed, and the CP confirmed no recommendation provided to the facility or the medical doctor to re-assess the use of long term Protonix. The CP stated she was aware of the FDA warnings regarding long term use of Protonix and other PPI. In a phone interview with MD 1, on 4/25/25, at 10:53 AM, MD 1 stated he did not recall getting any recommendation to address the long-term use of Protonix. MD 1 stated he heard about long term risks. MD 1 stated he did not see any active issues regarding resident's GERD or heartburn. MD 1 stated there were alternative and safer medication available if needed to treat the resident. MD 1 stated he was planning to reduce the dose and eventually discontinue if indicated. In an interview with the Director of Nursing (DON), in her office, on 4/25/25, at 12:22 PM, the DON stated the long-term use of Protonix should have been re-assessed since there was no compliant of stomach issues and she relied on the pharmacy and doctors to address it. Review of drug alert warning by FDA on long term use of Proton Pump Inhibitors (PPIs, i.e. Protonix), with date range of 5/25/2010, 2/8/2012, and 8/4/2017, the FDA had issued warnings about the potential risks associated with long-term use of PPI, including increased risk of fractures, hypomagnesemia (low magnesium level; Magnesium, a vital mineral that plays a crucial role in various bodily functions, including nerve and muscle function, bone health, and maintaining a steady heartbeat), and certain infections like Clostridium difficile (or C. Diff, a stomach infection that can lead to severe diarrhea). The FDA links were accessed on 4/29/25 via 1. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fda-drug-safety-communication-possible-increased-risk-fractures-hip-wrist-and-spine-use-proton-pump , 2. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-clostridium-difficile-associated-diarrhea-can-be-associated-stomach#:~:text=pump%20inhibitors%20(PPIs)-,FDA%20Drug%20Safety%20Communication:%20Clostridium%20difficile%20associated%20diarrhea%20can%20be,as%20proton%20pump%20inhibitors%20(PPIs)&text=%5B02%2D08%2D2012%5D,diarrhea%20that%20does%20not%20improve.&text=Marketed%20under%20various%20brand%20and,used%20to%20treat%20frequent%20heartburn , and 3. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-low-magnesium-levels-can-be-associated-long-term-use-proton-pump#:~:text=Data%20Summary-,Safety%20Announcement,PPI%20had%20to%20be%20discontinued. 2A. Review of Resident 19's electronic medical record, titled admission Records, dated 4/25/25, indicated Resident 19 was admitted on [DATE] to the facility with diagnosis of mental health issues, diabetes and obesity among others. Review of Resident 19's electronic MAR, dated 4/2025, indicated resident 19 was on three different medications to treat the diabetes, an order to check blood sugar four times a day, and order for a reversal agent called Glucagon (a drug that reverse very low blood sugar) as follow: a. Basaglar . (Insulin Glargine, a long-acting insulin); Inject 14 unit (a measure of the dosage) subcutaneously (shot under the skin) one time a day; For FBS (Fingerstick Blood Sugar) Reduce further by 2 units for each occurrence if AM FBS (morning blood sugar) is <70 mg/dl and stay at the lower dose thereafter; Active since 3/2/25 b. Insulin Lispro . (Insulin Lispro, is a short acting with quick onset insulin) Inject 4 unit subcutaneously three times a day for DM2 (Diabetes disease); Active since 6/14/24 c. Glucophage Tablet (or metformin, pill form of a drug to treat diabetes): Give 1000 mg (mg is milligram; a unit of measure) by mouth two times a day .; Active since:12/21/21 d. FBS (Fingerstick Blood Sugar) QID or four times per day for FBS monitoring; Order date: 5/30/22 e. Glucagon Inject 0.2 ml (ml is milliliter a measure of volume) subcutaneously as needed for S/S (Sign and Symptoms) Hypoglycemia (low blood sugar) for a blood glucose value less than 50, when the individual is unresponsive or unable to take an oral glucose replacement .; Order Date 9/29/22 The orders did not give guideline or parameters to the nursing staff what to do if blood sugar was very high and what was considered high or low before residents becoming unresponsive. In a telephone interview with the Consultant Pharmacist (CP), on 4/24/25, at 11:37 AM, the CP stated she did not notice Resident 19's insulin and blood sugar measurement orders not having parameters. The CP stated she did not ask the nursing or the doctor to provide parameters for use of insulin and four times a day blood sugar measurement. The CP stated having a reversal agent order and Residents 19's good blood sugar results were an indication that parameters were not needed. In a concurrent interview and record review of the Resident 19, with the Director of Nursing (DON), in her office, on 4/25/25, at 12:22 PM, the DON stated the short acting insulin and blood sugar measurement orders did not have parameters to address variation and extremes in blood sugar number. The DON agreed it was a safe thing to have parameters. The DON acknowledged hyperglycemia (high blood sugar) was as important as hypoglycemia (low blood sugar) in the setting of many mental health drugs used in the facility that could result in higher blood sugar level. 2B. Review of Resident 160's electronic medical record, titled admission Records, dated 4/25/25, indicated Resident 160 was admitted on [DATE] to the facility with diagnosis of mental health issues, diabetes and blood pressure among others. Review of Resident 160's electronic MAR, dated 4/2025, indicated resident 160 was on four different medications to treat the diabetes, an order to check blood sugar three times a day, and an order for a reversal agent called Glucagon (a drug that reversed a very low blood sugar) as follow: a. Insulin Degludec (or Tresiba, a long-acting insulin) 22 units subcutaneously one time a day for DM2; Increase by 2 units every week, if Average FBS (in the previous 6 days) is over 110 (the 110 number is blood sugar level), May go up to 30 units; Start date 3/3/25 b. Novolin R . Insulin Regular (human) [ a short acting insulin with quick onset]; Inject 3 unit subcutaneously three times a day for DM2 (Diabetes disease) After meals; Active since 3/4/24 c. Glucophage Tablet (or metformin, pill form of a drug to treat diabetes): Give 1000 mg (mg is milligram; a unit of measure) by mouth two times a day .; Active since:5/24 d. Ozempic (drug used to treat blood sugar) 1 mg Subcutaneous . once a week on Tuesday's for DM2 (Diabetes); Start Date: 11/2025 e. FBS (Fingerstick Blood Sugar) TID AC (same as Three Times per day before meals); Order date: 12/24 f. Glucagon Inject 0.2 ml subcutaneously as needed for S/S (Sign and Symptoms) Hypoglycemia (low blood sugar) for a blood glucose value less than 50, when the individual is unresponsive or unable to take an oral glucose replacement .; Order Date 6/24. The orders did not give guideline to the nursing staff what to do if blood sugar was very high and what blood sugar number was considered high or low before residents becoming unresponsive. The order for dose adjustment of insulin degludec (or Tresiba) based on 6 days average of blood sugar was not documented in the MAR. During a medication administration observations, with Licensed Nurse 6 (LN 6), at station 2 hallway, on 4/22/25, at 8:57 AM, LN 6 administered two insulins to Resident 160. LN 6 administered 3 units of insulin Novolin (a short acting with fast onset insulin) into the left side of abdominal area and injected 22 units of Insulin Degludec (or Tresiba, a long-acting insulin) into the right side of the abdominal area. The two orders did not have any parameters for nursing staff and the blood sugar number was documented as 81 (Normal blood sugar in adults 70 to 100 mg/dL or milligram per deciliter, a measure of sugar in blood). In an interview with Licensed Nurse 6 (LN 6) , at the nursing station 2, on 4/24/25, at 10:55 AM, LN 6 stated the parameters for hold to call MD or making interventions most of the times were included in the MAR. LN 6 stated the parameters were a safety alert to go beyond her nursing instincts and it would give directive from the doctor on what to do to prevent an event before actually happening. In a telephone interview with MD 1, on 4/25/25, at 10:53 AM, MD 1 stated he asked the facility to remind him of weekly blood sugar numbers. The MD 1 stated sometimes the facility continued the same orders from previous admission or hospital. MD 1 stated in the future we could write orders for nursing to review insulin orders. MD 1 stated moving forward he would make sure the safety parameters would be part of the order and implemented. In a concurrent interview and record review of the Resident 160's MAR, with Director of Nursing (DON), in her office, on 4/25/25, at 12:22 PM, the DON stated the short acting insulin and blood sugar measurement orders did not have parameters to address variation and extremes in blood sugar number. The DON agreed it was a safe thing to have parameters on when to call the doctor. The DON acknowledged hyperglycemia (high blood sugar) was as important as hypoglycemia (low blood sugar) in the setting of many mental health drugs used in the facility that could result in higher blood sugar level. Review of the facility's policy, titled Blood Glucose Testing, dated 9/1/13, the policy on section 7 indicated If the blood sugar result is abnormal or beyond the established ranges ordered by the physician: a. Notify the physician for further orders . Notify the physician and initiate treatment symptomatic of hypoglycemia or blood glucose value less than 60 mg/dL or as ordered by the physician .

