**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 196's medical information was kept private from unintended public view, affecting one of five residents observed during survey task observations. This deficient practice had the potential for anyone to access Resident 196 medical records that are confidential. Findings: During a review of Resident 196's admission Record, undated, the admission Record indicated, Resident 196 was admitted to the facility on [DATE]. During a review of Resident 196's Minimum Data Set (MDS - a resident assessment tool), undated, the MDS indicated diagnoses that included but not limited to, hypertension (HTN - high blood pressure) and seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] disorder or epilepsy. During an observation on 3/25/2025 at 2:05 p.m. in the facility's floor hallway near the nurses' Station 2, the computer screen was unattended and open on a mobile workstation showing Resident 196's medical information. There was no facility nurse near the computer screen. The computer screen indicated, but not limited to, Resident 196's name, date of birth , age, medical record number, code status, and medication administration record (MAR). The MAR indicated medications such as hydralazine (a medication used to treat HTN) tablet 50 milligrams ([mg] a unit of measurement for mass) three times daily along with doses given versus what was due, lamotrigine (a medication used to treat seizures) tablet 50 mg two times daily along with doses given versus what was due, and levetiracetam (a medication used to treat seizures) tablet 1000 mg two times daily. During a concurrent observation and interview on 3/25/2025 at 2:16 p.m. with the Unit Coordinator (UC) at Nurses' Station 2, the computer screen with Resident 196's medical information was reviewed. The UC stated the computer screen should be always locked to protect resident privacy. During an interview on 3/27/2025 at 3:58 p.m. with the Director of Nursing (DON), the DON stated, it is never okay to keep the patient information visible for public view because that can compromise patient privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 20) had side rails (bars or rails attached to the sides of a bed) were in up position. This failure had the potential to put Resident 20 at risk for injuries such as falls, strangulation and death. Findings: During a review of Resident 20's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility. During a review of Resident 20's History and Physical (H&P) dated 2/26/2025, the H&P indicated the resident had history of recurrent falls, hypertension (HTN- high blood pressure), and left clavicular fracture ( a break in theft left collarbone) after a fall at home. During a review of Resident 20's Minimum Data Set ( MDS- a resident assessment tool ) dated 3/4/2025, the MDS indicated the resident had severely impaired cognitive skills( a person has a significant difficulty in thinking, learning, remembering , using judgement, and making decisions affecting daily activities) and was dependent (helper does all the effort) on the staff with dressing, toileting hygiene, and bathing. The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort) with bed mobility and transfer to and from a bed to chair. During an observation on 3/25/2025, at 11:10 a.m. in Resident 20's room, Resident 20 had bed side rails up times four. Bruises were observed in both arms. During an interview on 3/27/2025, at 9:30 a.m. and at 3:12 p.m. with Certified Nursing Assistant (CNA 1), CNA1 stated Resident 20 should have three side rails in up position because four side rails up is a form of restraint and required a physician's order. CNA1 stated she had seen the resident when he came back from physical therapy and all the four side rails were in up position on 3/25/2025. CNA 1 stated she should have placed the other side rail down to ensure Resident 20's movement will not be restricted. During a concurrent observation and interview on 3/25/2025, at 11:27 a.m. in Resident 20's room and subsequent interview on 3/27/2025, at 9:19 a.m. with Registered Nurse (RN 1), RN 1 stated Resident 20 stated Resident 20's had four bed rails in up position because the resident was a high risk for fall. Observed Resident 20 tries to climb out of bed. RN 1 stated four bed rails up was considered a restraint ( any manual method, physical or mechanical device, equipment, or material that limits a resident's freedom of movement and cannot be removed by the resident) because it limits the mobility of a resident and could lead to injury. RN 1 stated four side rails in up position required a consent and a physician order. RN 1 stated the Physical Therapist (health care professional who helps people improve their movement and function through exercises) might have placed all four side rails up because he did not see the resident when he came back from physical therapy (healthcare profession that focuses on helping people with conditions or injuries that limit their ability to move and do physical activities). During an interview on 3/27/2025 at 2:26p.m., with Physical Therapist (PT 1), PT 1 stated Resident 20 was taken out of bed around 9 a.m. on 3/25/2025 and upon return to Resident 20's room at around 11:00 a.m., the resident was left sitting on the side of the bed because the resident wanted to use the restroom. PT 1stated he handed off Resident 20 with the nursing staff who was present in the room before he left. During an interview on 3/28/2025 at 11:45 a.m., with the Director of Nursing (DON), DON stated four side rails up was considered a restraint and can have a negative outcome. The DON stated the resident could get climb out of the bed and this would lead to fall and injury. During a review of the facility's policy and procedure (P&P) titled, TCC/TCU: Bedrails last revised 3/2020, the P&P indicated, Bed rails will not be used when a resident cannot raise and lower them easily, thereby meeting the definition of a physical restraint. During a review of the facility's P&P titled, Restraint for Non-Violent /Non-Self-Destructive Behavior revised on 5/2022, the P&P indicated all patients have the right to be free from any form of restraint that are imposed as a means of coercion, discipline, convenience, or retaliation by staff. The P&P indicated the facility will protect and preserve the rights , dignity , safety of the residents and eliminate inappropriate use of restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 2 crushed and administered each oral medication separately for one of five sampled residents (Resident 94) during medication administration observation. This failure had the potential to place Resident 94 at risk for drug interactions (occur when two or more drugs taken simultaneously affect each other's actions in the body) or intolerability to one or more medications without possibly knowing which medication caused intolerability. Findings: During a review of Resident 94's admission Record (a document containing demographic and diagnostic information), dated 3/27/2025, Resident 94 was admitted to the facility on [DATE] with diagnoses including, but not limited to, swallowing impairment and gastroesophageal reflux disease ([GERD] a condition where stomach contents flow back up to esophagus causing irritation). During a review of Resident 94's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/13/2025, the MDS indicated Resident 94's cognition was moderately impaired. The MDS indicated, Resident 94 needed supervision level assistance from facility staff for Activities of Daily Living (ADLs) such as for eating and oral hygiene, moderate assistance for personal hygiene, maximal assistance for upper body dressing, dependent for lower body dressing, putting on/taking off footwear and showering, and toileting hygiene not attempted due to medical condition or safety concerns. During a concurrent observation and interview on 3/26/2025 at 9:10 a.m. with RN 2, RN 2 prepared the following five medications to be administered to Resident 94. RN 2 stated she would need to crush Resident 94's four medications and administer docusate sodium (a medication used to treat constipation) oral liquid with a thickening agent. 1. One tablet of amlodipine (a medication used to treat high blood pressure) 5 milligrams ([mg] a unit of measure for mass) 2. One tablet of ferrous gluconate (a medication used to treat low level of iron) 324 mg 3. One tablet of bisoprolol (a medication used to treat high blood pressure and heart complications) 5 mg 4. One tablet of multivitamin with iron 5. 10 milliliters ([mL] a unit of measure for volume) of docusate sodium oral liquid 50 mg per 5 mL RN 2 placed four medications (amlodipine, ferrous gluconate, bisoprolol, multivitamin with iron) in a clear bag and crushed them together using a crushing device before pouring the powder mixture into a paper cup. RN 2 stated she would administer the powder mixture of four medications to Resident 94 with apple sauce. RN 2 stated if it was a gastrostomy tube (g-tube - a surgically placed tube used to administer medications or food directly into the stomach) then she should have crushed each medication separately and administered each medication separately. RN 2 stated because the medications were to be administered orally to Resident 94 it was okay to crush all medications together and administer altogether by mouth with apple sauce. RN 2 did not ask Resident 94 if she preferred to take crushed medications together before administering medications to the resident. During a review of Resident 94's Order Summary Report (a document containing a summary of all active current physician orders), dated 3/27/2025, the document did not indicate a physician order to crush oral medications. During a concurrent interview on 3/27/2025 at 3:27 p.m. with the Director of Nursing (DON) and pharmacist (RPH) 3, DON stated if medications were to be crushed and given by mouth, then facility nurse should have crushed one medication at a time, then mix with apple sauce and administer one medication at a time .second medication same way, crush it, mix it and give it. DON stated each medication should have been crushed separately and mixed with apple sauce one by one. DON and RPH 3 stated it was important to administer each crushed medication separately to be able to determine which medication caused an allergic reaction if the resident was allergic to a medication or had absorption issues with a certain medication. During a review of the facility's policy and procedure (P&P), titled, Oral drug administration, dated 5/20/2024, the P&P indicated, cardiovascular agents, antibiotics .are the most common drugs that cause drug interactions. The P&P indicated, Verify that you're administering the medication at the proper time by the correct route .errors. Administer the medication to the patient .as needed, to aid in swallowing, minimize adverse effects and promote absorption.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 95) received appropriate services to meet resident's behavioral health care needs by failing to: 1.Ensure the psychiatric services( type of mental health care that focuses on diagnosing and treating mental illness) were provided to Resident 95 who was prescribed Ativan (Lorazepam- drug used to treat anxiety) and Seroquel ( Quetiapine- drug to treat depression) after manifesting confusion, anxiety and climbing out of bed. Resident 95 had diagnoses of anxiety and depression and was on Prozac(Fluoxetine- drug used to treat depression), Ambien ( drug used treat insomnia) and Valium ( medicine used to treat anxiety disorder). 2. Ensure Interdisciplinary Team (IDT group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a patient) addressed resident's behavioral problems and the use of psychotropic medicines (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). These failures had the potential to put Resident 95 at risk for increased pharmacological treatment for resident's behavioral symptoms and lack or inappropriate treatment or management of Resident 95 's mental and psychosocial needs. Findings: 1.During a review of Resident 95's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility. During a review of Resident 95's History and Physical (H&P) dated 3/6/2025, the H &P indicated the resident had a history of multiple sclerosis ( disorder in which body's immune system attacks the protective covering of the nerve cells in the brain and spinal cord ), possible status epilepticus (a prolonged or continuous seizure activity that can be life threatening) and femur fracture ( a break in the thigh bone)surgery after a fall in the hospital. During a review of Resident 95's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated the resident had an intact cognition(thought process) and had no potential indicators of psychosis( a severe mental condition in which thought, emotions are so affected that contact is lost with reality) such as hallucinations(perceptual experiences in the absence of real external sensory stimuli) and delusions (having false or unrealistic beliefs). The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort) with bed mobility, oral hygiene and personal hygiene. The MDS indicated the resident had diagnoses that included anxiety disorder, seizure disorder or epilepsy( disorder of the brain characterized by repeated seizures) and hip fracture. During a review of Resident 95's Medication Administration Record (MAR-MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) 3/2025, the MAR indicated the resident was on Valium ( a medicine of the benzodiazepine family that acts as an anxiolytic) 10 milligrams( mgs.