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 176. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 32 opportunities which resulted in a facility wide medication error rate of 9.37% in 3 out of 13 residents (Resident 111, Resident 21 and Resident 163) observed for medication administration as follow: 1. Resident 111's eye drop administration did not follow standards of practice on ophthalmic (eye) drug medication administration. 2. Resident 21's Linzess (a medication used to treat bowl motility and promotion of bowel movement) was given after morning breakfast against manufacturer specification to be given before meal and on an empty stomach. 3. Resident 163's Blood Pressure (BP, the force of blood pushing against the walls of arteries as heart pumps blood throughout your body) medication called Metoprolol (lower the blood pressure and heart rate) was documented in the Medication Administration Record (MAR, a legal document that listed doctor's orders and nursing administration of drugs) as given when it was held due to low BP. These failures may result in unsafe medications use affecting residents' health and well-being. Findings: 1. During a medication administration observation, on 4/22/25, at 1:14 p.m., Licensed Psychiatric Technician (LPT) 2 administered eye drop to Resident 111's right and left eye. LPT 2 handed Resident 111 a piece of tissue paper which Resident 111 used to squeeze the eyeball and wiped the eye drops from both her eyes immediately after eye drop was administered. During an interview with LPT 2 outside Resident 111's Room, on 4/22/25 at 1:20 p.m., LPT 2 stated that she also noticed Resident 111 wiped her eye drops from her eyes while squeezing her eyeballs with the tissue. LPT 2 further stated that Resident 111 should not have wiped eye drops from her eyes using the piece of tissue paper. Review of Nursing Journal-2025, last accessed on 4/30/25 via https://journals.lww.com/nursing/citation/2007/05000/administering_eyedrops.14.aspx, the article titled Administering Eyedrops: Clinical Do's and Don'ts, indicated using proper technique helps ensure that the patient benefits from his medication. The document further indicated . Ask the patient to tilt his head slightly back and to look toward the ceiling . Instill the prescribed number of drops into the center of the conjunctiva sac . Ask him to gently close his eyes and move them while closed to help distribute the solution. Tell him not to rub his eyes or squeeze them shut . Use a tissue to remove excess medication that has escaped from the conjunctiva sac . on to the cheeks. 2. During a medication administration observation, on 4/23/25, at 8:50 a.m., Licensed Nurse (LN) 2 administered one capsule of Linzess mixed with apple sauce by mouth to Resident 21. During a concurrent interview with LN 2, and record review, on 4/24/25, at 1:54 p.m., LN 2 stated Linzess was ordered to be given at 8:00 a.m. and she administered it within the timeframe prescribed around 8:50 AM. LN 2 further stated breakfast was served to Residents 21 between 7:30 a.m. to 8.00 a.m. LN 2 stated there was no drug information resource available to look up Linzess and how it should have been administered. During an interview on 4/24/25, at 2:03 p.m., with Licensed Psychiatric Technician (LPT) 1, LPT 1 stated it would have been nice if instruction for Linzess to be administered on an empty stomach was entered on the MAR. During a concurrent interview with LN 2, on 4/24/25, at 1:54 p.m., and record review of resident 21's MAR, dated 4/2025, the MAR indicated the order for Linzess as follow: .Give 1 capsule by mouth one time a day for constipation . LN 2 confirmed the MAR order did not specify to be taken on empty stomach or before meal. Review of the DailyMed, a drug information database (a comprehensive, searchable online database providing access to drug labeling information submitted to the Food and Drug Administration (FDA) by pharmaceutical companies) on Linzess (or generic name of linaclotide), updated on 6/12/23, was last accessed on 4/30/25, via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=09beda19-56d6-4a56-afdc-9a77b70b2ef3, the drug information under Preparation and Administration Instruction indicated Take LINZESS on an empty stomach, at least 30 minutes prior to a meal, at approximately the same time each day. 3. During a medication administration observation, on 4/23/25, at 9:04 a.m., LN 2 measured Resident 163's blood pressure (the force of blood pushing against the walls of the arteries as it circulates throughout the body) and entered in the medical record. LN 2 stated the blood pressure medication called metoprolol needed to be held due to low blood pressure. LN 2 did not administer the metoprolol to Resident 163. During a review of Resident 163's electronic MAR, on 4/23/25, at 2:15 p.m., the MAR indicated the order for metoprolol as follow: .Give 50mg (a unit of measurement used to express the weight) .Hold if . SBP < 110 (systolic blood pressure less than 110) . The MAR further indicated the dose held on 4/23/25 at 9 a.m. was marked as given. During a concurrent interview with LN 2, and Resident 163's MAR review, on 4/24/25, at 2:06 p.m., LN 2 stated metoprolol was held because Resident 163's systolic blood pressure was low and was below the parameters ordered by the doctor. LN 2 further stated there was no documentation indicating metoprolol was held on 4/23/25 at 9 a.m. During an interview on 4/24/25, at 12:04 p.m., with the Director of Nursing (DON), the DON stated the licensed nurse should have prompted the resident not to squeeze out the eye drop with tissue. The DON further agreed that facility should have followed manufacturer's specification and asked for guidance from pharmacy on how to administer Linzess medication. The DON stated the nurse should have accurately documented in the electronic medical record when a medication was being held. Review of the facility's policy, titled General Dose Preparation and Medication Administration, dated 1/1/22, the policy on section 5 indicated During medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: . Position the resident properly if necessary . Administer medication within time frame specified by facility policy or manufacturer's information . Provide residents with any instructions. Review of the facility's policy, titled Med Pass, Medication Administration Essentials, dated 12/28/18, the policy on section B indicated Whenever a medication is held for any reason, it must be indicated on the Electronic Medication Administration Record (EMAR) by the licensed nurse. The licensed nurse shall document on the Electronic Medication Administration Record (EMAR), noting the time and reason for medication was held.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure safe medication storage and labeling practices in three out of three medication rooms and one out of 4 medication carts when: 1. Unlabeled and discontinued medications were stored in active storage areas in the medication rooms at Station 2 and Station 3. 2. Hazardous (drugs known to pose a health risk to healthcare workers due to their toxic properties upon skin contact) liquid medication with spills on the outer body of the medication bottle was stored in medication cart A at Station 3. 3. The pre-pour medication bins were observed to have sticky looking brownish spills in the top drawer of medication cart B at Station 1. 4. Supplies and discontinued medications were stored under the sink in medication rooms at station 1 and Station 2. 5. The refrigerator temperature upon inspection was above the temperature range listed on the temperature log for Station 2. These failed practices could contribute to unsafe medication use, medication error and risk of contaminated or spoiled product or supplies. Findings: 1. During a concurrent interview and inspection of facility's medication room at Station 2, on [DATE], at 9:40 AM, accompanied by Licensed Nurse 4 (LN 4), the bucket holding supplies of Linzess (a prescription medication used to treat and prevent chronic constipation and required to be kept in original manufacturer container) contained two bottles of medications with no pharmacy label with only a small label on the bottle cap. LN 4 was not sure why the unopened bottles did not have provider pharmacy label like other bottles in the same bucket. During a concurrent interview and inspection of facility's medication room at Station 2, on [DATE], at 9:40 AM, accompanied by LN 4, the cabinets stored bottles of a medication called Gavilyte-G (or GoLYTELY, a laxative powder containing medicine to help clean the gut prior to a surgery or procedure), dated [DATE] was stored in the active storage areas. LN 4 stated these were for one time use and should have been discarded. During a concurrent interview and inspection of facility's medication room at Station 3, on [DATE], at 10:11 AM, accompanied by LN 5 and LN 6, the Linzess prescription container did not have pharmacy label with full dispensing information as required for a prescription medication. LN 5 stated the bottles had not been opened and it was sent to the facility with a small label on the cap of the container. During a concurrent interview and inspection of facility's medication room at Station 3, on [DATE], at 10:15 AM, accompanied by LN 5 and LN 6, the cabinets stored bottles of a medication called Gavilyte-G, dated [DATE] and [DATE] was stored in the active storage areas. LN 5 stated these unused discontinued medications should have been discarded. In an interview with the Director of Nursing (DON), in her office, on [DATE], at 3:26 PM, the DON stated she expected the pharmacy to provide full label upon dispensing with information on use and handling of drugs such as Linzess. The DON stated the discontinued or one time use medications, such as Golytely, should have been removed from active spaces even though they were not used unless there was an active order for them. 2. During a concurrent interview and inspection of facility's medication cart A at Station 3, on [DATE] at 10:42 AM, accompanied by Licensed Psychiatric Technician 2 (LPT 2), the liquid form of a hazardous medication called Valproic Acid (drug in liquid form used to treat mood and help in controlling seizure [unusual brain activity]) had reddish color spills on the outer surface of the opened bottle inside the bottom drawer of the medication cart. LPT 2 stated they used glove to administer the medication but touching the bottle without gloves could have happened inadvertently when tying to find other liquid medications. In an interview with the DON, in her office, on [DATE], at 3:26 PM, the DON stated she expected nursing staff to use glove when handling the hazardous medication and any spill or contamination could have been contained if it was stored inside a Ziplock bag to prevent inadvertent skin contact. 3. During a concurrent interview and inspection of facility's medication cart B at Station 1, on [DATE] at 1:52 PM, accompanied by LN 7, the top drawer had pre-pour medication bins with traces of residues, sticky looking brownish spills and broken sections. LN 7 stated she was not sure what was the brownish sticky spills and residues and needed to be replaced or cleaned. In an interview with Director of Nursing (DON), in her office, on [DATE], at 3:26 PM, the DON stated she was not aware of the condition of the pre-pour container in the medication cart and the nursing staff should have cleaned any spills or contamination in the medication workspaces. 4. During a concurrent interview and inspection of facility's medication room at Station 2, on [DATE], at 9:40 AM, accompanied by LN 4, the cabinet underneath the sink stored multiple items including discontinued medication. LN 4 stated she was not sure why they were stored there. During a concurrent interview and inspection of facility's medication room at Station 1, on [DATE], at 1:49 PM, accompanied by LN 7, the cabinet underneath the sink stored multiple items including discontinued medication and cleaning supplies. LN 7 stated they have used the space for a while for storage. In an interview with the DON, in her office, on [DATE], at 3:26 PM, the DON stated the stored items placed under the sink could get soiled or contaminated for handling and use. 5. During a concurrent interview and inspection of facility's medication room at Station 2, on [DATE], at 9:40 AM, accompanied by LN 4, the digital thermometer inside the medication refrigerator was located on top of the narcotic box and the temperature was recorded as 43-degree Fahrenheit (a temperature scale). LN 4 stated the temperature were recorded twice daily by nursing staff. The review of the temperature log sheet located on the refrigerator door, dated [DATE], the record indicated the temperature range for the morning and afternoon temperatures were between 36-to-41-degree Fahrenheit. During a concurrent interview and inspection of the facility's medication room at Station 3, on [DATE], at 11:20 AM, accompanied by LN 5 and LPT 4, the digital thermometer inside the medication refrigerator had a reading of 33.3 Fahrenheit. LN 5 and LPT 4 both confirmed that the temperature of the medication refrigerator was below the accepted range of 36-to-41-degree F. LPT 4 stated that bottles of eye drops, insulin (A hormone in the body that controls the amount of sugar in the blood by moving it into the cells, where it can be used by the body for energy) pens, bottles of Risperidone (A drug used to treat certain mental disorders), and vials of Ativan (a calming effect on the brain and nerves, which helps to reduce anxiety symptoms and treat seizures) were located inside the refrigerator. LPT 4 further stated that the efficacy of medications inside the refrigerator could be affected and that the medicines could freeze if the temperature continued to be below the accepted range. During an interview on [DATE] at 10:10 AM with the Director of Staff Development (DSD), the DSD stated that medicines that needed to be refrigerated should be between the 36-to-41-degree F range. The DSD also stated that medications would not be as effective if stored at incorrect temperatures. The DSD further stated that medications would not have the intended effect that they should. During an interview on [DATE] at 2:40 PM, the DON stated she wanted medications that were refrigerated to be in the proper temperature range. The DON also stated that medications could be diminished or not work as effectively if they were not in the proper temperature range. Review of the facility's policy titled, Storage and Expiration Dating of Medications ., last revised on [DATE], indicated Facility should ensure that medications and biologicals are stored at their appropriate temperature according to the United Stated Pharmacopeia guidelines for temperature ranges . Refrigeration: 36-to-46-degree Fahrenheit Review of the facility's policy titled, Storage and Expiration Dating of Medications ., last revised on [DATE], the policy on section 15-18 indicated The facility should ensure that medication and biological for expired or discharged or hospitalized residents are stored separately, away from use, until destroy or return to provider. Facility should destroy or return all discontinued, outdated, expired or deteriorated medication or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law . Facility personnel should inspect nursing station storage area for proper storage compliance on a regularly scheduled basis. Facility should request that pharmacy perform routine nursing unit inspection for each nursing station in the in the facility to assist Facility in complying with its obligation pursuant to applicable law relating to the proper storage, labeling, security and accountability of medications and biologicals. Review of the facility's policy titled, NIOSH (National Institute for Occupational Safety and Health, a federal agency within the Centers for Disease Control and Prevention (CDC) that focuses on occupational safety and health research) Hazardous Drugs/Chemicals and Safety Data Sheets ., last revised on [DATE], the policy on section 7 indicated Any equipment in the preparation of NIOSH hazardous drugs should be cleaned after each use with disposable wipes containing hypochlorite[same as bleach] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 4 of 39 sampled residents (Resident 119, Resident 19, Resident 106 and Resident 80) had their rights related to treatment choices known and protected when: 1. Resident 119's signed Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) documentation was not found in the chart; 2. Resident 19 wanted to formulate an Advance Directive and no follow-up documentation was found in the chart; 3. Resident 106's chart did not contain documentation regarding Advance Directive discussion; and 4. Resident 80's code status (a medical directive that specifies what actions medical professionals should take in the event of a life-threatening emergency) was not found in both the electronic health record (EHR) and physical chart. These failures had the potential to result in not determining and/or honoring the residents' wishes related to the provision of medical treatment and health care services when the residents were unable to make decisions for themselves, and had the potential for Resident 80's wishes regarding emergency treatment would not be followed. Findings: 1. A review of Resident 119's medical record titled, admission RECORD, indicated Resident 119 was admitted to the facility in 2023. A review of Resident 119's EHR progress notes by Social Services, dated [DATE], indicated .Initial Social Service Note: .Resident sign advanced directives . and another note dated [DATE], indicated .Resident did not sign advanced directives at this time stating she was in pain and had difficulty at the time of interview . A review of Resident 119's physical chart at the Station 2 nurses station on [DATE], at 9:38 a.m., no copy of Advance Directive acknowledgement or forms were found in the chart. During a concurrent interview and record review on [DATE], at 10:16 a.m., with the Social Services (SS), the SS stated that the Advance Directive paperwork should be located in Resident 119's physical chart. The SS reviewed both Resident 119's physical chart and EHR at the Station 2 nurses station and stated he found documentation on Resident 119's EHR, per the admission initial SS notes on [DATE], Resident 119 was given copies of resident's rights and resident signed advance directives. During an interview on [DATE], at 11:43 a.m., with Resident 119, Resident 119 stated that she does not really remember about having an Advance Directive because all her items were in her old home in probate. Resident 119 further stated she thinks she does not have an Advance Directive but was not sure at this time and might change her mind. During a concurrent interview and record review on [DATE], at 8:47 a.m, the SS stated that the process of obtaining the Advance Directive was during the admission timeframe when the SS would interview the resident usually the same day of admission or the day after. The SS stated that the initial SS assessment packet included a form which had information regarding the Advance Directive where it asked if resident had an Advance Directive or whether they would like to formulate one. The SS further stated that if the resident wanted to formulate an Advance Directive, the SS would notify the conservator to start the process. The SS stated that Resident 119 was previously at Station 3 during the initial admission and then had surgery at the hospital and when she returned to the facility, she was then transferred to Station 2. The SS stated that the note from [DATE] was made during the time of Resident 119's initial admission from Station 3, so the physical records from Resident 119's old chart from Station 3 would not be in the chart at Station 2 anymore. The SS stated that whenever a resident got transferred to another station, the resident's chart got closed out and then placed in storage. During an interview on [DATE] at 9:07 a.m., the Unit Clerk (UC) stated that she could not find the copy of Resident 119's Advance Directive documentation in the facility's storage area for old charts. The UC verified that the Advance Directive documentation should be in Resident 119's chart. The UC stated that it was important to have the forms to acknowledge whether the Advance Directive was done and if the resident wanted to formulate one. During a concurrent interview and record review on [DATE], at 11:46 a.m., with the Director of Nursing (DON), the DON reviewed Resident 119's SS note dated [DATE] and stated it was her expectation for the Advance Directive documentation to be in Resident 119's chart. The DON stated that the facility's process during admission of a resident includes SS checking in with the resident about Advance Directive. The DON further stated that it was also her expectation for the SS to note the discussion with residents or conservators in the EHR about Advance Directives. The DON stated that it was important to have the Advance Directive copy in the chart to respect Resident 119's wants and needs, and if something happened to make sure that the facility would respect his wishes. 2. A review of Resident 19's medical record titled, admission RECORD, indicated Resident 19 was admitted to the facility in 2015. A review of Resident 19's EHR SS notes dated [DATE], indicated .Initial Social Service Note: .Resident signed advanced directives and checked yes that he would like to formulate one. Called conservator and left her a vm [voicemail] informing her that resident would like to formulate an advanced directive . A review of Resident 19's physical chart at Station 2 nurses station on [DATE], at 9:34 a.m., Resident 19's Advance Directive acknowledgement paperwork was not found in the physical chart. During an interview on [DATE], at 11:49, with Resident 19, Resident 19 stated he was interested in formulating an Advance Directive. Resident 19 stated he did not recall if the Advance Directive was offered at this facility. During an interview on [DATE], at 8:58 a.m., with the SS, the SS stated he reviewed Resident 19's physical chart and verified no notes or documentation back in 2015 regarding any follow-up about the Advance Directive were found. The SS verified that he did not find a copy or acknowledgement form in Resident 19's physical chart at Station 2. The SS stated he would check the facility's storage for overflow chart records to verify. The SS verified that a follow-up should have been done since Resident 19 specified that he wanted to formulate an Advance Directive. The SS further stated that it was important to keep the Advance Directive documentation in Resident 19's chart to ensure it was available and accessible. During an interview on [DATE], at 10:32 a.m., with the Director of Medical Records (DMR), the DMR stated that Resident 19's physical chart was sent to storage because he had been at this facility for a long time. The DMR verified that the Advance Directive documentation should be in the Resident 19's chart. During a concurrent interview and record review on [DATE], at 11:46 a.m., with the DON, the DON verified the SS note dated [DATE], during Resident 19's admission that Resident 19 wanted to formulate an Advance Directive. The DON stated it was her expectation for the SS to have documented and followed up regarding Resident 19's Advance Directive in both the EHR and physical chart. The DON further stated the importance of having the Advance Directive or offering the option of the Advance Directive was to respect Resident 19's wants and needs, and if something happens to ensure that the facility respects Resident 19's wishes. 3. A review of Resident 106's medical record titled, admission RECORD, indicated Resident 106 was admitted to the facility in late 2021. A review of Resident 106's physical chart at Station 2 nurses station on [DATE], at 9:17 a.m., indicated Resident 106's POLST form dated [DATE] section D for no Advance Directive box was marked. During a concurrent interview and record review on [DATE], at 9:23 a.m., with the UC, the UC checked Resident 106's physical chart and verified there was no Advance Directive documentation found in the chart. During an interview on [DATE], at 11:03 a.m., with the SS, the SS stated on [DATE] Resident 106 refused the initial SS assessment during the admission timeframe. The SS stated that Resident 106 kept saying I don't know during that time of the assessment. The SS verified that there was no documentation of Advance Directive follow-up found and stated that the documentation should have been done. The SS verified that Resident 106 did not have an Advance Directive acknowledgement form found in the chart. A review of Resident 106's social services notes, dated [DATE], indicated .Resident was oriented to situation, place and new room. Resident was very anxious and agreed to have formal Initial Social Services Assessment at another time .Social Services assessment and Primary Assessment will be done when resident is less anxious . During an interview on [DATE], at 11:46 a.m., with the DON, the DON stated that the SS would check in with the resident about Advance Directive during the admission process. The DON stated that it was her expectation to have the Advance Directive documentation and follow-up in both Resident 106's EHR and physical chart. The DON further stated that it was important to offer the option of formulating an Advance Directive to respect Resident 106's wants and needs, and to respect their wishes if something happened. A review of the facility document, titled, .ADVANCE DIRECTIVES, . dated [DATE], indicated .POLICY .The facility respects each resident/client right to participate in his/her life sustaining treatment decisions .PROCEDURE .2. When admitted , the resident/client is asked if he or she has executed an Advance Directive. If the answer is yes, a copy of the Advance Directive is obtained and placed in the clinical record .3. Residents who are competent and who have not previously executed an Advance Directive are asked if they would like one prepared .4. Social Services may provide information on preparing Advance Directive and contact the local Ombudsman for assistance. Social Services may also ensure a copy of any existing directive is obtained for the clinical record . 4. A review of Resident 80's medical record titled, admission RECORD, indicated Resident 80 was admitted to the facility in late 2015. A review of Resident 80's EHR on [DATE], at 12:32 p.m., indicated Resident 80 did not have a copy of the Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) form or a physician's order for the code status on the order list. A review of Resident 80's physical chart at Station 2 nurses station on [DATE], at 9:47 a.m., Resident 80's face sheet was found without a code status listed. During a concurrent interview and record review on [DATE], at 9:54 a.m., with Licensed Nurse (LN) 9, LN 9 reviewed Resident 80's EHR and verified there was no code status listed upon pulling up Resident 80's chart. LN 9 stated that the EHR normally had the code status listed and verified Resident 80's code status was missing in the EHR. LN 9 checked Resident 80's physical chart and verified that Resident 80's face sheet did not have the code status listed. LN 9 stated that if she could not find the code status on EHR, she would then check the resident's physical chart to verify the resident's code status. LN 9 stated that it was important to have the code status both in Resident 80's EHR and physical chart to respect his wishes and to know what the code status would be. During a concurrent interview and record review on [DATE], at 10:02 a.m., with Quality Control Manager (QCM) 1, QCM 1 stated to confirm a resident's code status the nurse needed to check the resident's EHR or the resident's physical chart for the POLST form which would indicate the resident's code status. QCM 1 verified that there was no code status order found in Resident 80's EHR list of orders. QCM 1 verified both Resident 80's physical chart and EHR did not have the code status listed. QCM 1 further stated that another way to determine the code status was by looking at the resident's physical chart label on the spine of the binder, if the label was white then the resident would be considered full code (healthcare professionals will do everything possible to keep a patient alive if their heart stops or they stop breathing) and a red label would be considered DNR (Do Not Resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR] if breathing stops or the heart stops beating). QCM 1 verified Resident 80's physical chart had a white label and would be considered full code. QCM 1 stated it was admissions who was responsible to have ensured the code status was entered in Resident 80's chart. QCM 1 stated that it was important to have the code status in both Resident 80's physical chart and EHR to respect his wishes whether he wanted CPR or not. During an interview on [DATE], at 2:26 p.m., with QCM 2, QCM 2 stated that each nurses station would have a designated QCM who did the admissions. QCM 2 stated during the admissions process, the code status had to be entered and the EHR system would automatically add the code status as an order on the resident's order list. QCM 2 stated if a resident's EHR and physical chart did not have the code status listed, another way to check would be to check the resident's physical chart's spine label color and to check the POLST form if available. QCM 2 stated if the resident's physical chart label was white, it meant the resident's code status would be full code and red label would be for DNR status. QCM 2 stated the code status would also be reviewed and brought up during the quarterly IDT (a group of healthcare professionals with different areas of expertise [like nurses, therapists, and social workers] working together to create a personalized care plan for each resident) meetings. QCM 2 further stated that the nursing staff could also verify the code status with the resident or their conservator. QCM 2 stated it was important to be able to find Resident 80's code status in an event of an emergency to be able to administer the appropriate medical intervention and to respect his wishes. During an interview on [DATE], at 12:31 p.m., with the RP, the RP verified Resident 80's code status was full code and there had been no changes to his code status. The RP further stated there were no discussions or concerns about changing the code status for Resident 80 with the facility. During an interview on [DATE], at 11:46 a.m., with the DON, the DON stated it was her expectation for Resident 80's code status to have been in both Resident 80's EHR and physical chart. The DON stated that the staff should verify a resident's code status by asking the resident directly or by confirming with the resident's conservator and once determined, the staff should notify the MD to obtain the order to be added to the resident's chart. The DON stated the nurse doing the admission process would be responsible in ensuring the resident's code status to have been entered in the chart for new admissions. The DON stated it was important to have the code status available in case of an emergency for the staff to have known whether to provide or not to provide care if Resident 80 was unresponsive and to respect his wishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 126's clinical document titled, admission RECORD, indicated Resident 126 was admitted to the facility with diagnoses which included diabetes (problems with blood sugar control). During an observation, on 4/22/25, between 12:10 PM and 12:20 PM, in the hallway, between the Station 1 dining room and the Station 1 Television/Activities (TV/Act) room, Resident 126 was observed stating she did not want to enter the TV/Act room with that (expletive) person. Staff members were observed trying to calm Resident 126. Staff were observed rolling Resident 126, in her wheelchair (w/c), into the TV/Act room. Resident 126 was observed yelling at staff, repeatedly, to get her out of the TV/Act room. Resident 126, at 12:20 PM, to be seated away from the table, Resident 126's lunch tray was placed on the table, and she was rolled up to the table to eat. Resident 126 was then observed to be yelling and tapping her plastic fork on her tray, and then Resident 126 purposefully spilled all the items on her lunch tray onto the table, spilling liquid all on the table where other residents were eating. During an interview with Resident 126, in Resident 126's room, on 4/22/25, at 1:24 PM, Resident 126 stated she was tired of being in the facility. Resident 126 explained they do not feed her, and she needed to eat. During an interview with licensed nurse (LN) 1, on 4/22/25, at 1:30 PM, LN 1 stated Resident 126 threw her plate during lunch and asked to go back to her room. LN 1 explained when a resident refuses to eat lunch staff were supposed to check on Resident 126 every 15 minutes, three times to see if she wanted a tray. During an interview with certified nursing assistant (CNA) 1, on 4/22/25, at 1:33 PM (I), CNA 1 stated Resident 126 returned to her room around 12:30 PM. CNA 1 explained she asked Resident 1 at 12:45 PM if she wanted a lunch tray and Resident 126 declined. CNA 1 further explained she did not ask Resident 126 again if she wanted a lunch tray and she should have. During an interview with the Director of Nursing (DON), on 4/24/25, at 3:16 PM, the DON stated Resident 126 should have been offered a replacement lunch meal directly following the initial incident. The DON explained when Resident 126 returned to her room a replacement meal should have been offered at least twice and it was not. A review of the facility policy titled, NUTRITION & MEALS, ASSISTING THE RESIDENT / CLIENT, effective 9/1/13, indicated, .It is the policy of this facility to assist resident with meal intake according to individual needs in a safe and dignified manner . Ensure residents dine in designated preferred locations . Offer meal replacement and/or substitution as appropriate if the resident refuses an item, or consumes 75% or less . Based on observation, interview, and record review, the facility failed to maintain a healthy nutrition status for two residents (Resident 140 and Resident 126) when: 1. Resident 140's weight was not maintained when an 8 pound (#)/5.8% weight loss occurred in one month; and, 2. Resident 126 was not offered a replacement lunch meal in a timely manner. These failures had the potential for leading to malnutrition, nutrient deficiencies, loss of muscle mass and independence, and increased susceptibility to illness for Resident 140, and had the potential for Resident 126 to experience food insecurity, negatively affecting Resident 126's health and well-being. Findings: 1. During an observation of the lunch meal service on 4/23/25 at 12:17 p.m. with the Dietary Supervisor (DS), Resident 140's meal tray was noted to contain both a shake and an oral supplemental drink, in addition to puréed food. The DS stated resident 140 had a history of poor intake and meal refusals with the nursing staff reporting that the resident had been pocketing food and spitting it out. When asked about a speech therapy evaluation, the DS stated the facility did not have a therapy department. Food pocketing is the accumulation of food between the cheeks and gums during chewing or swallowing. It's often associated with dysphagia (difficulty swallowing). Causes include weakened muscles, inability to feel what is going on inside of the mouth, or medical conditions such as a stroke or tumor. A speech therapist can evaluate swallowing function and recommend strategies for improving swallowing. Review of Resident 140's medical record on 4/24/25 at 10:47 am, showed that resident 140's diagnosis included hypothyroidism (low activity of the thyroid gland leading to metabolic changes), anxiety, depression, pain, and pneumonia (as of 4/9/25). Review of weights for Resident 140 indicated the following: 4/19/25=129# (pounds, a unit a measure), 3/15/25=137. This is a loss of 8# or 5.8% of body weight over a month, is considered severe weight loss by the Centers for Medicare/Medicaid. Review of Resident 140's orders included shakes (started on 4/7/25), oral supplemental drink (started on 4/14/25), an appetite stimulant (started on 4/7/25), and a pureed diet (smooth, blended, easy to swallow foods similar to baby food was started 4/22/25). Review of Registered Dietitian (RD) consult note for weight loss from 4/8/25 indicated that significant weight loss had occurred related to an issue with swallowing. Recommendations included an appetite stimulant and the addition of supplemental nutrition drinks. Review of nursing note from 4/12/25 indicated the resident was watched during mealtime and had pocketing of food with poor intake. Resident was offered alternatives but refused and spat out food. Review of nursing note on 4/13/25 indicated that meal refusals continued. Review of nursing note from 4/21/25 indicated that a trial of mac and cheese was offered. Resident did not eat, only drank fluids. Continued pocketing food. Resident does not want pureed foods. Interdisciplinary Team meeting notes from 4/22/25 regarding nutrition changes indicated that a pureed diet was ordered as of 4/22/25. Resident had been pocketing food and not eating. Interventions included ice cream, supplemental nutrition drinks, and an appetite stimulant. Observation of lunch intake on 4/24/25 at 12:32 p.m., showed Resident 140 had left her lunch tray on the dining table. Pureed foods had not been eaten. Supplemental drink had been opened with 1/3 of container (approximately 2 1/3 ounces) left, no other liquids had been drunk. The intake of the supplemental drink provided approximately 145 calories and 6 grams of protein for the 2/3rds consumed. Review of the facility provided Nutrition at a Glance ([NAME] Corporate Dietitians, 2025) indicated that the lunch provided on 4/24/25 would provide 1,015 calories and 36 grams of protein. During a telephone interview with the Registered Dietitian (RD) on 4/24/25 at 2:31 p.m., the RD confirmed that no referral had been made to a speech therapist but could occur if the physician were to order a speech therapy consult. Review of Registered Dietitian (RD) Job Description (Dietary Directions, Inc./Nutrition Therapy Essentials, Inc. Food Service Policy & Procedures Manual 2018) indicated the RD 1. Evaluates the nutrition needs of residents/patients and documents in the nutritional record. 2. Interprets, evaluates and utilizes current research relating to nutritional care. Review of Policy & Procedure titled Nutrition Care-Significant Weight Changes (Dietary Directions, Inc./Nutrition Therapy Essentials, Inc. Food Service Policy & Procedures Manual 2018) indicated Residents/patients experiencing significant weight changes will be identified and assessed in a timely manner in order to minimize further unplanned significant weight changes by identifying the underlying causes and contributing factors, and intervening as appropriate to resolve the problem .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a vegetarian (a person who does not eat meat, and sometimes other animal products) menu for the four residents for which a vegetarian diet had been ordered (Residents 30, 99, 129, and 165). This failure had the potential for leading to weight loss and nutrient deficiencies for those residents avoiding animal products. Findings: During an interview with the Dietary Assistant Supervisor (DAS) on 4/22/25 at 8:24 a.m., in the kitchen, facility offered diets were discussed. The DAS stated that the facility did not offer a vegetarian menu, and that they would serve fruit and cottage cheese to those avoiding animal products. During a concurrent observation and interview in the kitchen during the lunch preparation on 4/23/25 at 10:18 a.m., [NAME] 1 stated that residents on a vegetarian diet would get the Manicotti that day since the main entrée was without meat, but fruit and cottage cheese would be provided for other meals when meat was on the menu. Review of Week 5 Menu indicated 16 out of 21 meals contained meat products. During an observation of the lunch meal plating on 4/23/25 at 12:03, the Dietary Supervisor (DS) stated they do not have a vegetarian menu, as many residents claim to be vegetarian but will eat the regular entree. Review of lunch tickets indicated that the facility had four residents on the vegetarian diet, Residents 30, 99, 129, and 165. Review of medical chart for Resident 30 indicated an order for a vegetarian diet since admission earlier in the month. Review of medical chart for Resident 99 indicated vegetarian diet orders had been in effect since September of 2014. Review of medical chart for Resident 129 indicated a preference for vegetarian meals as of 10/1/24. Review of medical chart for Resident 165 indicated a vegetarian diet was ordered as of 5/26/24. During an observation of lunch on 4/24/25 at 12:18 p.m., Resident 99 received pureed peas, mashed potatoes, a pureed roll, and a serving of pureed cookie for lunch. No source of protein was on the meal tray. During an observation of lunch on 4/24/25 at 12:41 p.m., Resident 165 was noted to have received a fruit and cottage cheese plate with 2 packages of crackers and cookie bar. During an interview on 4/24/25 at 12:56 p.m., Certified Nursing Assistant (CNA) 1 (who had worked at the facility for 8 years) stated those on vegetarian diets received fruit and cottage instead of the main entrée. During an observation on 4/24/25 at 1:14 p.m., Resident 30 received a fruit and cottage plate with 2 packages of crackers, and a cookie bar. During an observation on 4/24/25 at 1:25 p.m., Resident 129 received meatloaf, mashed potatoes, peas, a roll and a cookie bar. Review of the facility provided Nutrition at a Glance ([NAME] Corporate Dietitians, 2025) indicated that the lunch provided on 4/24/25 would provide 1,015 calories and 36 grams of protein. Nutrition analysis of a fruit and cottage cheese plate (containing 1 cup of mixed fruit, 6 ounces of 4% fat cottage cheese, and 4 crackers) would provide approximately 280 calories and 9 grams of protein. This is 28% of the calories, and 25% of the protein provided by the regular meal. During a telephone interview with the Registered Dietitian (RD) on 4/24/25 at 2:31 p.m., the RD concurred that the fruit and cottage cheese plate with crackers would not provide the same nutrition as the regular diet. The RD further stated that the menu company the facility used had a vegetarian option but was unsure as to why it was not being used. Review of the RD Job Duties provided by the facility (Dietary Directions, Inc./Nutrition Therapy Essentials, Inc. Food Service Policy & Procedures Manual 2018) indicated that the RD, .1. Evaluates the nutrition needs of residents/patients and documents in the nutritional record .2. Interprets, evaluates and utilizes current research relating to nutritional care .3. Coordinates, implements, and evaluates the facility menus for nutritional adequacy .6. Evaluates and monitors the food service department to assure that the department is providing adequate, acceptable quality food . Review of the facility provided Dietary Manual section on Vegetarian Preferences ([NAME] Corporate Dietitians, revised 2/19) indicated, .The request for a vegetarian preference may come from a resident wishing to avoid foods that come from animals.Vegetarian meal plans can be well balance and meet the DRI's (Dietary Reference Intakes, a set of reference values for nutrient intake used to assess healthy diets) but may pose a challenge in providing all essential nutrients without the use of additional supplementation. Meeting adequate protein and calories for individuals on vegetarian preferences is essential. Include a wide variety of nutrient dense and fortified foods . Review of Senate [NAME] 1138 was signed into California law by Governor [NAME] in September 2018. It requires, .prisons, hospitals, nursing homes, and other state-operated facilities to offer plant-based meals . The law defines plant-based meals as entire meals that contain no animal products or byproducts, including meat, poultry, fish, dairy, or eggs.

2. During a medication pass observation, in the facility's Station 2 hallway, on 4/22/25, at 9:55AM, Licensed Nurse (LN) 4 took, along with insulin (drug in injection or shot form used to treat blood sugar disease) medications, a black plastic bucket containing supplies, into Resident 160's room to administer two insulin products. LN 4 placed the bucket at the bedside table and used the alcohol wipes to clean the injection sites for insulin administration. The black bucket stored supply of additional insulin needles, alcohol wipes and supplies to poke the finger. LN 4 returned the black bucket back to the bottom drawer of the medication cart without any cleaning or sanitizing. In an interview with LN 6, at facility's station 2 station, on 4/24/25, at 10:55 AM, LN 6 stated the facility trained them to use the bucket into the room when measuring blood sugar or giving insulin to have all supplies needed. LN 6 stated by taking the whole supply bucket into the room, there would be chances of contamination that could spread the germs. In an interview with the Director of Nursing (DON), in her office, on 4/23/25, at 3:26 PM, the DON stated the facility created the buckets with supplies for insulin and blood sugar measurement for nurses to take into the room so to reduce the number of times the nurse had to go in and out of the room to get supplies. The DON stated the practice could cause contamination of the supplies shared with other residents. Review of the facility's policy, titled Blood Glucose Testing, dated 9/1/13, the policy indicated Blood glucose (sugar) finger sticks will be done in a safe and comfortable manner within the standards of infection control, nursing practice and manufacturer's guidelines, . 3. During a concurrent interview and inspection of facility's medication cart B at Station 1, on 4/22/25 at 1:52 PM, accompanied by Licensed Nurse 7 (LN 7), the top drawer had pre-pour medication bins with traces of dark residue, sticky looking brownish spills and broken sections. LN 7 stated she was not sure what was the brownish sticky spills and residues and needed to be replaced or cleaned. In an interview with the DON, in her office, on 4/23/25, at 3:26 PM, the DON stated she was not aware of the condition of the pre-pour container in the medication cart and the nursing staff should have cleaned any spills or contamination in the medication workspaces. 4. During a concurrent interview and inspection of facility's medication cart B at Station 1, on 4/22/25 at 1:52 PM, accompanied by Licensed Nurse 7 (LN 7), the pill cutter (a device used to split pills in half) stored in the top drawer of medication cart had white powder like residue inside. LN 7 acknowledged and stated it should have been cleaned after use. In an interview with the DON, in her office, on 4/23/25, at 3:26 PM, the DON stated the pill cutter should be cleaned after each use to reduce risk of cross contamination. The DON stated the pharmacy provider should send medications in a size or dose that reduces nursing to cut pills. Review of the facility's policy, titled General Dose Preparation and Medication Administration, dated 1/1/22, the policy indicated Prior to preparing or administering medication, authorize and competent facility staff should follow facilities infection control policy . Dose Preparation: Facility should take all measures required by facility policy and applicable law, . Based on observation, interview, and record review, the facility failed to ensure proper and safe infection prevention practices were implemented and followed for a resident census of 176 when: 1. There was no separation between clean area and dirty area in three of three utility rooms observed. 2. A bucket stocked with clean supplies, used for insulin (a drug used to treat blood sugar disease) administration and blood sugar measurement, were taken inside residents' room without consideration for risk of contamination. 3. Drug administration platform inside the medicine cart was not cleaned with brownish residues. 4. The pill cutter stored in medication cart had white powder-like residue inside the lid. 5. Kitchen swamp cooler vent covers had peeling paint with dust and debris above food preparation areas. These failures had the potential to place the residents at risk for developing an infection and the potential to result in transmission of infection in the facility. Findings: 1a. During a concurrent observation and interview on 4/23/25, at 4:13 p.m. with the Infection Preventionist (IP) and the Interim Infection Preventionist (IIP) in the utility room at Station 2, the utility room was noted to have a hopper (a flushing-rim sink used for disposal of blood or body fluids which is not the same as a hand-washing sink). In the utility room were also a stack of clean gloves mounted on the wall, a clean paper towel dispenser, and two bottles of eye wash mounted on the wall next to the hopper. There were other clean supplies in the utility room with the hopper such as staffs' N95 masks (respiratory protective device designed to filter out at least 95% of airborne particulate matter), blood pressure apparatus, wound care supplies, and residents' supplies in the cabinets next to the hopper. There was no clear delineation between the hopper and the clean supplies. The IP confirmed the hopper was being used and clean items should not be next to the hopper. 1b. During a concurrent observation and interview on 4/23/25, at 4:23 p.m. with the IP and IIP in the utility room at Station 3, a hopper was noted. Above the hopper was a box of clean gloves and to the side of the hopper was a clean paper towel dispenser and an eyewash kit both mounted on the wall next to each other. There were other clean supplies kept in this utility room such as a blood pressure apparatus, staffs' personal N95 masks, laptop computers, and weighing scale. The IP confirmed the hopper was being used. 1c. During a concurrent observation and interview on 4/23/25, at 4:27 p.m. with the IP and IIP in the utility room at Station 1, a hopper was noted. And next to the hopper was a weighing scale. There were other clean supplies noted such as personal items for oral care and personal trays for the residents. The IP confirmed the hopper was being used at times. The IP stated the hopper and clean supplies in close proximity had the potential for possible contamination of the clean supplies and the contaminated supplies could had been used for residents' care, and there could be risk of spreading germs causing illnesses. A review of the facility's document titled, INFECTION CONTROL PROGRAM, dated 10/1/92, indicated, .The facility will establish and maintain an infection control Program designed to provide a safe, sanitary, and comfortable environment for residents and staff and to help prevent the development of transmission of disease and infection . 5. During an observation on 4/23/25 at 9:52 a.m., in the kitchen, there were three drop-down vent units on the ceiling in the kitchen. Each square unit had visible rusted areas, plus flaking, peeling, and/or missing paint on all four sides. The three vents were in a straight line and directly above the cooking and food preparation areas. During a concurrent observation and interview on 4/25/25 at 8:20 a.m., in the kitchen, the Plant Maintenance Supervisor (PMS) stated the three vents on the ceiling were for the facility swamp cooler and the vent covers on each unit were taken down monthly to be cleaned, and it was documented on a log. The PMS confirmed the presence of rusted areas, and/or flaking, peeling, or missing paint on all four sides of each vent. The PMS stated it was the responsibility of the kitchen staff to notify maintenance when problems were noticed, and the maintenance department would then scrub and paint them [the vents]. The PMS further stated, the risk was that the metal particles could fall on the food and once in the food, could harm residents, make them sick, or they could get stuck in the resident's throat. During an interview on 4/25/25 at 8:55 a.m., the Dietary Supervisor (DS) stated the rusted, flaking, peeling, and/or missing paint on the ceiling vents did not meet expectations and needed to be cleaned better, as it could lead to food borne illness. A review of The US Food and Drug Administration (FDA-a federal agency responsible for protecting public health by ensuring the safety and security of food, drugs, and other products) 2022 Food Code (US FDA 2022 Food Code), version 1/18/23, indicated, .Section 6-501 Premises, Structures, Attachments, and Fixtures .605.11 Repairing .PHYSICAL FACILITIES shall be maintained in good repair .Cleaning, Frequency and Restrictions .PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean .Cleaning Ventilation Systems .Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials .

Based on observation, interview, and record review the facility failed to ensure foods were stored, prepared, and served in accordance with professional standards for food service for 176 residents who ate facility prepared meals when: 1. Red onions were found to have mold (a type of fungus that grows in moist environments); and 2. Food products lacked an open date, complete labeling, and/or expiration dates on labels; and 3. Walk-in freezer found with ice buildup; and 4. Washed items were stacked and stored wet; and 5. Fixed can opener had visible food particles and metal worn off the cutting tip, had worn/missing metal on the base, and metal shavings were located on ledge behind the cutting tip; and 6. Coffee cups and pitchers found to be discolored and/or deglazed (no longer having a finished surface), and cutting boards found with deep gouges on both sides; and 7. Fruit and vegetable preparation sink and ice machine lacked an air gap (backflow prevention system that prevents contaminated water from re-entering the sink or ice machine). These failures had the potential to put residents at risk for foodborne illnesses (an illness resulting from eating contaminated food or beverages). Findings: 1. During a concurrent observation and interview during the initial kitchen tour, on 4/22/25, at 8:24 a.m., with the Dietary Assistant Supervisor (DAS), in the walk-in refrigerator, a box of red onions was found to have mold on one onion and another onion that was cracked, bruised, and discolored. The DAS confirmed the observation and stated it was not acceptable to have molded food in a container with non-molded food which would cause them to go bad faster. A review of The US Food and Drug Administration (FDA-a federal agency responsible for protecting public health by ensuring the safety and security of food, drugs, and other products) 2022 Food Code (US FDA 2022 Food Code), version 1/18/23, indicated, .Section 3-302.15 .Washing Fruits and Vegetables .Pathogenic microorganisms [organisms, like bacteria, viruses, and fungi, that can cause disease or illness], such as Salmonella ssp. [a group of bacteria that can cause diarrhea illness] .and chemicals such as pesticides [substances used to control or kill unwanted organisms], may be present on the exterior surfaces of raw fruits and vegetables .Infiltration [to enter or become established gradually] of microorganisms can occur through stem scars, cracks, cuts or bruises in certain fruits and vegetables .Once internalized, bacterial pathogens cannot be removed . 2. During a concurrent observation and interview during the initial kitchen tour, on 4/22/25, between 8:37 a.m. and 8:44 a.m., in the walk-in refrigerator, with the DAS, green onions were in a bag with no expiration date (ED). The DAS confirmed the observation and stated sometimes the staff forgets to write an ED on packages of food the facility had received. During a concurrent observation and interview during the initial kitchen tour, on 4/22/25 at 9:13 a.m., with the DAS, there was a plastic storage container in the kitchen refrigerator with a red lid that contained an undated bag of whipping cream. The sticker on the red lid was dated 4/20 and did not include the year. Additionally, several items in the kitchen did not include a complete open date (OD) and/or were not labeled correctly as follows: a. A tray of milk in cups with lids contained a label with Date poured 4/22, and did not include the year; b. An open carton of Potato Pearls without an OD; c. Food rack containing loaves of bread dated pulled out 4/18 and Exp [expired] 4/25 and did not include the year; d. Opened box of corn starch was not sealed and was without an OD; e. Opened container of ground cloves was without an OD; f. Opened box of baking soda was not sealed and was without an OD; g. Container of Greek yogurt with an OD 4/22 and ED 4/25 and did not include the year; h. Box of powdered sugar was opened, not sealed and undated; and i. Round container of baking powder with a plastic lid had an unreadable OD on the lid. The DAS confirmed the above observations and stated the potential problem of not writing an OD or the date on food items with the month/day/year would be that staff would not know when to throw the item out, when the item expired, and/or when the item needed to be discarded. During a telephone interview on 4/24/25 at 3:31 p.m. with the Registered Dietician (RD), the RD stated, her expectation was that items must have an OD and use by date, and the required elements of dated food included month/day/year. During an interview on 4/25/25 at 8:55 a.m., with the Dietary Supervisor (DS), the DS stated staff should use correct expiration dates including the year, as expired items can lead to foodborne illness. During a review of the facility's policy and procedure (P&P) titled, FOOD RECEIVING AND STORAGE OF COLD FOODS, dated 2018, the P&P indicated, .All perishable [food likely to go bad quickly] food items .will be stored properly .will have an open date and use-by-date . A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .Section 3-501.17 (A) (B) (C) (D) .required food labeling and dating .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day . 3. During a concurrent observation and interview on 4/22/25 at 8:50 a.m., with the DAS during the initial kitchen tour, in the walk-in freezer, there was ice buildup on the ceiling, as well as covering ¾ of the right side of the door (approximately ½-¾ inches thick), the entire top of the freezer door, the top 6 inches of the left side of the door, and plugging the vent on the door. The walk-in freezer door would not shut or latch completely due to ice buildup. The DAS acknowledged the above observation and stated he would report the issue to maintenance. During an interview on 4/25/25 at 8:20 a.m., the PMS confirmed ice buildup was on and around the door of the walk-in freezer, and the door did not latch securely. The PMS stated the problem was the hinges on the door needed to be replaced which resulted in the door not latching. The PMS further stated when the door is unable to close, freezer temperatures would not be maintained, ice would continue to build up around the door, and the food would not freeze properly. A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .Section 3-302.11 .Packaged and Unpackaged Food - Protection Separation, Packaging, and Segregation .The freezer equipment should be designed and maintained to keep foods in the frozen state .4-501.11 Good Repair and Proper Adjustment .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed . 4. During an observation on 4/22/25 at 9:40 a.m., in the kitchen, [NAME] 2 was working on the clean side of the dishwashing area. [NAME] 2 stacked trays before they were dry (wet stacked-the act of stacking or putting away kitchen items without allowing them to air dry completely), placed wet bowls and coffee cups on wet trays without a drying mat (a mesh mat that permits air to flow under dishes allowing them to dry completely), and placed a plate with a brown substance (possibly food residue) in the stack of clean plates. During an interview on 04/25/25 at 12:22 p.m., the DS confirmed the above observations and stated plates should be clean when stacked, and clean bowls and coffee cups should be allowed to air dry before stacking or being placed on trays with a drying mat. The DS stated the problem with placing a dirty plate with clean plates and when wet stacking clean bowls and coffee mugs could be bacteria growth causing illness to residents. During a telephone interview on 12/23/25 at 2:31 p.m., the RD stated, kitchen items should not be put away when still wet and should be left on a rack to air dry. The RD stated, the problem would be water collected in/on dishes could cause odors and bacterial growth and could make residents sick. A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .Section 4-901.11 .Equipment and Utensils, Air-Drying Required . Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow . 5. During an observation on 4/22/25 at 9:50 a.m., in the kitchen, the metal cutting tip on the fixed can opener had food particles stuck to it and had missing metal. Additionally, there was missing metal around the shaft, and metal shards were visible on the ledge behind the metal cutting tip. During a telephone interview on 4/24/25 at 2:31 p.m., the RD stated, when conducting a monthly kitchen inspection, she would check to see if the can opener was clean and without residual food on it. The RD stated, she was unaware of missing metal on the cutting tip and shaft. The RD further stated, if metal was chipping, metal could go into the food and become a safety issue. During an interview on 4/25/25 at 8:55 a.m., the DS confirmed the above observation and stated, the can opener does not meet his expectations. During a review of the facility's policy and procedure (P&P) titled, CLEANING SMALL APPLIANCES AND EQUIPMENT, dated 2018, indicated, .Equipment will be cleaned and sanitized to prevent food borne illness .Can openers will be cleaned after each use and sanitized daily . A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .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 . 6. During the initial kitchen tour on 4/22/25 at 10:00 a.m., food service items were observed in the following condition: a. Coffee mugs were found to be deglazed and had dark brown stains inside; b. Pitchers for water and other liquids intended for residents were found to be stained a tan to dark brown color and did not have an appealing appearance; c. Colored cutting boards in the food preparation area had visible, deep grooves on both sides: one red (typically used for meat products), one green (typically used for fruits and vegetables) and one white (typically used for dairy or bread products); and d. Colored cutting boards in the cook's station had visible deep grooves on both sides: two yellow (typically used for poultry) and a second green board. During an interview on 4/25/25 at 8:55 a.m., the DS confirmed the above observations and stated the cutting boards had too many deep grooves. The DS stated the problem was that bacteria could stay in the grooves and cause residents to contract food borne illnesses. The DS further stated, the pitchers used to serve residents were stained in a brownish color, resulting in an unappealing look which could cause the contents in them to be mistaken. The DS also stated the pitcher lids were cracked and looked old. During a review of the facility's P&P titled, TRAY ASSEMBLY, dated 2018, indicated, .Plates and serving equipment; plates, cups, silverware, special feeding devices, that are chipped or unsightly will be discarded . A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .Section 4-202.11 .Multiuse FOOD-CONTACT SURFACES shall be .Smooth . Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections . Free of sharp internal angles, corners, and crevices . 7. During a concurrent observation and interview on 4/22/25 at 10:47 a.m., in the main dining room, with the PMS and the PMA, the PMS confirmed the ice machine lacked an adequate air gap of 1-2 inches and a second line was inserted into the body of the air gap. The PMA stated, he did not know that air gaps were required and confirmed the presence of the second plumbing line coming from the ice machine and was inserted into the body of the air gap. During a concurrent observation and interview on 4/22/25 at 10:55 a.m., in the kitchen, with the PMS and the PMA, both confirmed the fruit/vegetable wash sink lacked an air gap, as the black plumbing pipe from the ground was directly connected to the sink's water outlet. The PMS and PMA further stated they had never heard of this requirement before. A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .5-202.13 Backflow Prevention, Air Gap .An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm [millimeter, a unit of measure] (1 inch) .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was permitted to return to the facility after Resident 1 was transferred from the facility to an acute care facility (hospital) for stabilization. This failure resulted in Resident 1 being held in a temporary facility (acute care) for five days and not returning to the facility she had been at for nearly nine months, which could have resulted in emotional distress. Findings: A review of Resident 1 ' s clinical record titled, admission Record (a document that contained the resident ' s demographic information), indicated Resident 1 ' s diagnoses included Schizophrenia (a serious mental health condition that affected how people think, feel, and behave) and an anxiety (worried) disorder. A review of Resident 1 ' s clinical record titled, Progress Notes, dated 8/17/24, at 1:00 p.m., by the Psychiatric Technician (PT), indicated Resident 1 showed signs of aggression toward staff and lorazepam (anti-anxiety medication) was administered to Resident 1 via an intramuscular (IM - in the muscle) injection (shot). A review of Resident 1 ' s clinical record titled, Progress Notes, dated 8/17/24, at 1:38 p.m., by Licensed Nurse (LN) 1, indicated Resident 1 was transferred to [ACUTE CARE HOSPITAL NAME] at 1:24 p.m. A review of Resident 1 ' s clinical record from [ACUTE CARE FACILITY NAME], titled, ED [Emergency Department] Physician Notes, dated 8/17/24, at 2:32 p.m., by ED Physician 1 (ED Phys) 1, indicated, . the patient is stable for discharge and does not need to be here in the emergency department. Unfortunately when we called the facility to discharge her back to the facility they refused stating that she was not allowed to come back . The patient will remain here in the emergency department pending disposition [discharge] . A review of Resident 1 ' s clinical record from [ACUTE CARE FACILITY NAME], titled, ED Note, dated 8/17/24, at 6:29 p.m., by Emergency Department Staff (EDS) 2, indicated Resident 1 ' s overall behavior was calm and cooperative. A review of Resident 1 ' s clinical record titled, Progress Notes, dated 8/17/24, at 10:30 p.m., by LN 2, indicated, Around 4:30 writer received a call from the social worker from [ACUTE CARE HOSPITAL NAME] and asking if we are taking resident back to the facility. Writer explained that we are not taking her back . A review of Resident 1 ' s clinical record from [ACUTE CARE FACILITY NAME], titled, ED Physician Notes, dated 8/18/24, at 4:05 PM, by ED Phys 2, indicated, . patient has been medically cleared . Currently the placement facility where she was staying is [sic] refused to take her back. Nursing is interviewed no acute [new] events overnight . A review of Resident 1 ' s clinical record from [ACUTE CARE FACILITY NAME], titled, ED Note, dated 8/18/24, at 6:12 p.m., by EDS 2, indicated Resident 1 was calm and cooperative and had not required a safety attendant (staff member who monitored the resident's behavior). A review of Resident 1 ' s clinical record titled, Physician ' s Orders, dated 8/19/24, by the Medical Director (MD), indicated Resident 1 was discharged from the facility. A review of Resident 1 ' s clinical record from [ACUTE CARE FACILITY NAME], titled, ED Note, dated 8/19/24, at 5:51 p.m., by EDS 1, indicated, . Following medical clearance, EDS 1 was advised that the facility is evicting (not allowed to return) the pt [patient] . During an interview on 8/20/24, at 10:40 a.m., with the Director of Nursing (DON), DON stated the facility did not have a bed hold (save the resident ' s bed for return) for Resident 1 and Resident 1 was discharged from the facility. DON stated Resident 1 would remain at the [ACUTE CARE FACILITY NAME] until placement at another facility was secured. During an interview on 8/20/24, at 10:50 a.m., with the Social Services Designee (SSD), SSD stated the facility ' s normal practice when a resident was transferred out of the facility included serving the resident and/or the resident ' s conservator (court appointed person who made decisions for the resident when the resident was not able to do so independently) with a 7-day bed hold or a 30 day transfer or discharge notice (notice that after 30 days the resident would be transferred or discharged from the facility). SSD stated the facility was not anticipating Resident 1 to return to the facility. During a follow up interview on 8/20/24, at 11:55 a.m., with DON, DON stated Resident 1 and/or her conservator were not provided at 7-day bed hold notice or a 30-day discharge or transfer notice as of 8/20/24 at 11:55 a.m. The DON stated the facility should have provided notice to Resident 1 and/or the conservator when the decision was made by the DON and Administrator (ADM) that Resident 1 would not be returning to the facility. During an interview on 8/20/24, at 12:30 p.m., with the Psychiatric Medical Doctor (PMD), PMD stated when Resident 1 took her prescribed medications she did not have many psychiatric (mental) problems. PMD stated he last evaluated Resident 1 the week of 8/5/24. PMD stated he did not re-evaluate Resident 1 after Resident 1 was transferred to [ACUTE CARE HOSPITAL NAME] on 8/17/24. During a follow up interview on 8/20/24, at 1:50 p.m., with DON, DON stated the facility currently had 12 empty beds. During an interview on 8/20/24 at 3:56 p.m., with DON, DON stated neither MD nor PMD had gone to [ACUTE CARE FACILTIY NAME] to re-evaluate Resident 1 for the ability to return to the facility. DON stated the facility had only been in contact with [ACUTE CARE FACILTY NAME] once on 8/17/24 when [ACUTE CARE FACILITY NAME] wanted to discharge Resident 1 back to the facility. During an interview on 8/21/24, at 1:45 p.m., with Resident 1's conservator (Conserv), Concerv stated Resident 1 was still at [ACUTE CARE HOSPITAL NAME]'s ED and waiting for placement at a facility. During a review of the facility ' s Policy and Procedure (P&P) titled, Bed-Hold and Return to the Facility, dated 11/18/16, indicated, . Residents . have the right to secure a bed hold during hospitalization . or leave from the facility . C. At the time of transfer to an acute hospital in a medical emergency, or within 24 hours of the transfer, the facility . will provide to the resident and the resident representative, written bed-hold notice which specifies: iii. The resident is permitted to return to the facility to their previous room . During a review of the facility's P&P titled, Transfer And Discharge/Notice, dated 11/16/16, indicated, . 4. Written notice of Transfer or Discharge includes A. The reason for the transfer or discharge; B. The effective date of transfer or discharge; C. The location to which the resident is transferred or discharged ; D. A statement of the resident ' s appeal rights . 7. When the resident is to be transferred to another . setting or discharged . a facility designee assures the notice of transfer/discharge has been given to the resident/family surrogate .