- unit of measurement) every 8 hours as needed for anxiety. The MAR indicated the Valium was ordered 3/8/2025 and was reordered on 3/29/2025. During a review of Resident 95's MAR, the MAR indicated Prozac (can treat depression, obsessive-compulsive disorder (OCD), bulimia nervosa, and panic disorder)60 mgs. daily was ordered 3/6/2025. During a review of Resident 95's MAR, the MAR indicated Seroquel 25 mgs. every 12 hours as needed for agitation was ordered on 3/5/29025. The MAR indicated Seroquel's physician order was changed to 25 mgs. nightly on 3/13/2025. During a review of Resident 95's MAR, the MAR indicated Zolpidem (Ambien) 5 mgs. nightly prn (as needed) for insomnia was ordered on 3/5/2025 and was reordered on 3/19/2025. During a review of Resident 95's Nursing Progress Note dated 3/17/2025 timed at 6:22 p.m., the Nursing Progress Note indicated the resident was confused, restless, agitated and had a feeling of sadness. The Nursing Progress Note indicated the resident was confused and forgetful to situation and time and the resident tend to say, help me, help me. During a review of Resident 95's Nursing Progress Note dated 3/17/2025, timed at 3:36 a.m., the Progress Notes indicated the resident was anxious, confused, and was climbing out of bed. The Nursing Progress Notes indicated the resident was awake, with episode of inability to relax manifested by calling out from time to time and received pain medication for the complaint of right forearm pain. The Progress Notes indicated on 3/17/2025, at 3:40 a.m. the resident woke up and requesting for anti- anxiety medicine again and medication was provided. During a review of Resident 95's Informed Consent (voluntary agreement to accept treatment after receiving education regarding risks, benefits and alternatives offered) dated 3/16/2025 timed at 7:30 p.m., the Informed Consent indicated a signed consent for the use of Ativan 1 mg. twice a day for anxiety. During a review of Resident 95's Informed Consent dated 3/17/2025 timed at 7:30 p.m., the Informed Consent indicated a signed consent for the use of Seroquel 50 mgs. nightly for psychosis. During a concurrent observation and interview on 3/27/2025, at 8:39 a.m. with Resident 95, Resident 95 was lying in bed. Resident 95 stated she was sleepy and not that awake yet. Resident 95 stated she could not remember the names of her medications that help her relax and there was no psychiatrist seeing her with her anxiety. During a concurrent interview and record review of Resident 95's electronic chart on 3/27/2025, at 10:43 a.m. with Registered Nurse (RN 2), RN 2 stated the psychotropic medicines were given to Resident 95 's anxiety. RN 2 stated the resident had psychosis, depression and anxiety and confirmed there was no psychiatrist evaluating resident's behavioral problems and psychotropic medicines RN 2 stated the resident should be seen by a psychiatrist so his behavioral needs and mental health will be addressed and reassessed. RN 2 stated Resident 95 could get sleepier, and her mental health could get worse if resident's psychotropic medicines were not reassessed for appropriateness of use. During a concurrent interview and record review of Resident 95's electronic chart on 3/27/2025, at 3:25 p.m. with RN 3, RN 3 confirmed the resident had no diagnosis for psychosis .RN 3 stated Resident 95 could be at risk for unnecessary medicines and could be at risk for adverse effects (undesired and unwanted harmful effects that can occur after taking a medication) of the psychotropic medicines if the medications are not properly monitored for its use. During a concurrent interview and record review of Resident 95's electronic chart on 3/28/2025, at 9:07 a.m. with Assistant Nurse Manager(ANM), ANM verified the resident was on Valium, Prozac, Ativan, Seroquel and Ambien. ANM stated on 3/17/2025, the resident had a change in condition (COC-significant change in someone's health, functioning, or circumstances that requires attention or intervention) when the resident was manifesting more anxiety. ANM stated the neurologist( medical doctor who specializes in the diagnosis, treatment, and management of disorders affecting the brain, spinal cord, and nervous system) ordered Ativan 1 mg. twice a day and increased the dose of Seroquel to 50 mgs. due to resident's agitation. ANM stated there was no psychiatrist involved in the resident's case. ANM stated the facility should have consulted a psychiatrist because the resident was manifesting more anxiety. ANM stated the resident's behavioral change should have been addressed properly so the resident can have a better quality of life. ASM stated using Seroquel and Ativan could act as a chemical restraint and could be also an unnecessary medicine. 2. During a review of Resident 95's IDT Care Conference( structured meeting where the care team , resident, and family members discuss the resident's care plan, progress, and any concerns to ensure a collaborative approach to care) dated 3/20/2025, the IDT Care Conference indicated psychotropic medicines usage and change in condition of the resident were not addressed during the meeting. During a concurrent interview and record review of Resident 95's electronic chart on 3/28/2025, at 9:07 a.m. with ANM, ANM confirmed the IDT Care Conference conducted on 3/20/2025 did not address the resident's change in condition regarding her increased anxiety on 3/17/2025. ANM stated the IDT Care Conference is performed twice a week and the facility should have addressed the behavior during IDT meeting. During an interview on 3/28/20245, at 11:45 a.m. with Director of Nursing (DON), DON stated the facility conducted IDT Meeting on all residents to ensure residents' goals are met, plan of care and residents' progress are discussed. DON stated psychiatric consultation should be expected to ensure Resident 95's behavior was addressed. DON stated Resident 95's increased anxiety was a change in condition with two psychotropic medicines added and should be discussed during IDT Care Meeting to reach resident's goals. During a review of facility's policy and procedure (P&P) titled Transitional Care Center: Interdisciplinary Team Conference, revised 11/2024, the P&P indicated resident's needs are assessed and the plan of care is established from admission through discharge by utilizing an interdisciplinary team approach composed of Physicians, Director of Nursing or designee, Activity Coordinator, Physical therapist, Speech Therapist, Social Services, and other members as is appropriate in caring for the resident. During a review of facility's P&P titled Psychotropic Drug Management for Long Term Care Facilities, revised 3/2022, the P&P indicated psychoactive medications (anti-psychotics, anti-depressants, anti-anxiety, hypnotics) must only be prescribed by a person authorize to prescribe medications, when a medication is necessary to treat a specific condition as diagnosed and documented in the medical record. The P&P indicated it is the responsibility of the physician or provider who prescribes psychoactive medications to include the specific condition and target behavior documented in the medical record. The P&P indicated if the physician wishes to write a new order for a prn antipsychotic, the physician should evaluate the patient to determine appropriateness of the order, evaluation and rationale must be documented in the medical order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of four sampled Residents (Resident 95 and Resident 293) were free of unnecessary psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) by failing to: A. Assess appropriateness of Resident 95's psychotropic medications and reevaluated when Resident 95's had increased anxiety (emotion characterized by feelings of tension, worried thoughts) on 3/17/2025. B. Document indication for the use of Seroquel (medication that treats several kinds of mental health conditions including schizophrenia [a mental illness that is characterized by disturbances in thought]) and Ativan (medication to treat anxiety) for Resident 95 and Resident 293. These failures had the potential to put Resident 95 and Resident 293 at risk for unnecessary psychotropic medicines and increased adverse effects (unwanted and harmful result that can occur after taking a medication) associated with the prescribed medications. A. During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was admitted to the facility on [DATE]. During a review of Resident 95's History and Physical (H&P) dated 3/6/2025, the H&P indicated Resident 95 had a history of multiple sclerosis ( disorder in which body's immune system attacks the protective covering of the nerve cells in the brain and spinal cord ), possible status epilepticus (a prolonged or continuous seizure activity that can be life threatening) and femur fracture ( a break in the thigh bone)surgery after a fall in the hospital and anxiety (emotion characterized by feelings of tension, worried thoughts ). During a review of Resident 95's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated Resident 95 had an intact cognition (ability to think, understand, learn, and remember) and had no potential indicators of psychosis( a severe mental condition in which thought, emotions are so affected that contact is lost with reality) such as hallucinations(perceptual experiences in the absence of real external sensory stimuli) and delusions (having false or unrealistic beliefs). The MDS indicated Resident 95 required partial/moderate assistance (helper does less than half the effort) with bed mobility, oral hygiene and personal hygiene. The MDS indicated the resident had diagnoses that included anxiety disorder, seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) or epilepsy (disorder of the brain characterized by repeated seizures) and hip fracture. During a review of Resident 95's Medication Administration Record (MAR), the MAR indicated Prozac (medication used to treat depression [ a mood disorder that causes a persistent feeling of sadness and loss of interest]) 60 milligrams (mgs. - unit of measurement) daily by mouth ordered on 3/6/2025.The MAR indicated Prozac had no indication for its use. During a review of Resident 95's MAR, the MAR indicated Seroquel (medication used to treat depression) 25 mgs. every 12 hours as needed for agitation ordered on 3/5/2025. The MAR indicated Seroquel's physician order was changed to 25 mgs. nightly on 3/13/2025. During a review of Resident 95's Physician Order Report, dated 3/17/2025 timed at 5:14 p.m. the Physician Order Report indicated an order of Seroquel 50 mgs. by mouth nightly and was started on 3/17/2025, at 11:15 p.m. During a review of Resident 95's MAR, the MAR indicated Zolpidem (Ambien) 5 mgs. nightly as needed (prn) for insomnia (difficulty falling asleep) was ordered on 3/5/2025 and was reordered on 3/19/2025. During a review of Resident 95's Nursing Progress Note dated 3/17/2025 timed at 6:22 p.m., the Nursing Progress Note indicated Resident 95 was confused, restless, agitated and had a feeling of sadness. The Nursing Progress Note indicated Resident 95 was confused and forgetful to situation and time and the resident tend to say, help me, help me. During a review of Resident 95's Nursing Progress Note dated 3/17/2025, timed at 3:36 a.m., the Nursing Progress Notes indicated Resident 95 was anxious, confused, and was climbing out of bed. The Nursing Progress Notes indicated Resident 95 was awake, with episode of inability to relax manifested by calling out from time to time. The Nursing Progress Notes indicated Resident 95 received pain medication for complaint of right forearm pain. The Nursing Progress Notes indicated on 3/17/2025, at 3:40 a.m. Resident 95 woke up requested anti- anxiety medication and was provided to Resident 95. During a review of Resident 95's Physician Order Report, dated 3/16/2025, timed at 7:30 p.m. an order of Ativan 1 milligram (mg.