Based on observation, interview, and record review, the facility failed to ensure one unsampled resident (Resident 19) was treated with dignity and respect when Certified Nursing Assistant (CNA) 2 stood over Resident 19 while assisting her with her lunch meal on 5/20/24. This failure had the potential for CNA 2 to miss a choking event and result in a loss of dignity for Resident 19. Findings: During a concurrent observation and interview on 5/20/23, at 12:31 p.m., in the large dining room located in Station one, CNA 2 was standing next to Resident 19 while assisting her with her meal. CNA 2 stated Resident 19 needed assistance and supervison with her meals. CNA 2 confirmed she should have been sitting next to Resident 19 while assisting her with her meal, not standing. CNA 2 stated, I forgot. A review of Resident 19's care plan, revised 3/4/24, indicated, .[Resident 19] has .self-care performance deficit r/t [related to] Dementia [impaired ability to remember, think, or make decisions], left hand contracture [inability to straighten fingers and wrist], and Schizophrenia [affects a person's ability to think, feel, and behave clearly] .Eating .staff to assist as needed with all meals/snacks . During an interview with the Assistant Director of Staff and Develpment (ADSD) on 5/23/24, at 12:55 p.m., the ADSD stated staff should sit next to the resident while assisting them with their meal to be able to see the resident eat and swallow their food, watch for choking, and to create a home-like environment. A review of the facility's policy and procedure titled, Dining Program, revised 7/1/15, indicated, .staff is to sit while feeding .Residents are observed for safety issues and functional difficulties .at meal time .issues are reported to the Charge Nurse on duty for follow-up .Smiling at the resident and providing words of encouragement will often help promote and increase intake .

Based on observation, interview, and record review, the facility failed to ensure 1 of 35 sampled residents (Resident 141)'s needs were met when his call light was found on the floor and not within reach. This failure could have resulted in a fall, injury, and/or immediate needs not being met for Resident 141. Findings: A review of Resident 141's clinical record titled, admission Record, indicated Resident 141's diagnoses included ataxia (loss of coordination and muscle control in arms and legs - leading to a lack of balance and trouble walking). A review of Resident 141's clinical record titled, Fall Risk Assessment, dated 5/13/24, indicated Resident 141 received a score of 10 (high fall risk), due to factors that included low blood pressure (can cause dizziness), unstable gait (a person's manner of walking), being chair bound, balance problems, required use of wheelchair, and was on medications that increased the risk for falls. During a concurrent observation and interview on 5/20/24, at 10:48 a.m., with the Certified Nursing Assistant (CNA) 1, Resident 141's call light was observed to be on the floor to the right side of the bed and not within reach of Resident 141. CNA 1 stated because the call light was not within reach, Resident 141 did not have a way to alert staff of an emergency or if he needed assistance. CNA 1 acknowledged the call light was on the floor and not within reach of the resident. During a concurrent observation and interview on 5/20/24, at 10:49 a.m., with Licensed Nurse (LN) 1, LN 1 stated Resident 141's call light should have been accessible to the resident at all times. LN 1 stated it was not acceptable for the call light to be on the ground. During an interview on 5/22/24, at 1:22 p.m., with LN 2, LN 2 stated Resident 141 moved very fast while in his wheelchair or while transferring from the bed to the wheelchair. LN 2 stated Resident 141 was at risk for falls. A review of Resident 141's clinical record titled, Section GG - Functional Abilities and Goals, (a portion of a standardized assessment that measured the health status of residents), dated 5/9/24, indicated Resident 141 relied on his wheelchair to move around the facility. Resident 141 was substantially dependent on staff assistance for oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on footwear, personal hygiene, change of position from lying to sitting on the side of the bed, transitioning from sit to stand, transferring from chair to bed, and transferring to the toilet. A review of Resident 141's clinical record titled, Care Plan, dated 3/1/21, indicated, Resident 141 was at risk for falls. Interventions included anticipate and meet the needs of Resident 141 and encourage use of call light if assistance was needed. During a concurrent interview and record review on 5/23/24, at 8:23 a.m., with the Director of Nursing (DON), the Policy and Procedure (P&P) titled, Call Lights, dated 9/1/13, was reviewed. The P&P indicated, It is the policy of this facility that each resident/client's call light will be accessible .to meet the needs of the resident/client .place the call light within reach of the resident/client upon leaving the room . The DON stated Resident 141 was dependent on staff for basic care. The DON acknowelged the P&P was not followed when Resident 141's call light was found on the floor and not within reach. During a concurrent interview and record review on 5/23/24, at 8:36 a.m., with the Administrator (ADM), the P&P titled, Call Lights, dated 9/1/13, was reviewed. The P&P indicated, It is the policy of this facility that each resident/client's call light will be accessible .to meet the needs of the resident/client .place the call light within reach of the resident/client upon leaving the room . The ADM stated the call light should have been within reach to ensure Resident 141 could call upon staff if needed. The ADM acknowelged the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure an evaluation or assessment was documented in the medical record for 1 of 35 sampled residents (Resident 75) when the use of a lap buddy (a device used to secure a resident in a seated position in a wheelchair) was initiated on 10/13/21, after multiple falls, without a documented initial evaluation for its use, or documented assessments for continued use of the lap buddy for Resident 75. These failures resulted in Resident 75 never being assessesed for a device that could potentially be a restraint. Findings: During an observation on 5/21/24, at 7:40 a.m., Resident 75 was observed sitting in Station one's large dining room in a wheelchair with a lap buddy secured across her lap. During an observation on 5/22/24, at 4:26 p.m., Resident 75 was observed sitting in Station one's activity room in a wheelchair with a lap buddy secured across her lap. During an interview with Certified Nursing Assistant (CNA) 4 on 5/22/24, at 4:40 p.m., CNA 4 stated Resident 75's lap buddy was used every time she was in her wheelchair. CNA 4 stated if Resident 75 tried to remove the lap buddy, staff would put it back on. During a concurrent observation and interview with Resident 75 on 5/22/24, at 4:44 p.m., Resident 75 was observed sitting in Station one's large dining room with a lap buddy secured across her lap. Resident 75 stated the lap buddy was used to keep her braced. Resident 75 stated if she tried to remove the lap buddy staff would secure it back in place. Resident 75 stated, Oh, they put it back on. A review of Resident 75's Interdisciplinary (IDT, a group of professionals who manage the care of residents) post fall progress note, dated 10/29/21, indicated, .Resident was found by staff sitting on floor next to bathroom .wheelchair unlocked .Resident ambulates [walks] via wheelchair .Resident has had 3 previous falls on 8/18/21, 9/9/21, 10/13/21 .These falls were unwitnessed and occurred during attempting to transfer independently. Resident is forgetful and has poor safety awareness .Resident was given a lap buddy to aid in reminding her to ask for assistance before attempting to transfer independently .on 10/13/21 . The note did not contain a documented evaluation or assessment prior to initiating the use of the lap buddy for Resident 75. A review of Resident 75's care plan, initiated 3/26/14, indicated, .[Resident 75] is at risk for falls r/t [related to] Gait [walking]/balance problems, Psychotropic [mind altering medication] .use, Glaucoma [vision impairment] .Osteoarthritis [pain and stiffness in joints] .Hx [history] of falls .10/30/23-unwitnessed fall outside of bathroom .12/27/23-unwitnessed fall in room .1/27/24-unwitnessed fall in room .4/23/24-Resident had unwitnessed fall in bathroom .10/13/21-May use lap buddy for safety .12/27/23-Client encouraged to use lap buddy at all times . A review of Resident 75's IDT post fall progress note, dated 12/29/23, indicated, .per [Resident 75] she didn't like using her lap buddy. [Resident 75] was found sitting on the floor next to her bed, lap buddy on the floor .[Resident 75] was encouraged to use her lap buddy at all times . The note did not contain a documented evaluation or assessment for continued use of the lap buddy for Resident 75. A review of Resident 75's quarterly IDT care plan conference meeting note, dated 12/13/24, indicated, .Falls: [Resident 75] is at risk for falls .[Resident 75] has a lap buddy but removes it at times . The note did not contain a documented evaluation or assessment for continued use of the lap buddy for Resident 75. A review of Resident 75's significant decline IDT care plan conference meeting note, dated 2/16/24, indicated, .A significant decline MDS [minimum data set, a resident assessment tool] was initiated d/t [due to][Resident 75] fracturing her 2nd-5th metatarsals [foot bones] and needing substantial assistance .unable to perform sit to stand activity .using a Hoyer lift [allows a person to be lifted and transferred with a minimum of physical effort] .The following care plans have been reviewed and updated .Falls . The note did not mention the use of a lap buddy and did not contain a documented evaluation or assessment for continued use of the lap buddy for Resident 75. During a concurrent interview and record review with Licensed Nurse (LN) 1 on 5/23/24, at 10:56 a.m., LN 1 stated Resident 75 sometimes refused to wear her lap buddy but recently had been compliant. LN 1 stated the reason the lap buddy was used for Resident 75 was to help prevent falls and for her safety. LN 1 confirmed there was not a medical diagnosis from a physician for the use of the lap buddy, or a documented evaluation or assessment in Resident 75's medical record for the lap buddy. LN 1 stated there should have been an initial assessment by a nurse for use of the lap buddy, and periodic assessments for the continued use of the lap buddy in case Resident 75 had a change in condition and could no longer remove the lap buddy or the IDT determined the lap buddy was no longer needed. LN 1 stated the documented assessments should have included whether or not Resident 75 knew what the lap buddy was used for and if Resident 75 was able to remove it on her own. A review of the facility's policy and procedure titled Assessment & Reassessment, revised 9/1/13, indicated, .Licensed Nurses conduct nursing assessment of the resident/client .at regular intervals .Additional ancillary assessments are conducted quarterly per facility protocol .a Registered Nurse will complete or directly oversee any necessary nursing assessments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's assessment was completed accurately for one of 35 sampled residents (Resident 166) when Resident 166's comprehensive assessment did not accurately reflect his dental condition. This failure increased the potential for a delay in dental care services. Findings: Review of Resident 166's admission Record indicated Resident 166 was admitted to the facility in September 2023 with multiple diagnoses including disturbances of salivary secretions (a combination of signs and symptoms associated with a decrease in the secretion of saliva). During a concurrent observation and interview on 5/20/24, at 3:30 PM, Resident 166 stated he had not been seen by a dentist while in the facility. Resident 166 stated, while pointing to his upper gum, that two of his teeth were gone and one tooth had something stuck in it. Resident 166's mouth was observed to have two missing teeth on his left upper jaw, and the first upper tooth (molar) on the right side was black and broken. Resident 166 further stated one of his upper teeth was loose. Resident 166 moved his third upper tooth (molar) on the right side with his fingers back and forth. Resident 166 stated he informed staff at the facility and was told that they would get a hold of a dentist, but nothing happened. Resident 166 stated it was hard to chew his food and took longer to chew his food. During a concurrent interview and record review on 5/22/24, at 1:24 PM, with Unit Secretary (US) 1, Resident 166's admission note was reviewed. US 1 verified Resident 166's admission note indicated Resident 166 was admitted with missing teeth and cavities. US 1 confirmed there was no record indicating when the last time Resident 166 was seen by a dentist and no attempts had been made to find out. US 1 stated it should have been done within the first 90 days of being at the facility especially with mention of missing teeth and cavities in the admission note. US 1 stated Resident 166 had not been seen by a dentist since being admitted to the facility. Review of Resident 166's nurses admission note dated 9/19/23, indicated, .Resident has own teeth in fair condition. Has Cavities. Has missing teeth to upper and lower gums . Review of Resident 166's baseline care plan dated 9/19/2023, indicated Resident 166 had natural teeth and poor dentition (condition of teeth). Review of Resident 166's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) assessment dated [DATE], indicated, .section L . Oral/Dental Status .Check all that apply .D. Obvious or likely cavity or broken natural teeth [was not selected] . Inflamed or bleeding gums or loose natural teeth [was not selected] .Z. None of the above were present [was selected] . During a concurrent interview and record review on 5/22/24, at 4:22 PM, the MDS nurse (nurse who ensures completion of the MDS) stated they assessed the resident and reviewed resident records to complete accurate resident assessments and to be able to compare for changes or decline between each assessment. Resident 166's nurse's admission note was reviewed with the MDS nurse. The MDS nurse verified Resident 166 had cavities and missing teeth to the upper and lower gums upon admission. Resident 166's comprehensive admission MDS assessment dated [DATE] was reviewed with the MDS nurse. The MDS nurse verified the assessment did not reflect that Resident 166 had cavities or broken natural teeth but should have. The MDS nurse stated Resident 166's assessment was inaccurate. The MDS nurse stated it should be accurate because that's how we take care of the resident. The MDS nurse stated when cavities were not documented facility staff would not think it was urgent for the resident to see the dentist. The MDS nurse further stated if it would have been coded correctly Resident 166 would have been referred to the dentist to follow up with concerns with his teeth. The MDS nurse stated Resident 166 did not receive dental services which could affect his chewing if he had pain due to cavities or missing teeth, cavities could have worsened and cause an infection and pain. During a concurrent interview and record review on 5/23/24, at 11:36 AM, the Director of Nursing (DON) stated nurses assessed residents' dental health upon admission. If a resident was admitted with cavities or missing teeth, then they would be referred for a dental consult and routine dental exams. The DON stated she expected the MDS nurse to communicate with Medical Records to coordinate a resident's initial dental visit. The DON stated resident assessments should be completed accurately to reflect the resident's present condition, so staff are able to create a plan of care. The DON stated if an assessment was not done accurately then the resident would not receive the required care. The DON stated if a resident did not receive dental services, then it would lead to health complications such as dental pain, infection, new cavities, worsening cavities, difficulty eating, and weight loss. Review of a facility policy titled, MDS, MINIMUM DATA SET / RESIDENT ASSESSMENT INSTRUMENT, REVISED 11/19/16, .using the resident assessment instrument (RAI) [ a tool allows care staff to collect the minimum amount of information they require about a resident's strengths, limitations, and preferences to create an individualized care plan] .The assessment must include at least the following .Dental and nutritional status .Documentation of the participation in the assessment will include direct observation and communication with the resident and communication with licensed and non-licensed direct care staff members on all shifts A comprehensive care plan will be developed by the IDT [An interdisciplinary team that brings together knowledge from different health care disciplines to help people receive the care they need], utilizing information obtained during the RAI process, and completed no later than day 21 of admission .