- unit of measurement) by mouth 2 times a day without indication and was started on 3/17/2025 at 8:00 a.m. During a review of Resident 95's Informed Consent (voluntary agreement to accept treatment after receiving education regarding risks, benefits and alternatives offered) dated 3/16/2025 timed at 7:30 p.m., the Informed Consent indicated a signed consent for the use of Ativan 1 mg. twice a day for anxiety. During a review of Resident 95's Informed Consent dated 3/17/2025 timed at 7:30 p.m., the Informed Consent indicated a signed consent for the use of Seroquel 50 mgs. nightly for psychosis. During a review of Resident 95' Neurology Transitional Care Unit Follow up Note dated 3/17/2025, the Neurology Transitional Care Follow Up Note indicated Resident 95 was still having depression and aphasia (disorder that makes it difficult to speak) was improving. The Neurology Transitional Care Unit Follow Up Note indicated Resident 95 continued to have mood changes and would treat depression/anxiety aggressively, reevaluate, increased the dose of Seroquel to 50 mgs. nightly for rage episodes as described by the resident's family member and would start Ativan (medicine to treat anxiety) 1 mg. twice a day. During a review of Resident 95's Care Plan titled Psychotropic Drug Use and Risk for related side effects initiated 3/6/2025, the Care Plan indicated Resident 9. were on psychotropic medicines such as Seroquel for psychosis manifested by hallucinations (sensory experiences that occur without external stimulus), Ambien for hypnotics manifested by insomnia, Fluoxetine for depression manifested by worthlessness/helpless/hopeless and Diazepam for anxiety manifested by inability to relax. The Care Plan's goals indicated the resident will have than less than two episodes of hallucinations, inability to relax, inability to sleep and feeling of worthlessness. The Care Plan's interventions included administration of medication as ordered and monitoring of resident's behavior. During a concurrent observation and interview on 3/27/2025, at 8:39 a.m. with Resident 95, Resident 95 was lying in bed. Resident 95 stated she was sleepy. Observed Resident 95 not fully awake. Resident 95 stated she could not remember the names of her medications that help her relax. During a concurrent interview and record review of Resident 95's electronic chart on 3/27/2025, at 10:43 a.m. with Registered Nurse (RN 2), RN 2 stated the psychotropic medicines were given to Resident 95 's anxiety. RN 2 stated Resident 95 had psychosis, depression and anxiety and confirmed there was no psychiatrist evaluating resident's behavioral problems and psychotropic medication. RN 2 stated the Valium, Prozac and Ambien were resident home medications that were continued in the facility and no documented diagnosis of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) was found in the electronic health record. RN 2 stated Resident 95 might become sleepier due to the use if these psychotropic medications. RN 2 stated Resident 95's mental health could get worse if resident's psychotropic medications were not reevaluated or monitored for appropriateness of use. During a concurrent interview and record review on 3/27/2025, at 12:22 p.m. with RN 3, reviewed Resident 95's electronic health record. RN3 stated there was no diagnosis of psychosis in Resident 95's electronic health the chart. RN 3 stated psychotropic medicines from home will be verified by licensed nurse with the physician who will reconcile the medications from home. RN 3 stated not reassessing the appropriateness of psychotropic medicines could put Resident 95 at risk for unnecessary medication and adverse effects. During a concurrent interview and record review on 3/28/2025, at 10:37 a.m. with RPH1 reviewed Resident 95's electronic health record. RPH 1 stated the physician's order for Ativan had no indication for its use and Seroquel was ordered for agitation. RPH 1 stated if he had seen the order for Ativan without indication, he would have clarified the order with Resident 95's physician. RPH 1 stated Resident 95 could be at risk for side effects like sedation (stated of calmness, relaxation, or sleepiness caused by a drug) and would not be able to participate in activities of daily living. RPH 1 stated psychotropic medication could act as a chemical restraint (medication given primarily to control a person's behavior, used for discipline or convenience and not required to treat medical symptoms) and could cause adverse effects if they are given without proper indication and monitoring for their appropriateness. During a concurrent interview and record review on 3/28/2025, at 9:07 a.m. with Assistant Nurse Manager (ANM), reviewed Resident 95's electronic health record. ANM stated Resident 95 took Valium, Prozac, Ambien at home prior to admission to the facility. ANM stated Seroquel and Ativan were started in the facility. ANM stated the physician order of Ativan 1 mg. twice a day had no indication for its use. ANM stated there should be an indication when ordering a psychotropic medication like Ativan. ANM stated Resident 95 had a change in condition (COC- any significant alteration in a patient's physical, mental, or emotional stays that requires attention and intervention) on 3/17/2025 for increased anxiety. ANM stated the neurologist (medical doctor who specializes in diagnosing and treating diseases of the brain, spinal cord, and nerves) ordered the Ativan and increased the dose of Seroquel 50 mgs nightly for psychosis. ANM stated the facility should have ordered psychiatric consultation, to ensure the use of psychotropic medication was addressed and Resident 95's increased anxiety. ANM stated the use of too many psychotropic medications could lead to unnecessary medication and could affect resident's activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). During an interview on 3/28/2025, at 11:45 a.m., with the Director of Nursing (DON), the DON stated the facility should know why the psychotropic medications were prescribed and why the resident would need the medications. The DON stated Resident 95 should have gotten a psychiatric consult to address the change in condition of increased anxiety on 3/7/2025 and Seroquel and Ativan were ordered for the increased anxiety. B. During a review of Resident 293's admission Record, the admission Record indicated Resident 293 was admitted on [DATE]. During a review of Resident 293's Hospitalist Progress Note dated 3/24/2025, the Hospitalist Progress Note indicated Resident 293 was oriented to person. During a review of Resident 293's History & Physical (H&P) dated 3/22/2025, the H&P indicated Resident 293 had diagnoses of anxiety (intense, excessive, and persistent worry and fear about everyday situations), cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure), and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). During a review of Resident 293's Active Medication Orders dated 3/28/2025 indicated Resident 293 was prescribed lorazepam (medication to treat anxiety) 0.5 mg every eight hours as needed for anxiety, insomnia (trouble falling asleep or staying asleep). The active medication orders also indicated that Resident 293 was taking Seroquel 25 mg nightly with no indication of its use. During a review of Resident 293's Completed Medication Administration Record (MAR) dated 3/28/25, the MAR indicated Resident 293 was given lorazepam 0.5mg on 3/24/25 at 1:44 p.m., and on 3/25/25 at 6:09 p.m. The MAR also indicated Resident 293 was given Seroquel 25 mg nightly on 3/24/2025 at 8:26 p.m., 3/25/2025 at 8:56 p.m., 3/26/2025 at 8:56 p.m., and 3/27/2025 at 8:22 p.m. During a review of Resident 293's Informed Consent for Psychotropic Medications, dated 3/21/2025, the Informed Consent indicated Resident 293 was taking Ativan 0.5 mg every eight hours as needed for anxiety as manifested by impatience, inability to relax and insomnia. During a review of Resident 293's Informed Consent for Psychotropic Medications, dated 3/24/2025, the Informed Consent indicated Resident 293 was taking Seroquel 25 mg nightly for agitation as manifested by persistent crying out. During an interview on 3/28/25 at 9:55 a.m. with ANM, the ANM stated agitation was not a diagnosis for giving Seroquel it was a manifestation of a behavior. The ANM stated that insomnia was not an appropriate manifestation to give lorazepam during the day. The ANM stated lorazepam should be given for insomnia at night. The ANM stated facility pharmacist should have caught this. The AMN stated that the use of too much psychotropic medication would be deemed unnecessary. During an interview on 3/28/25 at 11:45 a.m. with the DON, the DON stated we need to know the reasons why psychotropic medications were prescribed and if they were appropriate for Resident 293 to take. The DON stated to much psychotropic medication can cause respiratory depression, constipation and depression. During a review of facility's policy and procedure (P&P) titled Psychotropic Drug Management for Long Term Care Facilities, revised 3/2022, the P&P indicated Psychoactive medications (anti-psychotics, anti-depressants, anti-anxiety, hypnotics) must only be prescribed by a person authorized to prescribe medications, when a medication is necessary to treat a specific condition as diagnosed and documented in the medical record and to use the lowest effective dose to optimize treatment and reduce adverse effects. The P&P indicated it is the responsibility of the physician or provider who prescribes psychoactive medications to include the specific condition and target behavior documented in the medical record. The P&P indicated if the physician wishes to write a new order for a prn antipsychotic, the physician should evaluate the patient to determine appropriateness of the order, evaluation and rationale must be documented in the medical order.

Based on observation, interview, and record review, the facility failed to ensure safe, secured, and limited access to Resident 20's, Resident 94's and Resident 296's prepared medication that was left at the bedside and Resident 95's gabapentin (a medication used to treat nerve pain), affecting four of five residents sampled during medication administration. This deficient practice increased the risk of unintended access to medications, potential for misuse and medication errors for Residents 20, 94, 95 and 296. Findings: a. During a concurrent observation and interview on 3/26/2025 at 8:46 a.m. with Registered Nurse (RN) 2, RN 2 prepared five medications to be administered for Resident 20. RN 2 stepped away, stating she needed to find a pill-cutter and left the following medications unattended at her mobile computer station. 1. One tablet of losartan 50 milligram ([mg] a unit of measurement for mass) 2. Two tablets of vitamin D 25 microgram ([mcg] a unit of measurement for mass) 3. One tablet of vitamin C 500 mg 4. One-half tablet of hydrochlorothiazide 25 mg 5. One tablet of Thera-vite (multivitamin with iron) RN 2 performed blood pressure check for Resident 20 and based on blood pressure reading, RN 2 stated she would administer medications except for losartan 50 mg and hydrochlorothiazide 25 mg. RN 2 left Resident 20's room to ask a question to Certified Nurse Assistant (CNA), leaving behind the losartan 20 mg and hydrochlorothiazide 25 mg unattended in Resident 20's room. b. During a concurrent observation and interview on 3/26/2025 at 9:20 a.m. with RN 2, RN 2 prepared five medications to be administered for Resident 94. RN 2 crushed the tablet form of following medications to be administered with apple sauce. RN 2 stated she needed to find a spoon and left the mixture of medications and docusate oral liquid on the bedside table unattended when she left Resident 94's room. 1. One tablet of amlodipine 5 mg 2. One tablet of ferrous gluconate 324 mg 3. One tablet of bisoprolol 5 mg 4. One tablet of multivitamin with iron 5. 10 milliliters ([mL] a unit of measurement for volume) of docusate sodium oral liquid 50 mg per 5 mL c. During a concurrent observation and interview on 3/26/2025 at 10:22 a.m. with RN 4, RN 4 initially prepared five medications to be administered for Resident 296 and then returned them to automated dispensing storage when Resident 296 was not found to be in his room. On 3/26/2025 at 10:59 a.m., RN 4 stated she saw Resident 296 returned from therapy and so she was ready to retrieve medications and administer them. RN 4 stated she needed to bring the blood pressure monitor and left the following medications unattended on mobile computer station in resident's room. 1. One tablet of furosemide 20 mg 2. One tablet of amlodipine 2.5 mg 3. One tablet of aspirin 81 mg chewable 4. One-half tablet of metoprolol tartrate 25 mg 5. One tablet of amiodarone 200 mg d. During a concurrent observation and interview on 3/26/2025 at 2:07 p.m. with RN 2, RN 2 prepared one capsule of gabapentin 300 mg to be administered for Resident 95. RN 2 stated she needed to get apple sauce from the kitchen and left the gabapentin at Resident 95's bedside unattended. RN 2 stated she forgot the meds on the cart unattended. RN 2 stated medications should not be left unattended because that would increase the risk that residents could grab the medication and take them without supervision. During an interview on 3/27/2025 at 4:58 p.m. with the Director of Nursing (DON), DON stated no medications should be left unattended. DON stated if there was a reason for a facility nurses to step away, they should move the medications to medication room to prevent medication errors, prevent medications storage at unsafe temperatures, and to prevent unintended access to medications. During a review of the facility's policy and procedure (P&P) titled, Pyxis MedStation Nursing Use of Policy - So Bay Community, applicability includes TCC, dated 3/2023, the P&P indicated, Custody of the medication is the responsibility of the nurse removing the medication (e.g., the nurse removing the medication must be the one administering the medication - except .above). During a review of the facility's P&P titled, Labeling of Medications, applicability includes TCC, dated 5/2024, the P&P indicated, Drugs dispensed from Pyxis or floorstock and immediately administered to the patient do not require additional labeling. This includes unit dose administration. An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process. During a review of the facility's P&P titled, Medication Management, applicability includes TCC dated 7/2023, the P&P indicated, Medication Administration Procedures .Note: Do not leave the medication at the bedside. Facility did not provide any specific policy focused only on medication storage.