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to 1 of 35 sampled residents (Resident 166), when Resident 166 did not have oral hygiene supplies and did not receive oral hygiene from staff. This failure resulted in poor oral hygiene and had the potential to cause health complications for Resident 166. Findings: Review of Resident 166's admission Record indicated Resident 166 was admitted to the facility in September of 2023 with multiple diagnoses including disturbances of salivary secretions (a combination of signs and symptoms associated with a decrease in the secretion of saliva). During a concurrent observation and interview on 5/20/24, at 3:30 PM, Resident 166 stated, while pointing to his upper gum, that two of his teeth were gone and one tooth had something stuck in it. Resident 166's mouth was observed to have two missing teeth on his left upper jaw, and the first upper tooth (molar) on the right side was black and broken. Resident 166 stated it was hard to chew his food and took longer to chew his food. During a concurrent observation, interview, and record review on 5/21/24, at 3:32 PM, Certified Nursing Assistant (CNA) 3 verified Resident 166 had two missing teeth on his upper left gum, and his third upper tooth on right side was loose. CNA 3 verified Resident 166's first tooth on the upper right side was black, appeared to have a cavity, and looked broken. CNA 3 stated Resident 166's teeth looked not good. CNA 3 stated Resident 166's teeth needed a cleaning. CNA 3 stated Resident 166's teeth looked yellowish and had whitish/yellowish build- up on his teeth. CNA 3 added it might be food particles. CNA 3 stated Resident 166 needed his teeth brushed. CNA 3 stated they offered for residents to brush their teeth after dinner. CNA 3 stated each resident had a personal basket with a toothbrush, toothpaste, and personal hygiene supplies, and was kept in the utility room. CNA 3 stated residents were given their personal supplies anytime they wanted it and after dinner. CNA 3 stated residents would get their supplies in the morning as well. Residents' personal hygiene baskets labeled with their names in the utility room were observed with CNA 3. CNA 3 verified there was not a basket for Resident 166 with his name on it. CNA 3 stated, I don't see it. CNA 3 stated Resident 166's basket was supposed to be in the utility room, and he did not know why it was missing. CNA 3 stated he did not recall Resident 166 brushing his teeth and thought Resident 166 refused to brush his teeth. CNA 3 stated Resident 166 should still have a basket even if he refused to brush his teeth. CNA 3 stated a resident's refusal to brush their teeth would be recorded in their behavior monitoring log. Resident 166's behavior monitoring log was reviewed with CNA 3. CNA 3 verified Resident 166 did not have a refusal of care behavior to monitor. CNA 3 stated oral hygiene care was documented in the electronic record. During a concurrent observation, interview and record review on 5/21/24, at 4:23 PM, CNA 5 stated she cared for Resident 166 yesterday. CNA 5 stated after dinner she would ask residents if they wanted to brush their teeth. CNA 5 stated sometimes they would refuse. CNA 5 stated she would prepare the toothbrush, toothpaste, and mouthwash for the residents to brush their teeth. CNA 5 stated oral hygiene supplies were kept in the utility room. CNA 5 stated Resident 166 refused to brush his teeth yesterday and she documented it in the behavior log. Resident 166's behavior monitoring log was reviewed with CNA 5. CNA 5 verified Resident 166 did not have a refusal of care behavior to monitor. CNA 5 stated she documented residents' oral hygiene task in the electronic record where she would document if the resident performed the task independently, needed assistance, or refused. Resident 166's oral hygiene task for the last 14 days was reviewed with CNA 5. CNA 5 verified it was documented that resident performed the task independently and was not documented as refused. CNA 5 stated she documented yesterday incorrectly. Residents' baskets with personal hygiene supplies in the utility room were observed with CNA 5. CNA 5 stated, He [Resident 166] don't have a basket with oral hygiene supplies. CNA 5 stated Resident 166 should have a basket with a toothbrush, toothpaste, and mouthwash. During an interview on 5/22/24, at 08:49 AM, CNA 6 stated oral hygiene was provided to residents during their shower and after breakfast on non-shower days. CNA 6 stated resident's personal hygiene supplies were kept in the utility room in a basket labeled with their name. CNA 6 stated Resident 166's toothbrush and toothpaste were kept in the utility room because otherwise he would keep his toothbrush in his pocket all the time. During a concurrent observation and interview on 5/22/24, at 9:10 AM, Resident 166 stated he brushed his teeth this morning, and it was bleeding when he brushed. Resident 166 stated he still had build up in his tooth and pointed to his upper teeth on the right side. Resident 166's teeth were observed to be cleaner than the day before. During an interview on 5/23/24, at 11:36 AM, the Director of Nursing (DON) stated she expected staff to provide oral hygiene to the residents twice a day to make sure no food was left in the mouth, cavities did not worsen, and to make residents feel better that their mouth was clean. The DON stated she expected staff to offer and remind residents to brush their teeth, bring supplies to them when it was time for brushing in the morning and at bedtime. The DON stated staff would document in the electronic record if a resident refused oral care. The DON stated residents' toothpaste and toothbrush were kept in the utility room in their own labeled kits/baskets because of the nature of the facility type. Another resident could access and use the toothbrush and that would be an infection control issue. The DON stated residents might not be receiving oral care if they did not have their labeled basket in the utility room. Review of a facility policy titled, ORAL CARE & HEALTH, dated 9/1/13, indicated, .Residents/clients receive adequate oral care to maintain dignity, comfort and oral hygiene .

2. A review of Resident 141's clinical record titled, admission Record, indicated Resident 141's diagnoses included ataxia (loss of coordination and muscle control in arms and legs - leading to a lack of balance and trouble walking). During a concurrent observation and interview on 5/20/24, at 10:48 a.m., with Certified Nursing Assistant (CNA) 1, Resident 141's bed was observed to be in a low position to the floor. The left side bed rail was up, and the right-side rail was in the down position (touching the floor and angled away from the bed). CNA 1 stated she was unsure why the side rail was angled from the bed and on the floor. CNA 1 stated Resident 141 could have tripped on the bedrail if he got out of bed. During a concurrent observation and interview on 5/20/24, at 10:49 a.m., with LN 1, the left side bed rail was up, and the bottom portion of the right-side bed rail was in the down position against the floor and angled away from the bed. LN 1 stated the right side rail was at an angle because the bed was in the low position and forced the side rail to stick out. LN 1 stated Resident 141 was at risk for accidents because his foot could have gotten stuck in the side rail and then cause him to fall. During an interview on 5/22/24, at 1:22 p.m., with LN 2, LN 2 stated Resident 141 moved very fast while in his wheelchair or while transferring from the bed to the wheelchair. LN 2 stated Resident 141 was at risk for falls because his side rail stuck out from the bottom of his bed. During a concurrent interview and record review on 5/22/24, at 2:59 p.m., with the Maintenance Director (MD), the photograph of Resident 141's right bed rail (photo taken on 5/20/24 at 10:44 a.m.), was reviewed. The MD stated he was not informed of a problem with Resident 141's side rail. MD stated the staff should have informed him via an electronic notification system describing the broken equipment and that it needed to be fixed. MD stated the side rail should not have been at an angle from the side of the bed and could have caused an accident. A review of Resident 141's clinical record titled, Fall Risk Assessment, dated 5/13/24, indicated Resident 141 received a score of 10 (high fall risk), due to factors that included low blood pressure (can cause dizziness), unstable gait (a person's manner of walking), being chair bound, balance problems, required use of wheelchair, and was on medications that increased the risk for falls. A review of Resident 141's clinical record titled, Care Plan, dated 2/12/21, indicated, Resident 141 was at risk for falls. Interventions included to anticipate and meet the needs of Resident 141. A review of the facility's policy and procedure titled, Fall Prevention & Management, revised 4/3/2020, indicated, .Residents scoring high risk per the fall risk assessment process, have strategies implemented to reduce the potential for falls outlined in their plan of care .a care plan will be initiated or updated to provide staff with interventions which are deemed appropriate for the resident . During a concurrent interview and record review on 5/23/24, at 8:23 a.m., with the Director of Nursing (DON), the Policies and Procedures (P&P) titled, Side Rails, Bed, dated 11/17/16, and Safety and Dignity of Resident /Client, Maintaining, dated 11/23/16, were reviewed. The P&P titled, Side Rails, Bed, indicated, .Procedure .checking for loosening or bowing of the rails, gaps between the rails and the mattress, or large enough gaps within the rails itself, in which a resident's head, limbs or body may become entrapped . The P&P titled, Safety and Dignity of Resident /Client, Maintaining,, indicated, .report to maintenance or superior any environmental concerns within the resident rooms . The DON stated when the bed was placed in the low position, it bowed out the side rail and placed Resident 141 at risk for accidently stepping in the side rails and sustaining an injury. The DON acknowledged the P&Ps were not followed. During a concurrent interview and record review on 5/23/24, at 8:36 a.m., with the Administrator (ADM), the P&Ps titled, Side Rails, Bed, dated 11/17/16, and Safety and Dignity of Resident /Client, Maintaining, dated 11/23/16, were reviewed. The P&P titled, Side Rails, Bed, indicated, .Procedure .checking for loosening or bowing of the rails, gaps between the rails and the mattress, or large enough gaps within the rails itself, in which a resident's head, limbs or body may become entrapped . The P&P titled, Safety and Dignity of Resident /Client, Maintaining, indicated, .report to maintenance or superior any environmental concerns within the resident rooms . ADM stated the P&Ps were not followed and acknowledged there was a risk for injury with the bed side rail angled out. Based on observation, interview, and record review, the facility failed to ensure 2 of 35 sampled residents (Resident 75 and Resident 141) were free from potential accidents and injury when: 1. A fall mat (a soft mat laid on the floor to cushion a fall) was not laid on the floor while Resident 75 was in bed on 5/21/24 per Resident 75's care plan; and, 2. Resident 141's bed side rails (metal rail attached to the sides of the bed that could be used for assistance with repositioning) was left in an unsafe position (sticking out from the bed at the floor level). Findings: 1. During a concurrent observation and interview with Licensed Nurse (LN) 4 on 5/21/24, at 8:52 a.m., Resident 75 was observed lying in bed asleep with her fall mat folded up and positioned upright next to Resident 75's nightstand. LN 4 confirmed Resident 75's fall mat was not laid out on the floor next to Resident 75's bed and stated the risks for not implementing the fall mat included a fall with injury that could lead to death. During a concurrent interview and record review with LN 1 on 5/23/24, at 10:47 a.m., Resident 75's fall care plan was reviewed. LN 1 confirmed Resident 75 was at risk for falls according to the care plan and a fall mat was added as an intervention to the care plan to prevent injury from falls on 3/7/24. A review of Resident 75's care plan, initiated 3/26/14, indicated, .[Resident 75] is at risk for falls r/t [related to] Gait [walking]/balance problems, Psychotropic [mind altering medication] .use, Glaucoma [vision impairment] .Osteoarthritis [pain and stiffness in joints] .Hx [history] of falls .10/30/23-unwitnessed fall outside of bathroom .12/27/23-unwitnessed fall in room .1/27/24-unwitnessed fall in room .4/23/24-Resident had unwitnessed fall in bathroom .3/7/24-Elevated floor mat is added next to [Resident 75's] bed . A review of Resident 75's Fall Risk Assessment dated 5/10/24, revealed a score of 18 which indicated Resident 75 was at High Risk for falls.

Based on observation, interview, and record review, the facility failed to ensure residents received dental services for 2 of 35 sampled residents (Resident 166 and Resident 75), when: 1. Dental services were not provided for Resident 166; and, 2. Dental recommendations were not followed up on for Resident 75. These failures resulted in Resident 166 and Resident 75 not obtaining dental services and had the potential to cause health complications for Resident 166 and Resident 75. Findings: 1. A Review of Resident 166's admission Record indicated Resident 166 was admitted to the facility in September of 2023 with multiple diagnoses including disturbances of salivary secretions (a combination of signs and symptoms associated with a decrease in the secretion of saliva). During a concurrent observation and interview on 5/20/24, at 3:30 PM, Resident 166 stated he had not been seen by a dentist since being in the facility. Resident 166 stated, while pointing to his upper gum, that two of his teeth were gone and one tooth had something stuck in it. Resident 166's mouth was observed to have two missing teeth on his left upper jaw and the first upper tooth (molar) on the right side was black and broken. Resident 166 further stated one of his upper teeth was loose. Resident 166 moved his third upper tooth (molar) on the right side with his fingers back and forth. Resident 166 stated he informed the facility staff and was told that they would get a hold of a dentist, but nothing happened. Resident 166 stated it was hard to chew his food and took longer to chew his food. During a concurrent observation and interview on 5/21/24, at 3:32 PM, Certified Nursing Assistant (CNA) 3 verified Resident 166 had two missing teeth on his upper left gum, and his third upper tooth on the right side was loose. CNA 3 verified Resident 166's first tooth on the upper right side was black, appeared to have a cavity, and looked broken. CNA 3 stated Resident 166's teeth looked not good. CNA 3 stated Resident 166's teeth needed a cleaning. CNA 3 stated Resident 166's teeth looked yellowish and had whitish/yellowish build up on his teeth. During an interview on 5/22/24, at 11:09 AM, Resident 166 stated his teeth on the upper right side were hurting including his loose tooth. Resident 166 stated, I need a deep cleaning. Resident 166 further stated his teeth bled when he brushed. Resident 166 stated his teeth had been hurting since last month and he had told multiple staff members. A Review of Resident 166's nurses admission note dated 9/19/24, indicated, .Resident has own teeth in fair condition. Has Cavities. Has missing teeth to upper and lower gums . Review of Resident 166's baseline care plan dated 9/19/23, indicated Resident 166 had natural teeth, poor dentition (teeth). Review of Resident 166's care plan initiated 9/20/23, indicated, .The resident has oral/dental health problems r/t Poor oral hygiene. RESIDENTS PERCEPTION OF NEED: My teeth are ok. RESIDENTS STRENGTHS: able to make needs known .Interventions .Monitor/document/report PRN [as needed] any s/sx [sign and symptoms] of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed .The resident needs lip balm/ointment PRN . During a concurrent interview and record review on 5/21/24, at 4:38 PM, Licensed Nurse (LN) 3 stated resident's dental notes were kept in their physical chart (paper chart). Resident 166's physical chart was reviewed with LN 3. LN 3 stated, I don't see anything regarding dental in Resident 166's chart. LN 3 verified there was no record indicating Resident 166 was seen by a dentist. During a concurrent interview and record review on 5/22/24, at 1:24 PM, Unit Secretary (US) 1 stated residents obtained routine dental services every 6 months to a year. US 1 stated nurses assessed residents upon admission, listed their name in a binder if they needed to be seen by a dentist, and were usually seen within 90 days after admission. US 1 further stated nurses checked residents' history and updated their medical record with the last time the resident was seen by a dentist. US 1 stated some residents were seen by an outside provider for dental services based on their insurance and the facility would schedule them with their outside provider. Resident 166's admission note was reviewed with US 1. US 1 verified Resident 166's admission note indicated Resident 166 was admitted with missing teeth and cavities. US 1 confirmed there was no record indicating when the last time Resident 166 was seen by a dentist and no attempts had been made to find out. US 1 stated it should have been done within the first 90 days of being at the facility especially with mention of missing teeth and cavities in the admission note. US 1 stated it was important to know when the last time a resident had a dental check up to possibly avoid incidents of infection, choking, and also to know when the next follow up and/or routine checkup was due. US 1 stated Resident 166 had not been seen by a dentist since being admitted to the facility. During a concurrent interview and record review on 5/22/24, at 4:22 PM, the MDS (Minimum Data Set: a standardized assessment tool that measures health status in nursing home residents) nurse verified Resident 166 had cavities and missing teeth to the upper and lower jaw upon admission. The MDS nurse stated Resident 166 should have been referred to the dentist to follow up with concerns with his teeth. The MDS stated Resident 166 did not receive dental services which could affect his chewing if he had pain due to cavities or missing teeth, the cavities could have worsened and can cause an infection and pain. During an interview on 5/23/24, at 9:11 AM, US 2 stated she scheduled residents' dental appointments who were seen by outside providers. US 2 stated nurses assessed the residents upon admission, if they had any complaints then the nurses would list their name in a binder to be seen by the dentist. US 2 further stated the consultation coordinator checked the binder and informed her to schedule appointments for residents who needed to be seen by an outside provider. She thought residents who obtained dental services from outside providers were seen annually for routine dental services. When asked what the process was to keep track of residents' routine dental visits, US 2 replied, I have no idea who gets seen at what month and what year for routine dental services. US 2 stated she did not keep a log of residents' dental visits to ensure they received routine dental services. She thought even residents who were seen by outside providers received routine dental services from their in-house dentist. US 2 stated she was never told to schedule a dental appointment for Resident 166. During an interview on 5/23/24, at 10:09 AM, the MDS nurse stated residents who received dental services from outside providers due to their insurance were not seen by the in-house provider for routine dental services. The MDS nurse stated those residents received routine dental services from their outside provider. The MDS nurse stated residents were needed to be seen at least annually or as needed for dental services to find any problem with their teeth, including pain and infection, and to maintain dental health. The MDS nurse stated the MDS nurses would put newly admitted resident's name in the binder to see the dentist for routine services. During an interview on 5/23/24, at 11:31 AM, US 1 stated she obtained Resident 166's dental record from his outside provider which indicated his last dental visit was on 9/25/2019. US 1 stated, Yeah, that's bad. During a concurrent interview and record review on 5/23/24, at 11:36 AM, the Director of Nursing (DON) stated residents received routine dental services at least annually and as needed to make sure they were getting checked routinely to promote dental health, prevent oral issues such as cavities, and infection. The DON stated nurses assessed residents' dental health upon admission, if a resident was admitted with cavities or missing teeth, they were referred for a dental consult, and to initiate routine dental exams. The DON stated she expected the MDS nurse to communicate with Medical Records to coordinate resident's initial dental visit. The DON stated during care conferences the team reviewed resident records to make sure the resident received all consultations including dental and to ensure all follow ups were completed. The DON stated she expected the care conference team to ensure all residents received annual dental services including residents seen by an outside provider. The DON stated if a resident did not receive dental services, then it would lead to health complications such as dental pain, infection, new cavities, worsened cavities, difficulty eating, and weight loss. 2. During an interview on 5/21/24, at 10:28 a.m., Resident 75 stated she had not seen a dentist in a long time. A record review of Resident 75's dental care plan, initiated 5/17/15, indicated, .[Resident 75] has impaired dentition [teeth] r/t [related to] HX [history] poor oral hygiene .coordinate arrangements for dental care . A record review of Resident 75's dental note, dated 9/29/23, indicated, .several attempts made to extract #2 [the molar on the upper right side of the mouth] but still unsuccessful. Need to see patient in bed with bite block [help prevent your upper teeth and lower teeth from touching] . A record review of Resident 75's dental note, dated 10/27/23, indicated, .tooth #2 can be restored .DDS [dentist] recommends to restore tooth instead of ext [extraction] .NOA [authorization] pending . During an interview with the Consultant Coordinator (CC) on 5/22/24, at 2:33 p.m., the CC confirmed Resident 75's last dental visit was 10/27/23. The CC stated the company who performed the residents dental care came to the facility every month. The CC stated seven months was not an appropriate amount of time to wait for the recommended dental treatment for Resident 75. During an interview with Resident 75 on 5/22/24 at 4:50 p.m., Resident 75 pointed at a lower right molar in her mouth and stated she had tooth pain. Review of a facility policy titled, DENTAL SERVICES, revised 10/28/17, indicated, .Routine and emergency dental services are available to meet the oral and dental health needs of residents .Licensed Nursing staff are responsible for notifying Social Services of a resident's need for dental services .Social Services personnel are responsible for assisting the resident/family in making dental appointments and transportation arrangements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident when Resident 2 punched Resident 1 in the nose with a closed fist on [DATE], which caused Resident 1's nose to bleed. This failure caused Resident 1 to experience emotional distress and a physical injury. Findings: A review of Resident 1's face sheet (include's the patient's name, address, date of birth , insurance information, diagnoses, and emergency contact information) revealed a diagnosis of schizoaffective disorder, bipolar type (seeing and hearing things that are not reality, depression, and episodes of hyper activity). A review of Resident 1's nurse's progress note, dated [DATE], indicated [Resident 1] attempting to go to the bathroom, demanded roommate to get off the toilet so he could go. [Resident 2] upset and punched [Resident 1] in the face in bathroom both residents share. [Resident 1] had slight bleeding from nose, ice pack applied at nurses station and kept at nurses station until room change made for safety . A review of Resident 2's face sheet revealed diagnoses of dementia with psychotic disturbance (mental state where someone is not sure what's real or not and has problems with memory). A review of Resident 2's progress note, dated [DATE], indicated MD [doctor] in facility, assessed [Resident 2] d/t [due to] [Resident 2] punching peer on the nose with right hand. Per MD, noted swelling of right [3-5th fingers] . A review of Resident 2's care plan, initiated on [DATE], indicated .Inappropriate social behavior (yelling towards others) .resident can have outbursts towards others .when he doesn't get answers he wants . A review of Resident 2's care plan, initiated on [DATE], indicated .Assalutive behavior .resident assaulted a nurse at a previous placement XXX[DATE], spit in a staff members face . During an interview with Resident 1 on [DATE] at 3:02 p.m., Resident 1 stated he and Resident 2 were in the bathroom and were saying comments to each other when Resident 2 punched him with a fist and bloodied his nose. Resident 1 stated staff intervened and separated them, then moved Resident 2 to a new room. Resident 1 stated the incident stressed him out and messed with his program. During a concurrent interview and record review with Licensed Nurse (LN) 1 on [DATE] at 3:33 p.m., LN 1 confirmed Resident 2 punched Resident 1 in the nose. LN 1 stated Resident 2 had a history of assaultive behavior. A review of the facility's policy and procedure titled Elder and dependent adult abuse/suspicion of a crime, revised [DATE], indicated .[Name of facility] believes every person served .has the right to be free of .physical abuse .with resulting physical harm .or mental suffering .including .other residents . Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident when Resident 2 punched Resident 1 in the nose with a closed fist on [DATE], which caused Resident 1's nose to bleed. This failure caused Resident 1 to experience emotional distress and a physical injury. Findings: A review of Resident 1's face sheet (include's the patient's name, address, date of birth , insurance information, diagnoses, and emergency contact information) revealed a diagnosis of schizoaffective disorder, bipolar type (seeing and hearing things that are not reality, depression, and episodes of hyper activity). A review of Resident 1's nurse's progress note, dated [DATE], indicated [Resident 1] attempting to go to the bathroom, demanded roommate to get off the toilet so he could go. [Resident 2] upset and punched [Resident 1] in the face in bathroom both residents share. [Resident 1] had slight bleeding from nose, ice pack applied at nurses station and kept at nurses station until room change made for safety . A review of Resident 2's face sheet revealed diagnoses of dementia with psychotic disturbance (mental state where someone is not sure what's real or not and has problems with memory). A review of Resident 2's progress note, dated [DATE], indicated MD [doctor] in facility, assessed [Resident 2] d/t [due to] [Resident 2] punching peer on the nose with right hand. Per MD, noted swelling of right [3-5th fingers] . A review of Resident 2's care plan, initiated on [DATE], indicated .Inappropriate social behavior (yelling towards others) .resident can have outbursts towards others .when he doesn't get answers he wants . A review of Resident 2's care plan, initiated on [DATE], indicated .Assalutive behavior .resident assaulted a nurse at a previous placement XXX[DATE], spit in a staff members face . During an interview with Resident 1 on [DATE] at 3:02 p.m., Resident 1 stated he and Resident 2 were in the bathroom and were saying comments to each other when Resident 2 punched him with a fist and bloodied his nose. Resident 1 stated staff intervened and separated them, then moved Resident 2 to a new room. Resident 1 stated the incident stressed him out and messed with his program. During a concurrent interview and record review with Licensed Nurse (LN) 1 on [DATE] at 3:33 p.m., LN 1 confirmed Resident 2 punched Resident 1 in the nose. LN 1 stated Resident 2 had a history of assaultive behavior. A review of the facility's policy and procedure titled Elder and dependent adult abuse/suspicion of a crime, revised [DATE], indicated .[Name of facility] believes every person served .has the right to be free of .physical abuse .with resulting physical harm .or mental suffering .including .other residents .

Based on observation, interview, and record review, the facility failed to treat one of thirty six sampled residents (Resident 174) with dignity and respect when his request for drinking fluids was not honored. This failure had the potential to cause emotional distress and dehydration for Resident 174. Findings: Review of the admission Record indicated Resident 174 was admitted to the facility in 2022 with multiple diagnoses including abnormalities of gait and mobility. During a concurrent observation and interview on 5/2/23 at 10:42 a.m., Resident 174 stated one of his concerns was not getting enough fluids to drink. There was no water or fluid available at his bedside. During an interview on 5/3/23 at 8:42 a.m., Licensed Nurse (LN) 12 stated water pitchers were not kept at residents' bedsides due to behaviors and safety risk. LN 12 stated water was available at the nurses' station and was provided to the residents upon request. LN 12 added residents were provided fluids with meals and nourishments each shift. LN 12 further stated fluids were also offered to residents during activities every shift. Review of Resident 174's physician order dated 3/15/23, indicated, Push PO fluids to at least 2400ml/day [ml-milliliter per day: unit of measurement-equivalent to about 10 cups] every shift for low volume. Review of Resident 174's activity note dated 4/10/23, indicated, Staff spoke to resident today in his room. Staff asked him how he was doing? He said, Okay big brother. Staff then asked him did he want to attend canteen? He said, Yes I want a green drink. Staff said, Okay after lunch. Resident attend canteen today . Review of Resident 174's activity note dated 4/12/23, indicated, Staff met with resident today in the dining room. Resident was sitting down in his wheelchair waiting for his food. Staff greeted resident and asked him how he is doing today. Resident replied, Fine, I'm thirsty, can you get me some juice. Staff reassured resident that his food will be with him shortly . Review of Resident 174's activity note dated 4/22/23, indicated, Staff met with resident today in the hallways. Resident was sitting in his wheelchair when staff approached resident. Staff greeted resident and asked him how he is doing. Resident replied, I'm thirsty, can you give me some juice? Staff reassured resident that dinner will start soon and that he will have beverages on his tray. Staff invited resident to bingo but resident replied, No, I can't play. Staff notified resident about the other groups happening next week and the times they start. Staff will continue 1:1 to increase positive social interaction. During an interview on 5/4/23, at 5:04 p.m., Activity Assistant (AA) 1 stated if a resident requests water or juice he will provide it to the resident unless resident had fluid restrictions or on thickened liquids then he would check with the nurse before providing water/juice to the resident. AA 1 stated if a resident requests water/juice close to the mealtime such as 30 minutes or less to the mealtime then I will encourage him to wait, be patient till the mealtime or canteen. AA 1 stated he encouraged residents to wait for the drink just because it was close to the mealtime. AA 1 stated canteen was on Mondays, Wednesdays, and Fridays when activities passed nourishment at 2 p.m. which was different than daily nourishments. During a concurrent interview and record review on 5/4/23, at 6:12 p.m. AA 1 stated he did 1:1 activity visits with Resident 174. AA 1 reviewed Resident 174's activity note dated 4/22/23. AA 1 stated Bingo was at 4 p.m. and dinner starts at 5:30 p.m. AA 1 stated Resident 174 told him that he was thirsty and asked him for juice before 4 p.m. on 4/22/23. AA 1 confirmed he did not provide juice to Resident 174 when requested and assured him that he would get a drink at dinner time which was more than an hour and half later. AA 1 stated, I can see it looks bad because resident has right to have a drink when asked. AA 1 stated he should have asked the nurse or let a CNA know to provide Resident 174 juice when requested. AA 1 stated Resident 174's request was not honored, his need for beverage was not fulfilled, and he was thirsty. AA 1 stated waiting for a drink for 30 minutes or more would not make him feel good. During an interview on 5/5/23, at 1:01 p.m., the Assistant Director of Nursing (ADON) stated a resident's request for juice or drink should be fulfilled immediately. The ADON stated all staff including nursing assistants and activities were expected to provide fluids to the resident upon request immediately after checking with the nurse for any restrictions. The ADON stated staff should not tell the residents to wait for the meal to get fluids to drink. The ADON further stated if a resident was requesting fluids, they must be thirsty. The ADON added, We are here to help them .should not have resident wait for the drinks, should meet their need. Review of Resident 174's care plan revised 4/11/23, indicated, The resident is High risk for falls .Anticipate and meet The [sic] resident's needs . prompt response to all requests for assistance . Review of Resident 174's care plan revised 4/11/23, indicated, The resident is at risk for dehydration or potential fluid deficit RESIDENT STRENGTHS: able to make needs known . Review of the facility policy titled Resident Rights revised 11/15/16, indicated, .This facility respects and supports residents' rights .The facility respects each resident's autonomy and encourages free expression of all residents' rights .

Based on observation, interview, and record review, the facility failed to ensure daily quality control monitoring was completed for one of three glucometer devices in facility's Station 3. This failure had the potential for a resident to receive an inaccurate blood glucose test result and an incorrect amount of blood glucose medication. Findings: During concurrent observation and interview on 5/4/23, at 11:32 a.m., in Unit 3 hallway, Licensed Psychiatric Technician (LPT) 2 received permission to enter Resident 96's room for a scheduled blood glucose test (a measurement of blood sugar). LPT 2 used a lancet (a small device with a sharp point used to sample blood from a finger) to obtain a blood sample from Resident 96. LPT 2 then used a test strip (a small disposable plastic strip used to collect a drop of blood) to collect the blood sample from Resident 96's finger. LPT 2 inserted the strip into the glucometer (a small handheld device that measures blood sugar levels), and stated the glucometer was not working properly. LPT 2 stated she would return to the Unit 3 medication room and retrieve a new glucometer. During concurrent observation and interview on 5/4/23, at 11:37 a.m., in the Unit 3 medication room, LPT 2 located a different glucometer, inserted the test strip with the blood sample, and stated it was also not working properly. LPT 2 retrieved a third glucometer from a different medication cart, inserted the test strip with the blood sample, and stated the glucometer was functioning normally. During a concurrent record review of the facility's document titled, Weekly Quality Control Record for Blood Glucose Testing, and interview with LPT 2, on 5/4/23, at 11:48 a.m., in nursing Unit 3 medication room, LPT 2 stated there were three glucometers located at each nursing station. LPT 2 stated facility policy indicated glucometers were to be tested daily using control solutions (liquid used to test accuracy of glucometer measurements) by night shift nursing staff, and results were logged in the blood glucose log binder. LPT 2 acknowledged glucometer control testing was not completed daily. During an interview with Licensed Nurse (LN) 2, on 5/5/23, at 1:52 p.m., at Unit 1 nursing station, LN 2 was unable to locate the blood glucose log binder. LN 2 stated he was unsure what the blood glucose log binder was, stated he did not know where it was stored, and stated he would find another nurse to assist. During an interview with LN 4, on 5/5/23, at 1:55 p.m., at Unit 1 nursing station, LN 4 was unable to locate the blood glucose log binder. LN 4 stated control tests were performed nightly by nursing staff and logged in the binders, which were kept at each nursing station. LN 4 stated if testing was not done, there was a risk of a false reading, and the resident might get too much or too little insulin (medication used to treat high blood sugar). During concurrent interview and record review with the Assistant Director of Nursing (ADON), on 5/5/23, at 2:04 p.m., the ADON stated a blood glucose quality control log was kept on each unit for the purpose of recording control tests for each unit's three glucometers. The ADON stated glucometer control tests were completed daily per facility policy, and it was facility practice that they were completed on night shift. The ADON stated glucometer control checks should have been done per facility policy. The ADON stated if glucometer control testing was not completed as expected, there was a risk of obtaining a wrong test result. Review of resident medical records titled, Medication Administration Record (a record of doctor ordered medications and treatments) with date range 5/1/23 to 5/31/23, indicated routine physician blood glucose monitoring orders for Resident 43, Resident 96, and Resident 158. Review of the facility policy titled, Blood Glucose Testing, dated 9/1/13, indicated, . Quality control testing for both high and low ranges is completed daily during the designated shift and documented on the quality control log .

Based on interview and record review, the facility failed to ensure high-risk blood thinning medication (medications with bleeding risk) monitoring was completed on a daily basis for two of the five sampled residents (Resident 33 and Resident 69). This failure had the potential to result in undetected adverse effects that could occur when blood thinning medications were administered. Findings: 1. During a review of Resident 33's medical record, titled Medication Administration Record (or MAR, a legal document in medical records that listed medications use and monitoring), dated 5/2023, the MAR indicated Resident 33 received apixaban (also known as Eliquis, a blood thinning medication) 2.5mg (mg-a unit of weight) by mouth two times per day for DVT (Deep Vein Thrombosis, or blood clot) since 2/1/23. Further review of the MAR did not show any apixaban side effects (or adverse effect of the blood thinner medication such as bleeding or bruises) to watch for, or documentation of monitoring performed. During a review of Resident 33's care plan (a document containing a record of health conditions, treatment goals, and nursing care tasks), titled Alteration in hematological status related to anticoagulant [(blood thinner)] side effects, initiated on 2/27/23, the care plan indicated, . The client will be free from adverse effects related to intake of hematological [(relating to blood)] medications . Resident 33's care plan also indicated, . Monitor for side effects, effectiveness . The care plan did not list a sample of side effects including bleeding and bruises. During a review of Resident 33's medical records titled, Progress Notes, with date range of 4/6/23 to 5/3/23, the record did not show any nursing documentation for apixaban (Eliquis) side effects monitoring efforts. Further review under, Interdisciplinary Team Progress Notes (or IDT, a type of team meeting that covered all areas of care), dated 5/3/23, the IDT note did not address the status of the care plan for blood thinner medication use. 2. During a review of Resident 69's medical record titled, MAR, dated 5/2023, Resident 69 received apixaban 5mg by mouth two times per day for atrial flutter (an irregular heartbeat) since 4/30/18. Further review of the MAR did not include apixaban side effect monitoring documentation by nursing staff on their shifts. During a review of Resident 69's care plan-initiated problem titled, . Altered cardiovascular status related to atrial flutter ., last revised on 3/15/23, the care plan indicated, .on Eliquis for Aflutter: monitor for bleeding complications . During a telephone interview with the facility's Consultant Pharmacist (CP), on 5/4/23, at 2:31 PM, the CP stated daily side effect charting was not necessary because everyone knew that bleeding and bruising was a side effect of apixaban. CP further stated that nurses could refer to the residents' care plan. During an interview with Licensed Nurse (LN) 7, on 5/5/23, at 1:53 PM, at Unit 1 nursing station, LN 7 was not aware how to monitor for apixaban side effects or where such monitoring would be documented. During an interview with LN 4, on 5/5/23, at 1:56 PM, at Unit 1 nursing station, LN 4 was not aware of where to chart monitoring for a resident receiving apixaban. LN 4 stated nursing staff do not refer to care plans when charting. LN 4 stated monitoring notes needed to be on the MAR because it was easy access. LN 4 stated nurses look at the MAR every hour and it guided them for medication related monitorings. During an interview with the Assistant Director of Nursing (ADON), on 5/5/23, at 2:08 PM, the ADON stated apixaban was a high-risk medication, and it was good practice and safer to monitor side effects every shift. Review of the FDA's (Food and Drug Administration- a federal agency that approves safe drug use) drug information site called DailyMed (provides trustworthy information about marketed drugs and the official provider of FDA label information), last accessed on 5/10/23, the record indicated bleeding as the main adverse effect and warning for apixaban use and further indicated ELIQUIS (apixaban) increases the risk of bleeding and can cause serious, potentially fatal, bleeding. Review of the Institute for Safe Medication Practices (or ISMP, advocate for patient safety and promote safe medication practices) guideline titled, High-Alert Medications in Long-Term Care (LTC or nursing home) Settings, dated 2021, indicated high-alert medications are drugs that bear a heightened risk of causing significant patient or resident harm . including direct oral anticoagulants e.g.,[such as] . apixaban .

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for a census of 177 when water drainage (the system or process by which water or other liquids are drained from a place) from the washing machines was overflowing into the laundry area. This failure had the potential for clean laundry to be contaminated and increased the risk of infection for residents in the facility. Findings: During a concurrent observation and interview on 5/4/23, at 10:58 a.m., with the Laundry Aide (LA) in the laundry area, the LA confirmed water was overflowing from the drainage area behind the running washing machines. The LA stated water overflowed from the drainage when all three washing machines were running at the same time. The LA further stated water overflow was happening every day and laundry staff was mopping the floor two to three times a day. LA explained the maintenance supervisor was aware of the overflow. During a concurrent observation and interview on 5/4/23, at 1:49 p.m., the Maintenance Supervisor (MS) confirmed water was overflowing from the drainage into the laundry area. The MS further confirmed that even with one washing machine running, the water was overflowing from the drainage to the laundry floor. The MS stated the building was old and when the three washing machines would flush water out to the drainage, the water would then overflow from the drainage. The MS further stated the laundry staff had been placing blankets behind the washing machines to prevent the floor from getting wet. The MS explained that the pipe underneath the drainage needed to be fixed so water could flow better. The MS explained this was an infection control issue because the accumulation of water from the overflow could cause the growth of bacteria and could cause infection. During an interview on 5/4/23, at 2:41 p.m., the Infection Preventionist (IP) stated she was not aware of what was going on with the drainage in the laundry area. During an interview on 5/4/23, at 4:43 p.m., the ADM acknowledged the water was overflowing from the drainage into the laundry area when all three washing machines were running at the same time. When asked how long this had been going on, the ADM stated, for a while. The ADM further stated she did not know what had been done for the drainage overflow. The ADM explained there were designated rags being used for the leak in the laundry room. During an interview on 5/5/23, at 10:28 a.m., the LA stated the washing machines ran twenty-four hours a day and seven days a week. The LA further stated the only time the washing machines were not in operation was when the laundry staff were loading and unloading clothes and linens. Review of an undated facility policy titled, Maintenance of the Facility, indicated, .The building and grounds shall be maintained in a clean and sanitary condition and in good repair at all times .

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional and hydration status for 2 of 36 sampled residents (Resident 119 and Resident 174) when: 1. Resident 119's order to be fed by staff and nutritional care plan was not followed; and, 2. Resident 174's fluid intake was not monitored. These failures had the potential to cause further weight loss for Resident 119 and risk for dehydration for Resident 174; with the potential for a decline in each residents' physical health and functional status. Findings: 1. A review of Resident 119's admission Record indicated Resident 119 was admitted to the facility in 2023 with diagnoses which included abnormal weight loss and adult failure to thrive (a decline in adults that involves weight loss, decreased appetite, and poor nutrition). According to the Minimum Data Set (MDS, an assessment tool) dated 4/14/23, Resident 119 required extensive assistance for her activities of daily living including eating. A review of Resident 119's electronic health record, titled, Progress Notes, dated, 4/20/23, at 2:23 p.m., indicated, .Significant decline dietary CPC [care plan conference, a meeting which provides opportunities for the resident's and/or their representative, and each professional discipline to revise the residents' care plans] was held today with IDT [interdisciplinary team, a team of professional staff or a care team consisting of different disciplines] members .Sometimes [Resident 119] feds [sic] herself with staff supervision. She is on NCS/NAS [no concentrated sweets, no added salt] vegetarian pureed diet .Current weight is 120 lbs [pounds, a unit of measurement for weight], down x [by] 6 lbs in a month, up 3 lbs in 3 months and, down 7 lbs in 6 months .Meal intake is scattered and varies from 25-80% [25 to 80 percent]. Staff will continue to encourage resident to eat every shift . During a concurrent observation and interview on 5/4/23, at 5:40 p.m., with certified nurse assistant (CNA) 1, CNA 1 confirmed Resident 119 ate dinner by herself which was 80 percent of the meal except for the dessert. CNA 1 further confirmed she did not attempt to feed the resident and just put the dessert away on the food cart. CNA 1 stated everyone was aware Resident 119 required to be fed during meals, but Resident 119 had not been fed by staff during dinner. During a concurrent interview and record review on 5/4/23, at 5:50 p.m., licensed nurse (LN) 1 confirmed there was an order for Resident 119 to be fed by staff for all meals. LN 1 acknowledged staff did not attempt to feed Resident 119's dinner. LN 1 stated she expected staff to attempt to feed Resident 119 and the order should have been followed. LN 1 further stated the risk would be for Resident 119 to lose weight. During a concurrent observation and interview on 5/5/23, at 7:40 a.m., with CNA 2, CNA 2 confirmed Resident 119 ate 35 percent of her breakfast by feeding herself. CNA 2 further confirmed she did not attempt to feed Resident 119 her breakfast. CNA 2 stated Resident 119 required supervision and set up of her meals only and was not aware Resident 119 needed to be fed. During a concurrent interview and record review on 5/4/23, at 7:44 a.m., LN 2 confirmed Resident 119's order to be fed by staff was not followed. LN 2 further confirmed Resident 119's nutritional care plan for the staff to feed Resident 119 during meals was not followed. LN 2 stated the order and the care plan should have been followed. LN 2 stated Resident 119 was at risk for losing weight and having a nutritional deficiency. During an interview on 5/5/23, at 12:33 p.m., the Assistant Director of Nursing (ADON), acknowledged Resident 119's order and care plan were not followed. The ADON stated the licensed nurses were responsible for following all active orders. The ADON further stated licensed nurses were also responsible for communicating care plan interventions to the CNAs. The ADON explained both the order and care plan should have been followed and the risk for not following them included Resident 119 losing weight. 2. A review of Resident 174's admission Record indicated Resident 174 was admitted to the facility in 2022. A review of Resident 174's physician orders dated, 3/15/23, indicated, .Push PO [oral] fluids to at least 2400 ml [ml-milliliters, a unit of measurement equivalent to about 10 cups] / [per] day every shift for low volume . During a concurrent interview and record review on 5/3/23, at 6:08 p.m., licensed nurse (LN) 8 confirmed Resident 174 had an order to push more fluids. LN 8 further confirmed there was no documentation to show Resident 174's fluid intake was monitored. LN 8 stated only residents on a fluid restriction had their intake and output monitored. During an interview on 5/5/23, at 1:01 p.m., the Assistant Director of Nursing (ADON) stated if there was an order to push fluids, then staff should monitor and document a resident's fluid intake and output. The ADON further stated staff should use the same form to document a resident's intake and output. The ADON explained the documentation would be found in the intake and output (I&O) binder kept at the nurses' station. During a concurrent interview and record review with the ADON on 5/5/23, at 1:17 p.m., the facility's I&O binder was reviewed at the nurses' station. The ADON confirmed Resident 174's fluid intake and output was not monitored. The ADON stated Resident 174 was at risk for dehydration. The ADON further stated Resident 174 was on psychotropic (mood altering) medications which increased the risk for dehydration. During an interview on 5/5/23, at 2 p.m., Medical Records (MR) stated there was no record for intake and output monitoring for Resident 174 since March. Review of Resident 174's care plan revised 4/11/23, indicated, The resident has nutritional problem or potential nutritional problem .Monitor intake and [sic] record q [every] meal . Review of Resident 174's care plan revised 4/11/23, indicated, The resident is at risk for dehydration or fluid deficit r/t [related to] psychotropic medications .Monitor and document intake and output as per facility policy . Review of the facility policy titled, NUTRITION & WEIGHT MANAGEMENT, dated, 11/23/16, indicated, .Residents with poor intake, significant weight loss, cognitive or functional limitations that impair one's ability to feed self, dehydration, or other risk factors placing the resident at risk, will have appropriate measures implemented in their plan of care to promote weight gain and increase food and fluid consumption . Review of the facility policy titled INTAKE & OUTPUT MEASUREMENT dated 9/1/13, indicated, Fluid intake and output is monitored and documented when ordered by the resident's physician or initiated by a licensed nurse or the interdisciplinary team, as an assessment tool to evaluate hydration status or fluid needs .All nursing personnel are responsible for recording on the Intake and Output (I&O) .The licensed nurse is responsible for obtaining and completing the subtotal intake and output at the end of each shift from the worksheet and recording it on the Intake and Output record, which is part of the resident's permanent health record .