Based on observation, interview and record review, the facility failed to observe infection control measures by not ensuring staff perform hand hygiene when food server (FSW) failed to wash her hands when entering leaving the kitchen area. This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: During tray line observation on 03/26/2025 at 11:03 a.m., in the kitchen, FSW walk in the kitchen, from outside holding a used surgical mask on her right hand. FSW walked towards her co-worker who was preparing food in the kitchen. FSW left the kitchen again without washing her hands. During a concurrent observation and interview on 03/26/2025 at 11::46 a.m., with FSW, FSW stated she should wash her hands when entering and leaving the kitchen area. FSW stated she was in a hurry to ask another kitchen staff about something and don't want to forget. FS 1 stated that not washing her hands can cause cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and infection control issues. During an interview on 3/28/25 at 09:07 am, with the Kitchen Director Manager (KDM), KDM stated he does in-service once a month about handwashing and different area, and daily huddles, for all shift, KDM stated staff should wash their hands prior to entering the kitchen area and prior to leaving the kitchen area. During an interview on 03/28/25 at 09:14 a.m., with Kitchen Assistants Director (KAD), KAD stated it was important for staff to wash their hands prevent to cross contamination. KAD stated all kitchen staff including the cook, should wash their hands when entering the kitchen area and prior to leaving the kitchen area and must wear a hair net. During a review of the facility's policy and procedure (P&P) revised 10/22, titled Hand Hygiene, the P&P indicated, In the food &Nutrition Services Department: Hands are washed with soap and water at the following Times: After taking a break/when returning to kitchen, After touching hair, skin, beard or clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records updated to show documentation that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed and written information was provided to the residents and /or responsible parties for two of five residents (Residents 89 and 195). This failure violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was admitted to the facility on [DATE]. During a review of Resident 89's History and Physical (H&P), the H&P indicated Resident 89 was admitted with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 89's Minimum Data Set (MDS- a resident assessment tool) dated 3/23/2025, the MDS indicated Resident 89's cognition (ability to think, understand, learn, and remember) was severely impaired and required maximal assistance with toileting and personal hygiene and lower body dressing. During a review of Resident 195's admission Record, the admission Record indicated Resident 195 was admitted to the facility on [DATE]. During a review of Resident 195's H&P, the H&P indicated Resident 195 was admitted with diagnoses including atrial fibrillation (an irregular and often and very rapid heart rhythm) and hypertension (HTN- high blood pressure). During a review of Resident 195's MDS dated [DATE], the MDS indicated Resident 195's cognition was intact and dependent with toileting hygiene and lower body dressing. During a concurrent interview and record review on 3/27/2025 at 11:59 a.m. with the Social Worker (SW), the SW stated advance directives are discussed with each resident upon admission. SW stated residents are asked if they have an advance directive or would like to form one. SW stated there was no documentation that an advance directive was offered or discussed for Resident's 89 and 195. During an interview on 3/28/2025 at 12:13 p.m. with the Director of Nursing (DON), the DON stated all residents should be offered to formulate an advance directive for their protection, choices, and rights. The DON stated the advance directive is important to have so the staff are aware of what the resident's wishes are or who would make the decision for their care if they were unable to do so for themselves. During a review of the facility policy and procedure (P&P) titled, Advance Directives, dated 7/2018, the P&P indicated, In compliance with the Patient Self-Determination Act, all adult patients admitted to the medical center as inpatients, or their surrogates/family members, will be given specific information concerning Advance Directives unless they specifically state they do not need or want information on the topic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Certified Nursing Assistant's (CNA's) annual skills competencies were completed for CNA 2 and CNA 3 . These failures had the potential to put the resident's safety at risk during care. Findings: During a concurrent interview and record review on [DATE] at 10:45 a.m. with the Director of Staff Development (DSD), CNA 2 and CNA 3's Education & Professional Practice Competency Checklists. The DSD stated CNA 2 was hired on [DATE] and her last competency was done on [DATE]. The DSD stated CNA 3 was hired [DATE] and that her last skills competency was done on [DATE]. The DSD stated competencies are done annually. DSD stated we need to make sure that the staff are still preforming their skills appropriately. DSD stated CNA's can develop wrong habits and residents could receive poor care and be re-hospitalized if the CNAs are not providing good quality care. During an interview on [DATE] at 12:17 p.m. with the Director of Nursing (DON). The DON stated the DSD is responsible for education in the facility and that the CNAs should have annual skills competencies to ensure that the staff are performing their skills accurately and not missing anything . The DON stated there is a risk for the residents to develop an infection when not providing proper care. During a review of the facility's policy and procedure (P&P) titled Transitional Care Center Scope of Service - Education. Dated 7/2024, the P&P indicated, in keeping with the mission and core values of St. [NAME] Health Services Transitional Care, it is the policy of the facility to provide quality care for residents/customer satisfaction by individualizing, teaching, and coordination with other health services to assure continuity of care and to provide safe delivery of patient care to a culturally diverse young adult to geriatric community. A. The education department/ staff development assess and maintain the educational needs of the nursing staff and the interdisciplinary health team of Providence Little Company of [NAME] Transitional Care Center. B. Provides educational programs, in-services in accordance with the requirement of the federal and state regulations of Title XXII and TJC (The joint commission) C. Develops coordinates and implements competency based educational programs which are in compliance with the applicable standards and regulations. D. Maintains updated licenses, CPR certificates & health/physical exams. Validates and maintains competencies required for the nursing staff and other members of the health care team as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 20's physician orders for losartan (a medication used to treat hypertension [HTN - high blood pressure]) and hydrochlorothiazide (a medication used to treat HTN) indicated hold parameters for medications based on resident's blood pressure readings, affecting one of five sampled residents reviewed for medication administration. This deficient practice had the potential to result in medication errors, blood pressure abnormalities and heart complications for Resident 20. Findings: During a review of Resident 20's admission Record, dated 3/26/2025, the admission Record indicated, Resident 20 was admitted to the facility on [DATE]. During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 3/4/2025, the MDS indicated, Resident 20's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated, Resident 20 needed supervision level assistance from facility staff for Activities of Daily Living (ADLs) such as eating, oral hygiene and personal hygiene, moderate assistance for upper body dressing, and dependent for toileting hygiene, showering, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 3/26/2025 between 8:46 a.m. and 8:57 a.m. with the Registered Nurse (RN) 2, RN 2 prepared five medications to be administered to Resident 20 that included, but not limited to, the following: 1. One tablet of losartan 50 milligrams ([mg] a unit of measurement for mass) 2. One-half tablet of hydrochlorothiazide 25 mg (12.5 mg dose) RN 2 then conducted blood pressure check for Resident 20 using an automatic blood pressure monitor. RN 2 stated Resident 20's systolic blood pressure ([SBP] the pressure with which the heart pumps blood into the arteries) was 114 millimeters of mercury ([mmHg] a unit of measurement for blood pressure) and diastolic blood pressure ([DBP] the pressure in arteries when the heart is relaxed between beats) was 44 mmHg. RN 2 stated, the bottom BP reading (DBP) was low so she would recheck resident's blood pressure. During a concurrent observation and interview on 3/26/2025 at 8:57 a.m. with RN 2, RN 2 conducted blood pressure check again for Resident 20. RN 2 stated Resident 20's BP reading was 117(SBP) mmHg / 44 (DBP) mmHg. RN 2 stated she would hold losartan and hydrochlorothiazide and would determine later if able to administer them after rechecking Resident 20's blood pressure after his rehabilitation therapy. RN 2 stated she did not have physician orders or hold parameters to hold the losartan and hydrochlorothiazide but in her judgement, she would hold them because the DBP was lower than 50 mmHg. During a review of medication reconciliation and review of Resident 20's Physician Order Summary Report, dated 3/26/2025, the Physician Order Summary Report indicated, but not limited to, the following medications: 1. Hydrochlorothiazide 12.5 mg, take one tablet by mouth daily, order date 2/25/2025, start date 2/26/2025. 2. Losartan tablet 50 mg, take one tablet by mouth daily, order date 2/25/2025, start date 2/26/2025 During a review of Resident 20's Nursing Progress Notes, signed date 3/26/2025 timed at 3:21 p.m., the RN 2's Nursing Progress Notes indicated, BP was checked at 8:55 a.m., 114/44 mmHg and medication was held .BP rechecked at 11:00 a.m., and medication was given, BP at the time was 130/56 . During a review of Resident 20's Nursing Progress Notes, edited date 3/26/2025 4:06 p.m., RN 2's Nursing Progress Notes indicated, parameter for losartan 50 mg and hydrochlorothiazide 12.5 mg, hold for DBP less than 50, hold for SBP less than 100, put it in MAR. During a concurrent interview and record review on 3/27/2025 at 10:44 a.m. with the Assistant Nurse Manager (ANM) and the Registered Nurse (RN) 6, the order audit trail for Resident 20's hydrochlorothiazide 12.5 mg and losartan 50 mg were reviewed. The initial order details (after action #3, after action #2 and after action #1) for hydrochlorothiazide 12.5 mg and losartan 50 mg did not indicate hold parameters. Order details after action #4 which was a modified order, indicated the hold parameters for hydrochlorothiazide 12.5 mg daily and losartan 50 mg indicating to hold if SBP less than 100 or DBP less than 50. ANM stated if there was a hold parameter for resident's high blood pressure medications from the physician's order, then the nurse should follow that. ANM stated if the nurse did not feel comfortable administering the medication because of low blood pressure, she should have escalated the situation by calling the physician to ask if he/she could hold the blood pressure medication. ANM stated she did not have a facility specific protocol to show for blood pressure monitoring. ANM stated the facility nurse should have called the physician to get an order of 'hold parameters' when she decided to hold the medications due to low blood pressure. During an interview on 3/26/2025 at 1:45 p.m. with RN 2, RN 2 stated she knew she would need physician orders for medications before they can be administered or held if needed. RN 2 stated, in the past, doctor was okay with the medications being held if the nurse thought of doing so in her clinical judgement. RN 2 stated she did not contact the physician before holding administration of Resident 20's blood pressure medications. RN 2 stated if physician orders were not followed for blood pressure