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices for a census of 177, when the medication error rate was over 5% (% or percentage was a fraction of a number out of 100) during medication administration. The calculated medication error rate was 10.71%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. 1a. Licensed nurse administered a topical prescription medication to Resident 42 when it belonged to, and was labeled for Resident 70. 1b. Licensed staff pre-poured 10 medications for Resident 54 and: i. documented the administration 40 minutes after it was given, ii. did not follow the doctor's order and manufacturer instruction during medication administration of Zyprexa Zydis (Olanzapine, a mind altering/calming medication) iii. medications names or purpose were not explained to Resident 54. 1c. Licensed staff pre-poured medications for Resident 164 and, i. documented the drug administration 40 minutes after it was given, ii. a sleep medication was given at dinner time, iii. medications due at 9PM were given at 5:34 PM, but documented given at 9PM, and iv. medications names or purposes were not explained to Resident 164. 1d. Licensed staff did not guide Resident 31 after eye drop administration for best outcome and medication effectiveness per standards of practice. 1e. Licensed staff administered pre-poured medications to Resident 134, and three medications which were due but were not pre-poured, and not given, were documented as given with the others. 1f. Licensed staff administered medications for Resident 158 and documented the drug administration hours after it was given. Medications names or purpose were not explained to Resident 158. 2. Hazardous medication (medications with potential to cause serious effects when not handled per guidelines) were not safely handled by licensed staff per standards of practice and facility's policy during medication administration tasks on two unsampled residents out of census of 177 residents (Resident 73, Resident 54). These unsafe medication administration practices had the potential to negatively impact staff and resident's safety. Findings: 1a. During a medication administration observation, with Licensed Nurse (LN) 3, in the facility's Unit 3, on 5/2/23, at 4:50 PM, LN 3 administered a topical medication cream called triamcinolone . 0.1% (also known as TAC cream; a topical steroid which reduces inflammation of the skin) to Resident 42 when it was labeled for Resident 70. In an interview with LN 3 on 5/3/23, at 3:47 PM, in facility's Unit 3, LN 3 acknowledged the TAC cream she used on Resident 42, belonged to Resident 70, and stated many residents were on the same medications. 1b. During a concurrent medication administration observation and interview with Licensed Psychiatric Technician (LPT) 1, on 5/2/23, at 5:31 PM, in the facility's Unit 3, LPT 1 stated she pre-poured the medications between 4-5 PM for the doses due at 6 PM. LPT 1 pulled her medication cart next to Resident 54's room and offered a medication cup of 10 pills including a medication called Zyprexa Zydis (or Olanzapine, a mind altering/calming medication that dissolves or disintegrate in the mouth) with a cup of iced tea. Resident 54 was observed swallowing all the pills at once with the iced tea. LPT 1 then mixed Valproic acid liquid (a medication used for mental health and seizure) with iced tea and handed it to Resident 54 for administration. LPT 1 did not explain the name or what drugs she was administering. Review of Resident 54's medical record, titled, Medication Admin Audit Report (lists the date and times each medication order was documented in the computer as administered), dated 5/2/23, indicated LPT 1 documented Resident 54's medication administration at 6:10 PM, which was 40 minutes after the actual administration. Review of the physician orders for Resident 54 dated 6/13/22 indicated, Zyprexa Zydis Tablet; Disintegrating (Olanzapine); Give 10 mg ('mg, a unit of measure) by mouth one time a day for .dissolve in at least 30 ml [ml-unit of measure. 30 ml is equivalent to one ounce] liquid . Review of Lexicomp (an online drug information source) for drug Zyprexa Zydis (an oral disintegrating/self-dissolving tablet form), last accessed on 5/9/23, indicated Oral-disintegrating tablet . Do not swallow it whole. Do not chew, break, or crush it .Use oral-disintegrating tablet right after opening. 1c. During a medication observation with LPT 1, on 5/2/23, at 5:34 PM, in the facility's Unit 3, LPT 1 moved her medication cart next to Resident 164's room and proceeded to measure the blood pressure (blood pressure measured with a device, every time heart beats, the force of blood pushing against the walls of your arteries are measured). LPT 1 then went back to Resident 164's room who was lying in bed and gave her 5 pills with a cup of water. LPT 1 did not explain the name or purpose of medications. Review of resident 164's medical record titled, Medication Admin Audit Report, dated 5/2/23, indicated there was only one medication that was due at 6 PM which was documented as given at 6:12 PM, about 40 minutes after the actual administration time. The medications that were administered at 5:34 PM were as follows: Atorvastatin .Tablet: Give 20 mg by mouth one time a day .Order Date- 3/21/23. The due time listed was 6 PM. Risperdal Tablet [also known as risperidone, used for mood disorder]; Give 5 mg by mouth at bedtime .Order Date-3/25/22. The medication was given as a 1 mg and 4 mg tablets (total 2 tablets). The due time listed was 9 PM. Trazodone Tablet [medication that causes drowsiness]; Give 50 mg by mouth at bedtime for sleep . Order Date- 5/11/2022. The due time listed was 9 PM. Metoprolol .Give 25 mg by mouth two times a day for blood pressure .Order Date-3/22/22. The due time listed was 9 PM. Further review indicated the 9 PM medications which were administered on 5/2/23, at 5:34 PM, were documented in the computer as given at 9 PM, including administration of the sleep medication which was given at dinner time. During a medication observation with LPT 1, on 5/4/23, at 5:33 PM, in the facility's Unit 3, LPT 1 went inside Resident 164's room, measured her blood pressure and then gave her 5 pre-poured medications with a cup of water. LPT 1 did not explain the name or purpose of medications while Resident 164 was sitting on her bed. Review of Resident 164's medical record titled, Medication Admin Audit Report, dated 5/4/23, indicated there was only one medication that was due at 6 PM, which was documented as given at 5:38 PM. The medications that were administered at 5:33 PM were as follows: Atorvastatin .Tablet: Give 20 mg by mouth one time a day .Order Date- 3/21/23. The due time listed was 6 PM. Risperdal Tablet; Give 5 mg by mouth at bedtime .Order Date-3/25/22. This medication was given as a 1 mg and 4 mg tablets (total 2 tablets). The due time listed was 9 PM. Trazodone Tablet; Give 50 mg by mouth at bedtime for sleep .Order Date- 5/11/2022. The due time listed was 9 PM. Metoprolol .Give 25 mg by mouth two times a day for blood pressure .Order Date-3/22/22. The due time listed was 9 PM. Further review indicated the 9 PM medications which were administered on 5/4/23, at 5:33 PM, were documented in the computer as given at 9:12 PM, including administration of a sleep medication at dinner time. In an interview with LPT 1, on 5/4/23, at 5:36 PM, in the facility's Unit 3 hallway, LPT 1 stated she gave the 9 PM medications ahead of scheduled time because Resident 164 sometimes refused taking them at a later time. LPT 1 stated that she would document the 9 PM administration closer to the due time as the computer did not let her document it earlier. When asked if she had contacted the doctor about giving the medication earlier or resident's refusal, she stated she had not documented or called the doctor. Review of Resident 164's medical record titled, Progress Note, STP note, dated 5/4/23, indicated, Resident is noncompliance [sic] with medications as evidenced by resident does not believe she is mentally ill and doesn't need psych meds. Resident refuses other medications including constipation meds. Resident will be encouraged to attend medication education. The notes did not address if the doctor was consulted to adjust the timing of the medication administration or medication refusal. 1d. During a concurrent medication administration observation and interview, with Licensed Nurse (LN) 7, on 5/3/23, at 8:38 AM, in the facility's Unit 1, LN 7 went inside Resident 31's room and asked her to lay in bed for eye drop administration. LN 7 instilled one drop of eye medication into the left eye as follows: Dorzolamide . (eye drop drug); Instill 1 drop in left eye three times a day for Glaucoma [eye disease]; -Order Date 7/26/16. LN 7 then gave Resident 31 a tissue to wipe the eye and observed Resident 31 squeeze and rub the eyeball multiple times right after the administration. LN 7 stated that is the way Resident 31 wanted it (having tissue). LN 7 did not explain to Resident 31 not to rub or squeeze the eyeball right after administration. Review of Nursing 2023 journal article (a peer-reviewed nursing journal), titled Administering Eyedrops, dated 5/2007, last accessed on 5/9/23 via https://journals.lww.com/nursing/Citation/2007/05000/Administering_eyedrops.14.aspx, indicated after eye drop administration, Ask him [resident] to gently close the eyes . to help distribute the solution. Tell him not to rub his eyes or squeeze them shut. 1e. During a medication administration observation with LPT 1, on 5/4/23, at 5:05 PM, in the facility's Unit 3, LPT 1 measured Resident 134's heart rate by putting a device on his finger and then administered seven pre-poured pills which were due at 6 PM, while Resident 134 was standing by the medication cart. Review of Resident 134's medical record titled, Medication Admin Audit Report, with date range of 5/2/23 to 5/4/23, indicated three medications were documented in the computer as given at 5:07 PM that were not observed as administered at 5:05 PM on 5/4/23 along with pre-poured medications. The three medications that were not observed as given were as follows: Valproic Acid Solution 250 MG/5 ML [medication used for mood or seizure; MG is unit of measure; ML a unit of volume]; Give 15 ML by mouth two times a day for unstable mood .Order Date- 8/11/20. The due time listed was 6 PM. Fiber Powder [laxative]: Give 1 Tbsp [Tablespoon] by mouth two times a day for Constipation give with at least 16 ounces of fluid -Order Date- 5/9/2022. The due time listed was 6 PM. MiraLax Powder [laxative] .Give 17 gram by mouth two times a day related to CONSTIPATION .With . preferred drink -Order Date-11/1/21. The due time listed was 6 PM. 1f. During a medication administration observation with LPT 1, on 5/4/23, at 5:14 PM, in the facility's Unit 3, LPT 1 administered 6 pre-poured pills along with a cup of iced tea to Resident 158 without any objections from the resident. LPT 1 did not explain the name or purpose of medications to Resident 158. Review of Resident 158's medical record titled, Medication Admin Audit Report, dated 5/2/23 to 5/4/23, indicated two medications due at bedtime were administered along with 6 PM pills as follows: Atorvastatin . tablet [medicine for high cholesterol]; Give 10 mg by mouth at bedtime .Order Date- 11/30/22. The tablet was due at 9 PM. ZyPREXA Tablet (or OLANZapine, medicine for mood disorder); Give 20 mg by mouth at bedtime .Order Date- 5/6/21. The tablet was due at 9 PM. Further review indicated the 9 PM medications that were administered at 5:14 PM, were documented in the computer as given at 9:12 PM. Review of Resident 158's medical record, titled Progress Notes; STP Note, dated 4/8/23, the note indicated . Resident has shown to be Non-Compliance with Medications as evidenced by resident needs reminders and prompting to take medication. This has been noted 0X [means zero incidents of medication refusal] this month which remains the same as last month. The nursing notes did not address the timing of the medication administration and resident refusal plan. In an interview with the Director of Nursing (DON), on 5/3/23, at 4:35 PM, the DON stated the licensed staff should follow the Five Rights (Right medication, Right time, Right dose, Right resident and Right route) of medication administration and document administration as soon as it was given to the resident. In an interview with Assistant Director of Nursing (ADON), on 5/5/23, at 2:15 PM, the ADON stated the physician should be notified if a medication was refused or administered earlier or later than the scheduled time. In a telephone interview with facility's Nurse Consultant (NC), on 5/5/23, at 2:29 PM, accompanied by the ADON, the NC stated it was the facility's policy to pre-pour medications. The NC stated as a nurse, herself, she would feel safer to pour medications right before the due time and for one resident at a time. The NC stated in her teachings she promoted the nurses to read the label and MAR carefully, follow the pharmacy label warnings and see the whole picture for safer medication administration practice. The facility provided two versions of the policy,Med Pass, Medication Administration Essentials, dated 9/1/13, on 5/3/23 and the version received on 5/4/23 was revised on 6/15/15 and 12/28/18. The policy indicated, .medications are administered by a licensed nurse in a safe and dignified manner as ordered by the resident's . physician .medication and treatments are to be administered as prescribed. The Procedure under section 3, indicated, .preparation of dose for more than one scheduled administration time shall not be permitted. The policy on section 4 indicated, Medications will be pre-poured . Doses are to be administered within one hour of prescribed time . The policy on section D titled, Medication Rights, indicated Licensed nurses were to follow the seven rights of medication .Right time .resident's right to know what the medication does. The policy on last page titled, Routine Administration Times ., indicated, . Any deviation from the above time require a written order from a physician. A review of NCCMERP (or the National Coordinating Council for Medication Error Reporting and Prevention, an independent body composed of 27 national organizations that promote the safe use of medications and encourage standardization of processes to prevent error-prone aspects of drug procurement, prescribing, dispensing, administration, disposal), titled Recommendations to Enhance Accuracy of Administration of Medications, last accessed on 5/9/23 via https://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications, the document indicated,As one aspect of the overall medication use system, the following checks are to be performed immediately before medication administration: the right medication, in the right dose, to the right person, by the right route, using the right dosage form, at the right time, for the right reason, with the right response, with both desired effect and potential adverse effects in mind, and with the right patient education and documentation. The recommendation additionally indicated, Healthcare professionals only administer medications that are properly labeled, and labels should be read during the following 3 steps in the administration process: When reaching for or preparing the medication, immediately before administering the medication . 2a. During a medication administration observation, with LN 3, in the facility's Station 3, on 5/2/23, at 4:45 PM, LN 3 administered Resident 73's topical medication called fluorouracil . 5% topical cream (brand name Efudex, a chemotherapy or anti-cancer medication used to treat skin disorders). LN 3 squeezed the cream into a small medication cup with bare hand, then put on a single glove, entered Resident 73's room, applied the cream to the right toe and then covered it with a pre-cut duct tape. LN 3 then exited the room, discarded the medication cup and her gloves into a trash can attached to the medication cart. Further review of the medication container label dispensed by the provider pharmacy indicated a pink color label warning as follow: NIOSH; Hazardous Drug (NIOSH stands for National Institute for Occupational Safety and Health. The NIOSH List of hazardous drugs in healthcare settings assists employers in providing safe and healthy workplaces). Review of Resident 73's Medication Administration Record (or MAR, a medical record section that documents drugs ordered and given), dated 5/2023, indicated the following order with no instruction on how a nurse should have safely handled this product: Efudex Cream 5 % (Fluorouracil): Apply to . Rt hallux (right big toe) topically every evening shift under duct tape occlusion .Order Date- 01/04/22. In an interview with LN 3, on 5/3/23, at 3:47 PM, in the Unit 3 nursing station, LN 3 stated she didn't know what the term NIOSH meant and was not aware of special personal protection for safe handling. 2b. During a concurrent medication administration observation and interview with Licensed Psychiatry Technician (LPT) 1, on 5/2/23, at 5:31 PM, LPT 1 administered Resident 54's medication called Valproic Acid Solution (medication in liquid form used for mental health or seizure). LPT 1 picked up Resident 54's amber-color bottle of Valproic Acid which had red colored spills on the outer surface of the bottle, without using gloves. LPT 1 poured 10 mL(10 milliliters-equivalent to two teapoons) of the drug into a medicine cup and handed the cup to Resident 54 who was standing by the door of his room. LPT 1 did not use any glove when administering valproic acid and stated if she delayed the administration of medication, the resident may later refuse taking it. Further review of Resident 54's medication label for valproic acid solution, dated 4/25/23, dispensed by the provider pharmacy, indicated a pink color label warning as follows: NIOSH; Hazardous Drug (NIOSH stands for National Institute for Occupational Safety and Health; The NIOSH List of hazardous drugs in healthcare settings assists employers in providing safe and healthy workplaces) and another white color label indicating Medication has boxed warning; Caution NIOSH hazardous drug 3. Review of Resident 54's MAR order for valproic acid, dated 5/2023, was written as follows: Valproic Acid Solution 250 MG/5 ML (MG is a unit of measure; ML is unit of volume; solution is liquid form of the drug); Give 500 mg by mouth two times a day for Unstable mood . Give 10 mL; Order Date 5/5/21. The MAR order did not include how the nursing staff should be handling the hazardous medication. In an interview with LPT 1 on 5/4/23, at 5:36 PM, LPT 1 stated for drugs labeled as hazardous, they were supposed to use gloves. Review of the NIOSH's guideline titled Safe Handling of Hazardous Drugs, last updated in 2016, accessed via https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf, the guideline placed fluorouracil in the group 1 hazardous category and Valproic solution in group 3 that required, .use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal, and recommended double gloving and gown for topical drug administration of fluorouracil cream and Valproic solution form. Review of the facility's policy titled NIOSH Hazardous Drugs/Chemicals and Safety Data Sheets, last revised on 1/22, indicated facility staff preparing .administering or removing a hazardous drug/chemical from its package should be trained and used Personal Protective Equipment (PPE) such as nitrile gloves (waterproof), goggles, gowns or mask to protect themselves from exposure . The policy on section 2.3 indicated, .facility staff should review pharmacy labels that carry as cautionary statement when a medication dispensed by the pharmacy and administered by facility staff is a NIOSH Hazardous Drug and its table number . The policy on section 5 indicated, .facility staff administering NIOSH hazardous oral liquid drugs should wear double gloves and gown to protect staff from splashes and small spills. In an interview with Director of Nursing (DON), on 5/3/23, at 4:27 PM, the DON stated she was not fully familiar with NIOSH and hazardous drug handling policy by nursing staff, and she needed to review and improve the process. In an interview with Assistant Director of Nursing (ADON), on 5/5/23, at 2:15 PM, the ADON stated the policy should be followed as written to protect the staff from harmful effects of drugs.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices when: 1. Expired medications were found in one of three medication rooms (Medication room Unit 2). 2. Multiple unopened injectable medication called Ozempic (diabetic drug in a pen-style injection delivery system) labeled, Refrigerate Until Opened, were stored at room temperature in a storage area in one out of three medication rooms (Medication room Unit 1). 3a. Food items were stored along with medications in three of three medication room refrigerators (located in Unit 1, Unit 2, and Unit 3), where refrigerated ophthalmic (for eyes), oral, and injectable medications were kept in a storage container inside each refrigerator. 3b. Twice daily temperature monitoring was not completed of a refrigerator located in the Director of Nursing (DON) office which contained vaccine products, and the vaccine product temperature was not monitored twice daily. 4. A hazardous liquid medication called valproic acid (a medication used to treat mood and seizure) was stored in two out of two medication carts (Cart 3B and Cart 1A) with medication spilled on the outer surface of bottles. These failures could expose residents to unsafe medication use, medications with questionable potency, and placed staff at risk for exposure to hazardous medications. Findings: 1. During a concurrent observation and interview on 5/3/23, at 7:56 AM, in the Unit 2 medication room, accompanied by Licensed Nurse (LN) 5, the following expired medications were identified in the active storage areas: a. Lorazepam (or Ativan, an anxiety medication) injectable (a shot medicine), one vial expired on 3/2023. b. Desmopressin (a medication that treats frequent urination and bleeding disorders) injectable, one vial open and undated. LN 5 stated the expired and undated medications should have been removed from the medication room and disposed of. Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, dated 12/1/7 indicated, . Facility staff should record the date opened on the primary medication container . If a multi-dose vial of an injectable medication has been opened or accessed . the vial should be dated and discarded within 28 days .Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications . in accordance with Pharmacy return/destruction guidelines . 2. During a concurrent observation and interview with LN 2, in the Unit 1 medication room, on 5/3/23, at 10:25 AM, three unopened boxes of Ozempic (medication for high blood sugar) labeled, Refrigerate Until Open, were stored on a shelf in the active storage area. LN 2 acknowledged the Ozempic should be stored in the medication refrigerator until opened. 3a. During a concurrent observation and interview, with LN 5, in the Unit 2 medication room, on 5/3/23, at 7:56 AM, the refrigerator contained both food and medications. LN 5 stated the food contained in the refrigerator consisted of yogurt and applesauce. LN 5 stated the pitchers in the refrigerator contained either water or tea. LN 5 stated the pull-out drawers at the bottom of the refrigerator contained single size juice cartons. LN 5 stated the facility purchased a separate refrigerator for the medications, but it had not been delivered. Further observation indicated on a lower refrigerator shelf, there was a metal container consisting of ophthalmic, and injectable commingled medications. LN 5 stated refrigerated medications in small containers were usually stored in this manner. LN 5 acknowledged the container was full and the medications were closely packed. During a concurrent observation and interview, with Licensed Nurse 2 (LN 2), in the Unit 1 medication room, on 5/3/23, at 8:34 AM, the refrigerator contained both food and medications. LN 2 confirmed there was food stored with medications that required refrigeration. LN 2 stated the refrigerated food items were applesauce, yogurt, and pudding. LN 2 also identified tea, water, and single serving juice cartons in the medication refrigerator. Further observation indicated the lower refrigerator pull-out drawer contained commingled oral, ophthalmic, and injectable medications. Some of the medication containers were in plastic outer wrap, and others were not. The refrigerator had frost on the upper interior side walls of the Unit 1 medication refrigerator. LN 2 stated it was normal facility practice to store refrigerated medications together with food and drink items. During a concurrent observation and interview, on 5/3/23, at 11:24 AM, at Unit 3 medication room, accompanied by Licensed Nurse 6 (LN 6), the medication refrigerator contained both food and medications. LN 6 identified food items as applesauce, pudding, yogurt, juice, water, and tea. Further observation indicated the lower refrigerator pull-out drawer contained commingled oral, ophthalmic, and injectable medications. LN 6 stated it was normal facility practice to store refrigerated medications together with food and drink items. 3b. During a concurrent observation and interview, with the DON, in her office, on 5/4/23, at 3:40 PM, the DON stated vaccines were stored in a small refrigerator in her office. The DON stated the only vaccines stored in her office refrigerator were for pneumonia (lung infection) and flu. The DON further stated the refrigerator temperature was checked and logged twice a day during the week, but was not checked or logged on the weekends. The DON stated no one entered her office on the weekend, and she was the only one with an access key. The DON stated vaccines were not administered on the weekend. Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, dated 12/1/7, indicated, . Facility should ensure that external use medications and biologicals are stored separately from internal use medications .Facility should ensure that food is not to be stored in the refrigerator .where medications .are stored .Facility staff should monitor the temperature of vaccines twice a day .Facility should monitor cold storage containing vaccines two times per day . Review of undated CDC (Centers for Disease Control, a U.S. government agency that works to protect public health) guidelines, titled Vaccine Storage and Handling, last accessed on 5/10/23, via: https://www.cdc.gov, indicated, . the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday). 4a. During a concurrent observation and interview on 5/3/23, at 10:40 AM, at Unit 1 nursing station, medication cart 1A was observed with LN 2. NIOSH (The National Institute for Occupational Safety and Health-conducts research and makes recommendations for the prevention of work-related hazards) labeled valproic acid medication bottles located in the bottom medication cart drawer had dried spillage on the top and sides of the bottle's outer surface. LN 2 acknowledged the valproic acid liquid medication bottles had spillage on the top and sides of bottles and were not stored in plastic outer wrap. 4b. During a concurrent observation and interview with Licensed Psychiatric Technician (LPT) 2, on 5/3/23, at 11:34 AM, in the Unit 3 nursing station, the medication cart 3B was observed to contain a NIOSH labeled medication called valproic acid liquid. The valproic acid bottle had spillage on the outer surface. LPT 2 stated the liquid medication was not contained in a separate plastic outer wrap. LPT 2 stated she used a single pair of gloves when handling the NIOSH medications including liquid valproic acid. In an interview with the DON, in her office, on 5/3/23, at 4:27 PM, the DON stated she had to review the facility's policy on handling the NIOSH medications. The DON stated there was a need to improve the process. Review of the facility document titled, Quality Improvement: Consultant Pharmacist Summary ., with a timeframe from 3/1/23 to 3/31/23, indicated, Comments/Suggestions for areas of improvement .Personal food/drink (Starbucks drink) stored in medication food (medication refrigerator) . Review of the facility policy titled NIOSH Hazardous Drugs/Chemicals and Safety Data Sheets (SDSs), dated 12/1/7, indicated, .Facility Staff should review pharmacy labels that carry as cautionary statement when a medication dispensed by the pharmacy and administered by facility staff is a NIOSH Hazardous Drugs .Facility staff administering intact hazardous tablets or capsules should wear single gloves .Facility staff administering NIOSH hazardous oral liquid drugs should wear double gloves and gown to protect staff from splashes and small spills .