medications, it could have caused abnormal blood pressure. RN 2 stated she did not see any parameters for Resident 20's blood pressure medications. RN 2 stated she could not describe or explain if there was a facility protocol or guidelines that she was following but usually saw parameters such as hold if BP less than 110. During a review of the facility's policy and procedure (P&P) titled, Medication Management, applicability includes TCC, dated 7/2023, the P&P indicated, Medication Orders: medication may only be administered by an RN and LVN on the order of a licensed physician The P&P indicated, Protocol orders are performed only on order of the physician as a patient's condition warrants. Titrate orders include specific limits and guidelines for dosage adjustment and frequency of patient assessment. Taper orders include specific dosage adjustments and frequency of change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of five reviewed residents for medication errors (Residents 95 and 296) by failing to: a. Administer Resident 95's Vimpat ([generic name - lacosamide] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), gabapentin (a medication used to treat nerve pain and seizures), levetiracetam (a medication used to treat seizures) and metoprolol tartrate (a medication used to treat high blood pressure), within one hour before or after the scheduled administration time of 9:00 a.m., per facility's policy and procedure (P&P) titled, Medication Management, dated 7/2023. b. Administer Resident 296's furosemide (a medication used to treat fluid retention and high blood pressure), amlodipine (a medication used to treat high blood pressure), metoprolol tartrate and amiodarone (a medication used to treat heart complications), within one hour before or after the scheduled administration time of 9:00 a.m., per facility's P&P titled, Medication Management, dated 7/2023. These deficient practices of medication error rate of 26.67 percent (%) exceeded the five (5) % threshold and placed Residents 95 and 296 at risk for adverse medical consequences such as seizures, high blood pressure and cardiac complications. Findings: a. During a review of Resident 95's admission Record, the admission Record indicated, Resident 95 was admitted to facility on 3/5/2025. During a review of Resident 95's History and Physical (H&P), dated 3/5/2025, the H&P indicated Resident 95's diagnoses including to, history of multiple sclerosis ([MS]- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), possible status epilepticus (seizure), hypertension ([HTN] high blood pressure), history of depression and anxiety, and deep venous thrombosis ([DVT] a medical condition characterized by blood clots in deep vein, in the leg) risk. During a review of Resident 95's Minimum Data Set (MDS -resident assessment tool), dated 3/12/2025, the MDS indicated, Resident 95's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated, Resident 95 needed maximal assistance from facility staff for activities of daily living (ADLs) such as eating and upper body dressing, moderate assistance for oral hygiene and personal hygiene, and activities such as toileting, showering, and lower body dressing. During an observation on 3/26/2025 at 8:32 a.m. with Registered Nurse (RN) 2, RN 2 prepared and administered one tablet of lorazepam (a medication used to treat anxiety) 1 milligrams ([mg] a unit of measurement for mass) to Resident 95 before moving on to the next resident during medication administration. During the process of medication reconciliation and review of Resident 95's Physician Order Summary Report, dated 3/27/2025, the Physician Order Summary Report indicated, the following medications were also scheduled to be administered starting at 9:00 a.m. daily, in addition to Lorazepam administered during medication administration observation: 1. Gabapentin capsule 300 mg, take 1 capsule by mouth three times daily, order date 3/5/2025, start date 3/5/2025. 2. Lacosamide 200 mg, take 1 tablet by mouth two times daily, order date 3/5/2025, start date 3/5/2025. 3. Levetiracetam 1000 mg, take 1 tablet by mouth two times daily, order date 3/5/2025, start date 3/5/2025. 4. Lorazepam 1 mg, take 1 tablet by mouth two times daily, 0800 (8:00 a.m.) & 1800 (6:00 p.m.), order date 3/16/2025, start date 3/17/2025. 5. Metoprolol tartrate 12.5 mg, take 1 tablet by mouth two times daily, hold if systolic blood pressure ([SBP] the pressure with which the heart pumps blood into the arteries) less than 105 or heart rate (HR) less than 65, order date 3/6/2025, start date 3/6/2025 During a review of Resident 95's Medication Administration Record (MAR), dated 3/26/2025, the MAR indicated the following medications were administered at 10:36 a.m. which was one hour and 36 minutes after the scheduled medication administration time of 9:00 a.m.: 1. One capsule of gabapentin 300 mg (300 mg dose) administered on 3/26/2025 at 10:36 a.m. 2. Four tablets of lacosamide 50 mg (200 mg dose) administered on 3/26/2025 at 10:36 a.m. 3. Two tablets of levetiracetam 500 mg (1000 mg dose) administered on 3/26/2025 at 10:36 a.m. 4. One-half tablet of metoprolol tartrate 25 mg (12.5 mg dose) administered on 3/26/2025 at 10:36 a.m. b. During a review of Resident 296's admission Record, the admission Record indicated Resident 296 was admitted to the facility on [DATE]. During a review of Resident 296's H&P dated 3/24/2025, the H&P indicated Resident 296's diagnoses including chronic kidney disease (CKD a gradual, progressive loss of kidney function) and non-ST elevation myocardial infarction (MI - heart attack). During a concurrent observation and interview on 3/26/2025 at 10:22 a.m. with RN 4, RN 4 removed the following five medications from automated dispensing machine to be administered to Resident 296. 1. One tablet of furosemide 20 mg 2. One tablet of amlodipine 2.5 mg 3. One tablet of metoprolol tartrate 25 mg, but dose of one-half tablet (12.5 mg) to be given 4. One tablet of amiodarone 200 mg 5. One tablet of aspirin 81 mg chewable tablet RN 4 stated Resident 296 left for his therapy upon reaching Resident 296's room to administer medications. RN 4 stated she would need to return to administer medications to Resident 296 after he returned from therapy. RN 4 stated Resident 296's medications were scheduled for 9:00 a.m. and were supposed to be given latest by 10:00 a.m. RN 4 stated it was important to administer medications on time to ensure stable blood concentrations. RN 4 stated Resident 296 was on a few blood pressure medications as listed above, so Resident 296 was at risk for high blood pressure, and could get symptoms of headache. RN 4 stated high blood pressure could place Resident 296 at risk for stroke (loss of blood flow to a part of the brain) and hospitalization. RN 4 stated, sometimes medications could be administered late because there were a lot of activities during medication administration task and all residents have therapy. During an observation on 3/26/2025 at 10:59 a.m., RN 4 administered Resident 296's medications after checking his blood pressure. During a review of Resident 296's Physician Order Summary Report, dated 3/26/2025, the Physician Order Summary Report, indicated the following medications scheduled to be administered starting at 9:00 a.m. daily, unless specified otherwise: 1. Amiodarone 200 mg, take 1 tablet by mouth two times daily, order date 3/24/2025, start date 3/25/2025. 2. Amlodipine 2.5 mg, take 1 tablet by mouth daily for radial artery spasm prevention, order date 3/24/2025, start date 3/25/2025. 3. Aspirin chewable tablet 81 mg, take 1 tablet by mouth daily, initiate within 6 hours of arrival in the intensive care unit, if aspirin was not administered preoperatively. If unable to take by mouth tablet, may give rectal aspirin, if ordered, order date 3/24/2025, start date 3/25/2025. 4. Furosemide 20 mg, take 1 tablet by mouth daily, order date 3/24/2025, start date 3/25/2025. 5. Metoprolol tartrate 12.5 mg, take 1 tablet by mouth daily, hold for HR less than 60, SBP less than 100, order date 3/24/2025, start date 3/25/2025. During a review of Resident 296's MAR, dated 3/26/2025, the document indicated the following medications were administered at least two hours after the scheduled medication administration time of 9:00 a.m.: 1. One tablet of amiodarone 200 mg (200 mg dose) administered on 3/26/2025 at 11:07 a.m. 2. One tablet of amlodipine 2.5 mg (2.5 mg dose) administered on 3/26/2025 at 11:08 a.m. 3. One tablet of aspirin chewable tablet 81 mg (81 mg dose) administered on 3/26/2025 at 11:08 a.m. 4. One tablet of furosemide 20 mg (20 mg dose) administered on 3/26/2025 at 11:06 a.m. 5. One-half tablet of metoprolol tartrate 25 mg (12.5 mg dose) administered on 3/26/2025 at 11:08 a.m. During a concurrent interview and record review on 3/27/2025 at 11:23 a.m. with Assistant Nurse Manager (ANM), Resident 95's MAR for 9:00 a.m. was reviewed. ANM stated, Resident 95's gabapentin, lacosamide, levetiracetam and metoprolol tartrate were due at 9:00 a.m. and should have been administered within one hour time frame from scheduled administration time. ANM stated Resident 95's medications were administered on 3/26/2025 at 10:36 a.m., which was late by at least 35 minutes. ANM stated it was important that facility nurses gave Resident 95's medications on time to be able to manage pain and seizures. ANM stated if the medications were not administered on time, there was a risk of hospitalization due to seizures, high blood pressure and stroke. During a concurrent interview and record review on 3/27/2025 at 11:37 a.m. with ANM, Resident 296's MAR for 9:00 a.m. was reviewed. ANM stated, Resident 296's aspirin, amlodipine, metoprolol tartrate, amiodarone and furosemide were due at 9:00 a.m. and were administered late after 11:00 a.m. which was beyond the allowed one hour after scheduled administration time of 9:00 a.m. ANM stated facility nurse was supposed to follow the policy to administer medications within one hour before and one hour after the scheduled time of administration. ANM stated facility nurse should have called the physician by 10 a.m. to get authorization whether to administer medications late. During a concurrent interview and record review on 3/27/2025 at 11:23 a.m. with the Director of Risk and Regulatory (DRR), the facility's P&P, titled, Medication Management was reviewed. The DRR stated, medications due at 9 a.m., could be given as early as 8 a.m. and as late as 10 a.m. The DRR stated, there was an addendum to the Medication Management policy titled, 'Addendum B Missed Dose and 1st Dose Home Medication Decision Guide - Post-EPIC,' that supposed to act as a guide for facility staff for retiming of missed doses - If a medication was missed daily for 9 a.m. dose, then could give dose now (then) and resume at 9 a.m. tomorrow (next day). The DRR stated, by policy, it was considered a missed dose, and then the policy gave instructions on when it could be safely given and resumed. The DRR stated, this addendum was followed for all skilled nursing facility medications as well as for hospital medications. During a concurrent interview and record review on 3/27/2025 at 12:29 p.m. with ANM, Resident 296's physical therapy schedule and notes were reviewed. ANM stated Resident 296's physical therapy start time on 3/26/2025 was at 10:21 a.m. During an interview on 3/27/2025 at 2:27 p.m. with RN 2, RN 2 stated, she thought that it was okay to administer 9:00 a.m. medications until 10 a.m. to 10:30 a.m. RN 2 then stated she could have administered Resident 95's medications on 3/26/2025 along with her lorazepam, to prevent their late administration at 10:36 a.m. RN 2 stated there was a risk for Resident 95 to experience seizures, nerve pain and high blood pressure because she received her medications late. During an interview on 3/27/2025 at 4:48 p.m. with the Director of Nursing (DON), the DON stated, the medications scheduled for 9:00 a.m. administration and given at 10:36 a.m. and 11:00 a.m. would be considered late administration. The DON stated, licensed nurse should follow one hour before and one hour after the scheduled administration time window. The DON stated if medications like amiodarone and others such as those for high blood pressure and seizures were given later than scheduled time, it would place residents at increased risk for seizures, high blood pressure, stroke and hospitalization. During a review of the facility's P&P, titled, Medication Management, applicability includes TCC, dated 7/2023, the P&P indicated, Medication Administration Procedures: Refer to Lippincott's Nursing Procedures and Skills for Medication Administration Procedures and Safe Medication Practices. For Non- Time-Critical Scheduled Medications - medication prescribed with a minimum frequency of every four (4) hours and not greater than every 24 hours, the goals for timely administration - within one (1) hour before or after the scheduled time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for one of one sampled resident (Resident 1), a morse fall risk assessment (a tool used to assess a resident's risk of falling in a hospital setting) was completed every shift in accordance with the facility's policy regarding Fall Risk Assessment and Prevention. These deficient practices had the potential to cause a delay in determining Resident 1's fall assessment and/or provision of proper fall intervention needed, which could result in fall that could cause Resident 1 harm or even death. Findings: During a review of Resident 1's History and Physical (H&P), dated 10/21/2024, the record indicated Resident 1 was a [AGE] year-old female with ongoing medical problems including history of hemorrhagic cerebrovascular accident (occurs when a blood vessel in or on the brain breaks or leaks, causing bleeding) June 2022, and seizure (a temporary episode of abnormal electrical activity in the brain that causes a sudden change in behavior, movement, or consciousness) disorder diagnosed March 2024. Resident 1 was admitted to the hospital for breakthrough seizures. During a concurrent interview and record review of Resident 1's electronic medical record (EMR) on 11/18/2024 at 11:43 a.m., with the Assistant Nurse Manager (ANM), the EMR indicated Resident 1 had an unwitnessed fall incident on 10/26/24 at 1:15 a.m., and Resident 1's bed was alarming and Resident 1 was found on the floor by a facility certified nursing assistant. The last morse fall risk assessment (a tool used to assess a Resident's risk of falling in a hospital setting) prior to Resident 1's fall incident was completed on 10/25/24 at 7:26 a.m.; approximately 17 hours before the fall incident. Resident 1 was missing two morse fall risk assessments prior to the fall incident. The ANM stated that a morse fall assessment must be completed every eight-hour shift. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment and Prevention, last revised 4/2021, the P&P indicated the following: 1. General precautions are taken to prevent all patients from a fall. 2. Each patient is assessed at time of admission, transfer, each shift and change in condition (e.g., change in ambulation status and/or recent fall incident) for fall risk and risk for sustaining injury. 3. The Morse Fall Assessment is the tool used to assess fall risk. A score of 24 or greater is considered an increased fall risk and triggers fall prevention actions. 4. Brain dead and/or comatose patients and patients receiving paralytics do not need to be assessed. 5. Patients' mobility is assessed using the Basic Mobility Tool to accurately assess how much assistance and what mobility assist devices should be utilized to safely mobilize the patient. 6. Upper side rails are customarily kept up for patient to use in getting up while lower side rails are kept down. 7. Patients at the highest risk for injury from a fall are those a. over age [AGE] b. frail due to a medical condition c. with a history of orthopedic conditions d. on anti-coagulation therapy e. with a bleeding disorder f. post-surgery or post-procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a cover (dignity bag) for a urine collection bag for one of two sampled Residents (Resident 32). This deficient practice had the potential to negatively affect Resident 32's sense of self-worth and self-esteem. Findings: During a review of Resident 32's admission record the admission record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses of congestive heart failure (a condition in which the heart doesn't pump blood as well as it should ), peripheral artery disease ( a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs ), and urinary retention (inability to empty all urine from the bladder). During a review of Resident 32's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 2/29/2024, the MDS indicated Resident 32 was moderately cognitively (ability to think, make decisions of daily living) impaired, dependent (helper does all effort or the assistance of 2 or more helpers required for the resident to complete the activity ) for toilet hygiene, lower body dressing and shower/ bathing. During a review of Resident 32's physician order dated 2/22/2024, the physician's order indicated an order for an indwelling foley catheter (plastic tubing inserted into the urinary canal that drains urine from the bladder into a bag outside of the body ) on 2/22/2024. During an observation on 03/14/2024 at 08:55 a.m , in Resident 32's room, Resident 32 had a foley catheter bag hanging on the lower bed frame with no dignity bag ( a cover used to hide the urinary bag's contents). During an interview on 3/14/2024 at 9:20 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 verified Resident 32 had no dignity bag . LVN 3 stated dignity bags are used for residents' privacy and all residents with a foley catheter should have one. During an interview on 3/15/2024 at 9:46 a.m., with the Nurse Manager the Nurse manager stated all residents in the facility who have a foley catheter must have dignity bags put on by the nurse for the residents' privacy . During an interview on 3/15/2024 at 2:46 p.m., with the Director of Nursing (DON), the DON stated it is the nurse's responsibility to provide a dignity bag for all residents with foley catheters for infection control and the residents dignity. During a review of the facility's policy and procedure (P/P) titled TCC/TCU : Residents Rights last revised 12/2023, the P/P indicates , in keeping the mission of this facility, it will be the policy of the facility that all residents have the right to a dignified existence , self- determination, and communication with and access to individuals and services, inside and outside of the facility. The facility must protect and promote the rights of each resident including those with limited cognition and other barriers that limit the exercise of rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the nursing staff failed to ensure residents' activated call light's (requests for assistance) were answered promptly for one of three sampled residents (Resident 255). This deficient practice had the potential to cause delay in meeting Resident 255's need. During a review of Resident 255's admission record note dated 3/1/2024, the note indicated Resident 255 was admitted on [DATE] with diagnoses including hypertension (high blood pressure), history of falls, and a lumbar compression fracture (when one or more bones in the spine weaken and crumble). During a record review of Resident 255's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 3/7/2024, the MDS indicated Resident 255's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact. The MDS indicated Resident 255 required partial/moderate assistance (helper does less than half of the effort) for toilet hygiene and required supervision on upper body dressing, transferring from sit to lying, chair/bed to bed transfer, and walking. During an observation on 3/12/2024 at 12:06p.m., Resident 255's call light was activated, inside the room, by Resident 255's bed, the call light had been pulled out of the wall, and was on the floor. After three minutes and fifty-six seconds, Resident 255's call light had been turned off by facility staff, and no one had gone to Resident 255's room to see what he needed. During an observation on 3/12/2024 at 12:28 p.m., Resident 255's call light was still on the floor (dislodged from the wall). None of the staff were observed coming to Resident 255's room to check on him and 18 minutes had passed. During a concurrent observation and interview on 3/12/2024 at 12:35p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 had observed Resident 255's call light was on the floor dislodged from the wall. CNA 2 stated if the call light is pulled from the wall, the call light will be activated and lit on the outside of the resident's room. CNA 2 stated call lights should be answered when they are lit, because a resident requires assistance. CNA 2 stated if the call light was not answered, the resident would have to wait, until a staff happen come into the room or if staff is doing their hourly rounding. CNA 2 stated the Certified Nursing Assistants are the ones that answer the call light most of the time, but if the resident required medication, they would inform the nurse. The total time it took for Resident 255's call light to be answered was 27 minutes and 58 seconds by CNA 2. During a review of the facility's P&P titled, TCC/TCU: admission of Patients/Residents revised on 12/2019, the P&P indicated under call light responsibility: it is everyone's responsibility to answer call lights. Caregiver answering call light will call or go back to the room to ensure call light has been answered and resident needs are met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality for one out of one sampled resident (Resident 33) when Registered Nurse (RN) 8 failed to administer the full ordered dose of Enoxaparin (a medication used to prevent blood clots that comes in a prefilled syringe). This deficient practice had the potential for Resident 33 to get blood clots due to not getting the prescribed amount of medication. During a review of Resident 33's admission note dated 2/9/2024, the note indicated Resident 33 was admitted on [DATE] with diagnoses including liver cirrhosis (scarring of the liver)/hepatitis C (inflammation of the liver), right tibia (shin bone) and fibula (calf bone) fracture, left calcaneal (heel bone) fracture, and anemia (not having enough healthy red blood cell to carry oxygen to the body's tissue). During a review of Resident 33's Minimum Data Set (MDS), a standardized assessment and care planning tool dated 2/15/2024, the MDS indicated Resident 33 was cognitively (mental action or process of acquiring knowledge and understanding ability) intact and required supervision for toilet hygiene, transferring from chair/bed to chair, rolling side to side, and is independent (ability to perform activities on their own) for eating, oral hygiene, and dressing the upper body (arms, shoulder). During a review of the Active Orders Quick View (Medication Orders), the Active Orders Quick View indicated Resident 33 has an order for Enoxaparin (Lovenox: medication used to prevent blood clots) 40 milligram (mg: a unit of measure of weight)/0.4 milliliter (ml: a unit of measure of volume) dated 3/1/2024. During a concurrent observation and interview on 3/15/2024 at 8:20 a.m., with Registered Nurse 8 (RN) 8, RN 8 was preparing to administer the Lovenox 40mg and was observed tapping the plunger of the syringe to 'clear the air bubbles' .When RN 8 pushed the syringe plunger, it forced the medication to shoot up from the tip of the needle to an approximate height of six inches into the air. During an interview on 3/15/2024 at 8:34 a.m., with RN 8, RN 8 stated the process of administering Lovenox is to clear the air bubble. RN 8 stated this was a standard practice for her but did not know what the standard of practice for the facility is. RN 8 reiterated that prior to administering Lovenox, she clears the air bubbles until she does not see any bubbles. RN 8 stated indicated the resident did not get the full dose of Lovenox as intended. During an interview on 3/15/2024 at 10:43a.m., with Medication Safety Regulatory Pharmacist (MSR PharmD), the MSR PharmD stated for the Lovenox 40mg, none of the medication should be wasted and the whole dose that is in the syringe should be administered. MSR PharmD stated Lovenox 40mg can be administered as it is without having to clear out the air bubble. The MSR PharmD stated the medication would not be as effective if half of the dose of the medication was wasted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the professional standards of practice in administering intravenous ([IV] administered through vein) medications when the IV antibiotic bags for 3 of 3 sampled residents (Residents 99, 103 and 106) were not labeled with resident's names, date, time and signature of staff administering, as indicated in their facility's policy and procedures (P&P) IV bag Preparation, dated 8/21/2023. This deficient practice had the potential for medication errors and to result in severe drug reactions, anaphylactic (a severe immune system reaction) shock, requiring hospitalizations or even death. Findings: a). During a review of Resident 99's admission Record, the admission record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses including clostridium difficile (a bacterium that causes an infection of the longest part of the large intestine). During a review of Resident 99's physician order dated 3/8/2024, the physician's order indicated intravenous antibiotic therapy of vancomycin antibiotic to treat bacterial infections 50 milligrams ([mg] unit of measurement) /milliliter (ml) liquid, 125 mg to be administered every twelve hours, until 3/20/2024. During an observation on 03/12/2024 at 3:20 p.m., Resident 99's hanging intravenous vancomycin antibiotic bag, had no label. b). During a review of Resident 103's admission Record, the admission record indicated Resident 103 was admitted to the facility on [DATE] with diagnoses including skin and soft tissue infection. During a review of Resident 103's physician order dated 3/10/2024, the physician order indicated intravenous antibiotic therapy of nafcillin (an antibiotic) two grams in sodium chloride (solution) 0.9% every six hours (frequency) until 4/13/2024. During an observation on 03/12/2024 at 2:52 p.m., Resident 103's hanging intravenous nafcillin antibiotic bag, had no label. c). During a review of Resident 106's admission Record, the admission record indicated Resident 106 was admitted to the facility on [DATE] with diagnoses including aspiration pneumonia (food or liquid is breathed into the airways or lungs, instead of being swallowed). During a review of Resident 106's physician order dated 3/7/2024, the physician order indicated intravenous antibiotic therapy of metronidazole (drug for the treatment of infections) in saline (solution), 500 mg three times daily (timing) until 3/11/2024. During an observation on 03/12/2024 at 2:55 p.m., Resident 106's hanging metronidazole intravenous antibiotic bag had no label. During an interview on 03/15/2024 at 3:03 p.m., Registered Nurse (RN) 4 stated that IV medications must be labeled and dated properly when administering to resident because of the possibility of medication errors and the potential that an IV medication administered belonged to a different resident. RN 4 also stated, it can lead to adverse reactions and even death. During an interview on 03/15/2024 at 3:23 p.m., RN 1 stated that it was a very bad practice not to date and label IV antibiotic administration properly as the medication could potentially be given to the wrong resident which could lead to anaphylactic shock, adverse reaction or even death. During a review of the P&P titled, IV bag Preparation, dated 8/21/2023, the P&P indicated, the IV bag must be labeled with the patient's name and identification number, date and time, the bag number (if applicable), the ordered rate and duration of infusion, and initials. The P&P also indicated to label the IV tubing, IV route at the proximal and distal ends to avoid misconnections to a different route or entry into the body.