Based on observation, interview, and record review, the facility failed to properly store, label, and prepare food in accordance with the professional standards for food service safety for 177 of 177 residents who received food from the facility kitchen, when: 1. One jug of lemonade, one jug of cranberry juice and one jug of tea in the kitchen refrigerator were available for use after the labeled use by date, and one expired bread bag with five whole wheat breads was available to use on the bread rack in the kitchen; 2. Four bags with 12 burger buns in each bag on the bread rack were not dated when taken out of the freezer and 13 boxes with 24 ice cream cups per box in the kitchen freezer were not labeled with a received date and use by date; 3. The kitchen thermometer was not calibrated weekly; 4. Expired test strips were used to test dishwasher solution; 5. Wet dishes were stacked together; 6. The ice machine filter was not changed annually; 7. One sherbet ice cream in the freezer at nurses' station 1, six vanilla ice creams in the freezer at nurses' station 2 and three sherbet ice creams and one vanilla ice cream at nurses' station 3 were not labeled with a received date or use by date; 8. One vanilla ice cream and one sherbet ice cream were melted and available to use in the freezer at nurses' station 1; 9. The freezer temperature at nurses' station 3 was out of range; and, 10. The freezer temperature of nurses' station 1, nurses' station 2 and nurses' station 3 was not logged. These failures placed residents at risk of food borne infections (illness caused by consuming contaminated foods or beverages). Findings: 1. During the initial kitchen tour with the Assistant Dietary Services Supervisor (ADSS) 1 on 5/2/23, at 8:51 a.m., one jug of lemonade, one jug of cranberry juice and one jug of tea stored in the kitchen refrigerator were labeled prepared on 4/29/23. One bag with five whole wheat breads on the bread rack was labeled with an expiration date 5/1/23. ADSS 1 confirmed the food items had passed the use by dates/expiration dates and were available to use. ADSS 1 stated the beverages were good for 3 days once made and should have been thrown away on 5/1/23. 2. During the continue initial kitchen tour with ADSS 1 on 5/2/23, at 8:51 a.m., four bags of burger buns with 12 buns in each bag on the bread rack were not labeled with a date. 13 boxes with 24 ice cream cups in each box in the reach-in kitchen freezer were not labeled with a date. ADSS 1 stated burger buns were good for 7 days once pulled out of the refrigerator. ADSS 1 confirmed the burger buns were not dated and were available to use on the bread rack. ADSS 1 stated burger buns should have been labeled with a date when pulled out of the freezer. ADSS 1 stated food items that did not have a manufacturer expiration date were labeled with a received date when delivered. ADSS 1 confirmed ice cream boxes did not have a manufacturer expiration date, and were not labeled with a received date. ADSS 1 stated ice cream boxes should have been labeled with a received date when delivered on 5/1/23. 3. During a concurrent observation and interview on 5/3/23, at 11:59 a.m., ADSS 1 calibrated the thermometer in ice water which read 35-degree Fahrenheit (°F: unit of measurement). ADSS 1 recalibrated the thermometer to 32°F. ADSS 1 stated the thermometer was calibrated once a week either on Monday or Tuesday. During a concurrent interview and record review on 5/4/23, at 10:28 a.m., review of the facility document titled, WEEKLY THERMOMETER CALIBRATION CHART dated September 2022, indicated the thermometer was calibrated on 4/6/23 (Thursday), 4/12/23 (Wednesday), 4/21/23 (Friday) and on 5/2/23 (Tuesday). ADSS 1 stated there was no set schedule to ensure the thermometer was calibrated weekly as long as the thermometer was calibrated once a week. ADSS 1 verified the thermometer was not calibrated last week, the week of 4/23/23. ADSS 1 stated the thermometer needed to be calibrated every week to ensure it was checking an accurate temperature. ADSS 1 confirmed when the thermometer was not calibrated weekly it was possibly not giving the right temperature reading and food would not be cooked or served at the right temperature, which posed, danger for the residents. During an interview on 5/5/23, at 11:18 a.m., the Dietary Services Supervisor (DSS) stated the thermometer should be calibrated once a week every Monday to ensure it was working properly. The DSS stated if the thermometer was not calibrated weekly there was a risk food served was not hot or cold enough, and food might not be cooked properly, which had the potential to make residents sick. 4. During a concurrent observation and interview on 5/4/23, at 9:31 a.m., Dietary Aide (DA) 1 stated the dishwasher solution was tested three times a day with chlorine test strips before washing dishes at each meal. DA 1 used a chlorine test strip to test the dishwasher solution. The test strip container indicated test strips were expired 9/2022. DA 1 confirmed chlorine test strips were expired. DA 1 stated they should not use expired chlorine test strips to test the dishwasher solution. During an interview on 5/5/23, at 11:18 a.m., the DSS stated expired chlorine test strips should not be used to test dishwasher solution because it would not provide accurate reading of disinfectant in the dishwasher solution, dishes would not be sanitized properly or would have too much chemical. The DSS further stated if dishes were not sanitized properly then residents could get infections and too much chemical could also cause toxicity and could make residents sick. 5. During an observation of the dishwashing process on 5/4/23 at 9:16 a.m., DA 1 stacked wet plates together and placed them on a cart. DA 1 stacked wet dessert bowls together and placed them in a container. DA 1 stacked wet sippy cups together. During an interview on 5/4/23 at 9:31 a.m., DA 1 stated stacked plates were ready to be placed at the steam table to use to serve the food, so were dessert bowls and sippy cups. DA 1 stated plates were completely dried since they used a jet drier and she waited a couple minutes before she stacked them together. DA 1 stated it took only 2 minutes for dishes to dry after being washed. DA 1 verified the sippy cups and dessert bowls were still wet and were not completely dried. DA 1 stated she should have placed them individually on the tray to dry rather than stacking them together. During an interview on 5/5/23, at 11:18 a.m., the DSS stated dishes should be allowed to air dry. The DSS stated wet dishes should not be stacked together to prevent standing water, bacterial growth, and food contamination. 6. During a concurrent interview and record review on 5/5/23, at 11:47 a.m., the Maintenance Supervisor (MS) stated the ice machine filter was changed annually per manufacture guidelines. Review of the service invoice indicated the ice machine filter was last changed on 1/12/22. The MS verified the ice machine filter had not been changed since 1/12/22. The MS stated the ice machine filter should have been changed in January 2023. The MS stated ice machine filters should be changed as per manufacture guidelines to ensure the water was clean and drinkable. The MS further stated since the ice machine filter was not changed, ice was not good and placed residents at risk of becoming sick. 7. During a concurrent observation and interview on 5/4/23, at 5:21 p.m., Licensed Nurse (LN) 9 stated the freezer in the refrigerator at nurses' station 3 was used only to keep residents' nourishments. LN 9 verified three sherbet ice creams and one vanilla ice cream in the freezer at nurses' station 3 were not labeled with a received date or use by date. LN 9 stated she did not know if ice cream should have a date. LN 9 further stated she knew residents' nourishments such as pudding, yogurt and beverages should be dated and were good for 2 days. During a concurrent observation and interview on 5/4/23, at 5:44 p.m., LN 10 stated the freezer of the refrigerator at nurses' station 2 had residents' nourishments. LN 10 verified six vanilla ice creams in the freezer at nurses' station 2 were not labeled with a received date or use by date. LN 10 stated she did not know what the expiration date/use by date was of those ice creams. During a concurrent observation and interview on 5/4/23, at 5:54 p.m., LN 11 stated they kept residents' nourishments in the fridge at nurses' station 1. LN 11 confirmed one sherbet ice cream in the freezer of the mini refrigerator at nurses' station 1 was not labeled with a received date or use by date. LN 11 stated he did not know if sherbet ice cream should be dated. LN 11 further stated he would go by the manufacture expiration date. LN 11 verified sherbet ice cream had no manufacturer expiration date. During a concurrent observation and interview on 5/5/23, at 1:27 p.m., the Assistant Director of Nursing (ADON) verified 12 ice creams in the freezer at nurses' station 2 were not labeled with a received or use by date. The ADON stated food should be dated and labeled so that they know when to discard the food and not use it. The ADON stated there was a possibility expired ice creams were served and placed residents at risk of getting sick. 8. During a concurrent observation and interview on 5/4/23, at 5:54 p.m., LN 11 verified one vanilla ice cream and one sherbet ice cream in the freezer at nurses' station 1 were melted and were available to use. LN 11 stated ice cream should be frozen. LN 11 stated melted ice creams could go bad and upset a resident's stomach. 9. During a concurrent observation and interview on 5/4/23, at 5:21 p.m., LN 9 verified the temperature of the freezer at nurses' station 3 was 18 degrees Fahrenheit (°F: unit of measurement). LN 9 stated she thought freezer temperature should be between 18 - 20 °F, but she was not sure. 10. During a concurrent interview and record review on 5/4/23 at 5:21 p.m., LN 9 verified the freezer temperature of the refrigerator at nurses' station 3 was not monitored. LN 9 stated they were only monitoring the temperature of the refrigerator but not the freezer. LN 9 verified there was no freezer temperature log. LN 9 stated they used the freezer to store residents' nourishments. During a concurrent observation and interview on 5/4/23, at 5:44 p.m., LN 10 verified there was no thermometer in the freezer at nurses' station 2. LN 10 stated they were only monitoring the temperature of the refrigerator at Nurses' Station 2 but not the freezer. LN 10 verified there was no freezer temperature log. LN 10 stated they used the freezer to store residents' nourishments. During a concurrent observation and interview on 5/4/23, at 5:54 p.m., LN 11 verified there was no thermometer in the freezer at nurses' station 1 and were not monitoring the freezer temperature. LN 11 stated they should keep a log of freezer temperature as well to ensure it was at the right temperature and residents' nourishments stored there would not go bad and make residents sick. During an interview on 5/5/23, at 1:20 p.m. the ADON stated freezer temperatures should be monitored and a freezer temperature log should be maintained. The ADON stated if freezer temperature was not maintained then it was possibly not cold enough and food would go bad and would make residents sick. During an interview on 5/5/23, at 2:08 p.m., the Registered Dietitian (RD) stated all food including in the freezer should be dated. The RD stated beverages and nourishments were good for 3 days once made and should be thrown away afterwards. The RD stated bread should be dated when pulled out of the freezer to know not to serve after 7 days. The RD stated expired/outdated food should be thrown away right away. The RD stated expired or outdated food should not be available to use due to poor food quality and potential of causing food borne illness. The RD stated the thermometer should be calibrated weekly or if staff drops it to ensure it gives correct readings and food is cooked and served at the right temperature. The RD stated the thermometer should be calibrated weekly every 7 days and no later than 7 days. The RD stated expired testing strips should not be used to test dishwasher solution. The RD stated dishes should air dry and should not be stacked together when still wet to prevent the risk of contamination and food borne illness. The RD stated dishes take longer than 2 minutes to dry. Review of the facility policy titled, FOOD RECEIVING AND STORAGE OF COLD FOODS, dated 2018 indicated, .Frozen food will be stored at 0°F or below at all times .Temperatures will be logged twice daily on refrigerators and freezers .Freezers <0°F .food must be labeled and dated .Labeled with pull by date and used by date all frozen .food Beverages such as milk or juice, should be labeled and dated to assure use for the following meal, then discarded at the end of the day . Review of the facility policy titled SANITATION AND INFECTION CONTROL SANITATION/FOOD SERVICE EVALUATION dated 2018 indicated, .The Director of food service and Registered Dietitian Nutritionist will periodically check the department of food and dining services to ensure highest quality food service environment .All items are covered, labeled, dated, and not expired . Review of the facility policy titled, FOOD PREPARATION CALIBRATING AND SANITIZING THERMOMETERS, dated 2018 indicated,Thermometers will be calibrated routinely to ensure accurate temperatures are obtained and meeting appropriate guidelines for safe food preparation and service .thermometers be calibrated weekly or more often as needed . Review of the facility policy titled, SANITATION AND INFECTION CONTROL DISHWASHING PROCEDURES, dated 2018 indicated, .Dish machines will be used per manufacturer guidelines .Chemical low temperature dish machines .Use a chemical sanitizing rinse to achieve and maintain 50-100 PPM [parts per million] of chlorine at the dish surface or according to manufacturer's specifications .Obtain test strips .for testing PPM on low temperature machines .follow the manufacturer's recommendation in dishwashing to ensure sanitation of dishes and utensils .Allow racks of dishes/trays/utensils to air dry. If drying space is not ample for dishes to air dry, use utility carts .Do not rack and stack wet dishes or trays . Review of the facility policy titled, SANITATION AND INFECTION CONTROL CLEANING ICE MACHINE, dated 2018 indicated, .Follow manufacturer recommendations . Review of the facility policy titled, SANITATION AND INFECTION CONTROL FREEZER STORAGE, dated 2018 indicated, .The freezer areas will be managed so that proper time temperature is maintained to avoid food spoilage and Time temperature abuse .Each freezer must have a thermometer that is easily visible .Freezer temperatures should be recorded two times each day .Upon receipt, frozen foods should be immediately stored in the freezer. The freezer should be maintained at a temperature equal to or less than 0°F . Frozen food should be labeled with the date it was placed in the freezer .recommended storage time of food items .ice cream .3 months .

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean and safe manner, when four ovens had baked-on grease and food. This failure had the potential to cause a fire, food contamination and health hazards. Findings: During the initial kitchen tour with Assistant Dietary Services Supervisor (ADSS) 1 on 5/2/23, at 8:51 a.m., double wall ovens and two under range ovens were not clean, had baked-on dark brown grease and food on the racks, oven doors and on the bottom of the ovens. During a continued initial kitchen tour with the Dietary Services Supervisor (DSS) on 5/2/23, at 10:17 a.m., the DSS confirmed all four ovens were not clean and had baked-on grease and food. The DSS stated, That's dirty. The DSS stated ovens were cleaned weekly on Tuesdays. The DSS verified the oven cleaning task was not on the daily cleaning schedule for today (Tuesday). The DSS stated he could not find a cleaning log for the ovens. The DSS stated he did not know when the ovens were last cleaned. During an interview on 5/5/23, at 10:53 a.m., the DSS stated kitchen staff had daily cleaning tasks and weekly cleaning tasks. The DSS stated neither daily nor weekly cleaning schedules had the oven cleaning task assigned. The DSS stated he expected cooks to clean the ovens daily after use, and expected deep cleaning of ovens weekly which had not been assigned or included in the staff assignment. The DSS stated ovens should be cleaned for sanitary reasons and to prevent food borne illness. During an interview on 5/5/23, at 12:11 p.m., the Registered Dietitian (RD) stated ovens should be cleaned daily after each use and weekly to maintain sanitization and prevent food contamination. Review of the facility policy titled, SANITATION AND INFECTION CONTROL CLEANING SCHEDULES, dated 2018, indicated, .Cleaning schedules will be developed and enforced by the Director of Food and Nutrition Services .Schedules should include the frequency of cleaning (i.e. daily, weekly, monthly), with tasks designated to specific positions .Employees will initial on the schedule when designated tasks are completed .The Director of Food and Nutrition Services should routinely check cleaning scheduled and cleanliness of the kitchen .cleaning schedule for the kitchen and dining areas .CLEANING FREQUENCY .AFTER EACH USE .CLEANING AREAS .All kitchen equipment and surfaces, which come in contact with food, will be cleaned and sanitized after each use .WEEKLY .Oven . Review of the facility policy titled,SANITIZING EQUIPMENT, FOOD AND UTILITY CARTS, dated 2018, indicated, .All equipment will be sanitized properly utilizing guidelines specified by the manufacturer .All kitchen equipment and surface, which come in contact with food, will be cleaned and sanitized after each use .Weekly Clean/Sanitize .Ovens .