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement infection control measures by not ensuring the following for five out of seven sample residents (Residents, 11,17, 198 and 201): 1. Ensure Resident 198's peripherally inserted central catheter (PICC) line (a thin flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) dressing was changed weekly. 2. Change gloves and perform hand hygiene while administering medication and wiping down equipment for Residents 11, 17, and 201. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: a. During a review of Resident 198's admission record (face sheet), the face sheet indicated Resident 198 was admitted to the facility on [DATE] with diagnoses of congestive heart failure (a condition in which the heart doesn't pump blood as well as it should ), peripheral artery disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and enterococcal bacteremia ( an infection that spreads through the blood stream ). During a review of Resident 198 's history and physical (H&P) report dated 2/ 5 /2024, the H&P indicated resident 198 had the capacity to understand and make decisions. During a review of Resident 198 's Interdisciplinary Team Conference (IDT - Resident's health care team consisting of various specialties) notes, the notes indicated Resident 198 was admitted with a PICC line. During a concurrent observation and interview in Resident 198's room on 3/12/24 at 2:23 p.m., Resident 198 stated she had had the PICC line since she was admitted to the facility on [DATE] (8th day since admission). During a concurrent observation and interview on 3/12/2024 at 2:30 p.m., with Registered Nurse (RN) 1, RN 1 verified the last date of cleaning for the left arm PICC line was 2/24/2024. RN 1 stated that facility staff are to clean the PICC line, sign the dressing, and date it every seven days. RN1 stated the importance of cleaning a PICC line is to prevent the resident from getting infections. During an interview on 3/15/2024 at 9:46 a.m., with the Nurse Manager (NM), the NM stated the facilities protocol is PICC line dressings are to be changed every seven days to prevent line infection. NM stated even if the dressing looks clean you still must clean the site regardless. During a review of the facility's policy and procedure (P/P) titled Comprehensive Vascular Access Management Revised 5/2023, the P/P indicates site care, including skin asepsis and dressing changes, are performed at every seven (7) days and as needed when the dressing integrity is compromised (e.g., damped , loosened or visibly soiled); if moisture , drainage, or blood are present under the dressing; or for further assessment. b. During a review of Resident 11's untitled admission note dated 2/18/2024, the note indicated Resident 11 was admitted on [DATE] with diagnoses including graves' disease (autoimmune disorder [immune system attacks the healthy cells of your organs and tissues by mistake] that can cause hyperthyroidism, or overactive thyroid (hormone)), dysphagia (difficulty swallowing), hypertension (high blood pressure), and gastrostomy (g-tube: creation of an artificial opening into the stomach for nutritional support). During a record review of Resident 11's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 2/23/2024, the MDS indicated Resident 11's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact. The MDS indicated Resident 11 was dependent on toileting, eating, lower body dressing, changing positions (sit to lying, sit to stand) and required partial/moderate assistance for oral hygiene and upper body dressing (arms, shoulders). During an observation on 3/14/2024 at 9:39 a.m., with Registered Nurse (RN) 7, RN 7 had four medications that were to be administered to Resident 11 through the g-tube, one medication patch to be applied on the back, and one subcutaneous injection (medications administered between skin and muscle) to the stomach. From the moment RN 7 performed hand hygiene and wore gloves upon entering Resident 11's room, RN 7 was noted scanning Resident 11's wrist band, the medications that were to be administered, and was actively documenting on the computer with the same gloves. RN 7 proceeded to administer the four medications through the g-tube, placed the Lidocaine (medication to help reduce itching and pain) five (5) percent (%) patch on Resident 11's back, and prepared the Heparin (medication to help prevent harmful clots from forming in blood vessels) 5,000 units/milliliter (ml a unit of measure of volume) injection that was to be administered subcutaneously. RN 7 disposed the needle and medication cups after administering all six medications, removed her gloves. RN7 then, without performing hand hygiene wore a new set of gloves, and wiped down (sanitized) the computer station, keyboard, and mouse. With the same gloves, RN 7 got another wipe and wiped down the blood pressure machine so that it can be used for the next resident. During an interview on 3/14/2024 at 10:25 a.m., with RN 7, RN 7 stated hand hygiene should be performed before entering the room, in between touching one's surroundings, taking care of other residents, and before leaving the room. RN 7 stated every time equipment (ex: blood pressure machine) is used on a resident, it should be cleaned right after, and prior to using the device for the next resident. RN 7 stated when she received the blood pressure machine she had assumed it was clean. RN 7 stated since everyone uses the equipment for other Residents, they have the responsibility to clean and disinfect the equipment and cannot assume that it was cleaned prior to using the equipment. RN 7 stated if you are not sure whether the equipment was cleaned, it should be cleaned prior to use, to prevent infections. RN 7 stated hand hygiene is done to prevent infection and if not done properly, it could spread infections to the residents. c. During a review of Resident 17's untitled admission note, dated 2/1/2024, the note indicated Resident 17 was admitted on [DATE] with diagnosis including diabetes (irregular management of blood sugar in blood), stroke (occurs when something blocks the blood supply to part of the brain), and history of fall with right shoulder pain. During a record review of Resident 17's MDS dated [DATE], the MDS indicated Resident 17's cognitive skills were intact. The MDS indicated Resident 17 is dependent on showering and required partial/moderate assistance for all other activities of daily living (ADLs). During an observation on 3/14/2024 at 8:41a.m., with Registered Nurse (RN) 6, RN 6 was observed performing hand hygiene and applying gloves when entering Resident 17's room, RN 6 checked the resident's identity and started scanning each medication and signed off each medication on the computer for nine medications that were to be administered. RN 6 proceeded to give five medications that were given by mouth, three Lidocaine (Lidoderm: help reduce itching and pain) 5% patches that were applied to the right shoulder, right knee, left knee, and Heparin (help prevent harmful clots from forming in blood vessels) 5,000 units/mL injection that was given on the left upper arm. LVN 6 did not perform hand hygiene nor change gloves throughout the administration and documentation of administration for all nine medications. During an interview on 3/14/2024 at 9:06 a.m., with RN 6, RN 6 stated hand hygiene is performed before coming into contact with a resident, before and after changing gloves, and before leaving the room. RN 6 stated he should have done hand hygiene after administrating each Lidocaine 5% patch prior to giving the Heparin injection. RN 6 stated hand hygiene should be done when coming in contact with skin to prevent infections. RN 6 stated residents may not manifest any symptoms at the moment but still be infected, and he wants to avoid cross contamination and infection since he sees multiple residents. RN 6 stated he should have done hand hygiene and put new gloves on but did not and said he forgot. d. During a review of Resident 201's untitled admission note dated 3/10/2024, the note indicated Resident 201 was admitted on [DATE] with diagnoses including chronic kidney disease (CKD: damaged kidneys that cannot filter blood normally), coronary artery disease (CAD: narrowing and limiting blood flow to the heart), diabetes (irregular management of blood sugar in blood), dyslipidemia (imbalance of fats in the blood), esophageal (muscular tube through which food passes from the throat to the stomach) and gastric ulcer (open sores that develop on the lining of the stomach), and mild hypertension (high blood pressure). During an observation on 3/15/2024 at 10:59 a.m., with Registered Nurse (RN) 1, RN 1 was preparing to administer Heparin (help prevent harmful clots from forming in blood vessels) 5,000 units/mL injection to Resident 201's right lower stomach region. RN 1 administered the medication, disposed of the needle, and signed off on the computer that the medication as given. With the same gloves that was used to administer Heparin, RN 1 got a sanitizing wipe and wiped down the computer and computer mouse. During a review of the facility's P&P titled, Hand Hygiene Policy revised on 9/2019, the P&P indicated compliance with the proper hand hygiene procedure before and after patient contact is an expectation of all healthcare disciplines. Gloves are a protective barrier for the healthcare worker and patients according to Standard Precautions. Gloves are removed when the need for protection no longer exists, and hand hygiene should be practiced immediately after removal of gloves. Hand hygiene will be performed before or after the following activities: before putting on gloves, after taking off gloves, and if moving between contaminated body sites to another body site during care of the same patient.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1) Label and date an opened container of carrots, and bread rolls, and discard stored expired cooked chicken meat and expired cooked beef meat. 2) Ensure the executive chef handed food to [NAME] 1 while wearing gloves. 3) Ensure [NAME] 2 did not repeatedly touch the serving plate during food preparation without gloves. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for the vulnerable residents residing in the facility. Findings: During a concurrent facility kitchen tour observation and interview on 03/12/2024 at 8:33 a.m., there was an opened container of carrots and bread rolls that were unlabeled and undated, and containers of expired cooked chicken meat and beef meat inside the freezer. The kitchen operational manager stated that all expired cooked meat products must be discarded and must not be found in the freezer. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1) Label and date an opened container of carrots, and bread rolls, and discard stored expired cooked chicken meat and expired cooked beef meat. 2) Ensure the executive chef handed food to [NAME] 1 while wearing gloves. 3) Ensure [NAME] 2 did not repeatedly touch the serving plate during food preparation without gloves. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for the vulnerable residents residing in the facility. Findings: During a concurrent facility kitchen tour observation and interview on 03/12/2024 at 8:33 a.m., there was an opened container of carrots and bread rolls that were unlabeled and undated, and containers of expired cooked chicken meat and beef meat inside the freezer. The kitchen operational manager stated that all expired cooked meat products must be discarded and must not be found in the freezer. During a concurrent observation and interview on 03/12/2024 at 8:42 a.m., there was a scooper in the panko (breadcrumbs or bread flour) container, a scooper inside the long grain rice container, a scooper on top of the parboiled rice container. The kitchen operational manager stated the scooper should not be on top of the breadcrumbs, long grain rice and parboiled rice because it is an infection control issue and could cause cross contamination problem that can lead to foodborne illness. During a tray line (a process of preparing and setting food for the residents' meals in the facility) observation on 03/13/2024 at 10:45 a.m., [NAME] 1 was only wearing a baseball cap and did not wear a hair net. During a tray line observation on 03/13/2024 at 11:07 a.m., the executive chief handed food to [NAME] 1 without wearing gloves. During a tray line observation on 03/13/2024 at 11:12 a.m., dietary aide 3 came to the tray line and started handling the food and transferring it to the food cart without wearing gloves. During a tray line observation on 03/13/2024 at 11:20 a.m., [NAME] 2 repeatedly touched different trays and residents' meal plates without wearing gloves. During a concurrent observation and interview with the kitchen operational manager on 03/13/2024 at 11:25 a.m., a clean paper towel wiped along the inside lining of the ice maker machine resulted in visible black substance on the dirty paper towel. The kitchen operational manager confirmed it the findings. During an interview on 03/14/2024 at 10:13 a.m., the executive chief stated that any staff handling food and transferring food to any other staff without gloves can potentially touch and cross contaminate the foods, and that it was a bad practice. During an interview on 03/14/2024 at 10:15 a.m., [NAME] 2 stated that any kitchen staff handling foods must always wear gloves to prevent contamination. During an interview on 03/14/2024 at 10:20 a.m., the kitchen operational manager stated the ice maker machine must be checked every day to make sure it is clean and free of dirt to prevent from contamination and infection issues. During an interview on 03/14/2024 at 10:25 a.m., [NAME] 1 stated that hair nets must be worn during food preparation to prevent cross contamination. During a review of facility's policy and procedure titled Food Preparation & Distribution revised 12/2020 indicated: To ensure the safe, sanitary, and timely provision of food service to patients. All prepared perishable foods and custard shall be covered, labeled, and dated with a three-day expiration date to be discarded on the day of expiration. During a review of facility's policy and procedure titled Personal Appearance Standards & Uniform Policy revised 12/2020 indicated: Gloves or tongs to be used for handling food. During a concurrent observation and interview on 03/12/2024 at 8:42 a.m., there was a scooper in the panko (breadcrumbs or bread flour) container, a scooper inside the long grain rice container, a scooper on top of the parboiled rice container. The kitchen operational manager stated the scooper should not be on top of the breadcrumbs, long grain rice and parboiled rice because it is an infection control issue and could cause cross contamination problem that can lead to foodborne illness. During a tray line (a process of preparing and setting food for the residents' meals in the facility) observation on 03/13/2024 at 10:45 a.m., [NAME] 1 was only wearing a baseball cap and did not wear a hair net. During a tray line observation on 03/13/2024 at 11:07 a.m., the executive chief handed food to [NAME] 1 without wearing gloves. During a tray line observation on 03/13/2024 at 11:12 a.m., dietary aide 3 came to the tray line and started handling the food and transferring it to the food cart without wearing gloves. During a tray line observation on 03/13/2024 at 11:20 a.m., [NAME] 2 repeatedly touched different trays and residents' meal plates without wearing gloves. During a concurrent observation and interview with the kitchen operational manager on 03/13/2024 at 11:25 a.m., a clean paper towel wiped along the inside lining of the ice maker machine resulted in visible black substance on the dirty paper towel. The kitchen operational manager confirmed it the findings. During an interview on 03/14/2024 at 10:13 a.m., the executive chief stated that any staff handling food and transferring food to any other staff without gloves can potentially touch and cross contaminate the foods, and that it was a bad practice. During an interview on 03/14/2024 at 10:15 a.m., [NAME] 2 stated that any kitchen staff handling foods must always wear gloves to prevent contamination. During an interview on 03/14/2024 at 10:20 a.m., the kitchen operational manager stated the ice maker machine must be checked every day to make sure it is clean and free of dirt to prevent from contamination and infection issues. During an interview on 03/14/2024 at 10:25 a.m., [NAME] 1 stated that hair nets must be worn during food preparation to prevent cross contamination. During a review of facility's policy and procedure titled Food Preparation & Distribution revised 12/2020 indicated: To ensure the safe, sanitary, and timely provision of food service to patients. All prepared perishable foods and custard shall be covered, labeled, and dated with a three-day expiration date to be discarded on the day of expiration. During a review of facility's policy and procedure titled Personal Appearance Standards & Uniform Policy revised 12/2020 indicated: Gloves or tongs to be used for handling food.

Based on interview, and record review, the facility failed to provide oxygen therapy for one (1) of three (3) sampled residents (Resident 1). Resident 1 had a change of condition, on 11/27/2023 at 8:08 a.m., and staff did not provide oxygen to Resident 1 prior to the arrival of Emergency Medical Services (EMS, 911). This deficient practice resulted in Resident 1 not receiving oxygen therapy until Emergency Medical Services (911) arrived on 11/27/2023 at 8:14 a.m. (resulting in 6 minutes delay of oxygen therapy). Findings: A review of Resident 1's Physician Note by Medical Doctor 1 (MD 1), dated 11/25/2023, indicate Resident 1 was admitted at the facility on 11/22/223 at 19:35 (7:35 p.m.) with diagnosis that included right MCA (mid cerebral [brain] artery) stroke and had nasogastric tube (NGT, tube inserted in the nose to the stomach and used for feeding and medication administration). A review of Resident 1's Physician Orders of Life-Sustaining Treatment (POLST), signed by MD 1 on 12/25/2023 and signed by Family Member 1 (FM 1), on 12/22/2023, indicated Resident 1 was Do Not Attempt Resuscitation (life-saving treatment [chest compression])/DNR ([Do Not Resuscitate] Allow to Natural Death). Resident 1's POLST indicated medical interventions was Selective Treatment - goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV (intravenous, medication given into the vein) antibiotics, and IV fluids as indicated. Do not intubate (tube inserted into the mouth to the trachea [windpipe] to assist with breathing. May use non-invasive positive airway pressure (oxygen therapy to help keep the lung open). A review of Resident 1's Progress Note, written by Registered Nurse (RN 3), dated 11/27/2023 at 8:08 a.m., indicated RN 3 created Resident 1's progress note. The Progress Note indicated, on 11/27/2023 at 8:14 a.m., RN 3, Assumed care for patient (Resident 1) this morning and patient seemed restless. N A (Nurse Assistant) unable to obtain vital signs. Extremities were cold. Attempted paging doctor but no answer. CRN (Charge Registered Nurse) informed. Called 911. EMS arrived and called son over the phone. Son agreed to transfer patient to little company main hospital. The record did not indicate oxygen was administered to Resident 1. A review of Resident 1's Internal Medicine Discharge Summary, by MD 1, dated 11/27/2023 created at 13:23 (1:23 p.m.), indicated under the Discharge Summary notes, Event 11/27: patient (Resident 1) found by nurse to have low BP and restless, could not obtain vitals here, EMS called . The noted indicated, On transfer to ER, had lost of pulse in ambulance bay. Patient passed prior to triage in ER. During an interview on 12/20/2023 at 2:15 PM with Registered Nurse Charge Nurse (RN Charge Nurse 2) stated, As a charge RN verify and assess patient during a change of condition. We can apply oxygen based on emergency procedures if not contraindicated to the specific Resident. RN Charge Nurse 2 stated, I would not deny the patient oxygen if the patient had a DNR unless specified on the POLST or Advance Directive.? During an interview on 12/20/2023 at 4:00 PM with RN (Charge Nurse 1), In response to this patient (Resident 1) we would place oxygen on this patient. Charge Nurse 1 stated, I do not recall seeing oxygen on this patient (prior to emergency medical services arrival).? A review of the facility's policy and procedure, titled, Transitional Care Center (TCC)/Transitional Care Unit (TCU): Code Blue, effective date 01/2023, indicated, In the event of cardiac and/or respiratory arrest or other like emergencies; Primary RN starts IV and oxygen (O2) if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop comprehensive care plans for two of 17 sampled residents (20, 91). Resident 20 did not have a comprehensive care plan for the use of an indwelling catheter (catheter that drains urine from the bladder into a bag outside the body). Resident 91's oxygen that was administered via nasal cannula ([NC] tube connected to oxygen inlet through a tube to the resident's nose) was not care planned. The deficient practice had the potential for Resident 20, and 91's treatment plan not be made available among staff for continuity (consistent) of care. Findings: a. On 5/20/19, at 12:48 a.m., during the initial tour of the facility, Resident 20 was observed lying in bed, with an indwelling catheter in place, draining yellow urine into an urinary collection bag. According to the admission record Resident 20 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection ([UTI] an infection in any part of the urinary system), and urinary retention requiring an indwelling catheter. According to the Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 4/24/19, indicated Resident 20 had an intact cognitive skills for daily decision-making and required extensive assistance from staff for activities of daily livings such as ambulating, transferring, and dressing. The MDS care area assessment was triggered for indwelling catheter which required frequent assessment by the nursing staff. A review of the physician's order dated 5/17/19, indicated an order for the indwelling catheter French (Fr) 16 for the diagnosis of urinary retention. A review of Resident 20's clinical record revealed the facility did not develop a comprehensive care plan, focusing on indwelling catheter that had goals and measurable objectives. On 5/23/19, at 10:19 a.m., during an interview, the Director of Nursing (DON) was asked why there was no comprehensive care plan developed specifically for Resident 20, who had an indwelling catheter and history of UTI. The DON stated a care plan should have been done to focus on the concern for indwelling catheter with follow up with the physician for adequate urine output. b. On 5/20/19, at 12:50 a.m., during the initial tour of the facility, Resident 91 was observed lying in bed and receiving oxygen at 2.0 liters per minute through a nasal cannula (NC). According to the admission records Resident 91 was admitted on [DATE], with diagnoses that included cardiovascular accident (stroke). A review of Resident 91's clinical record revealed the facility did not develop a specific comprehensive care plan for the use of oxygen therapy to maintain oxygen saturation between 94 to 98 percent as ordered by the physician. On 5/24/19, at 10:15 a.m., during an interview, the DON was asked if the facility develop a specific care plan for the resident receiving oxygen. The DON stated no specific care plan was developed but a discharge care plan and cardiac output care plan was done. According to the State Operation Manual (SOM) Care Plan, the facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The care planning drives the type of care and services that a resident received (SOM revised November 22, 2017, P.207).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff administered the total parental nutrition ([TPN] a method of feeding that bypasses the gastrointestinal tract; fluids are given into a vein to provide most of the nutrients the body needs; the method is used when a person can not or should not receive feedings or fluids by mouth) through the peripherally inserted central catheter ([PICC] a thin, soft, long tube that is inserted into a vein on arm, leg or neck, with the tip of the catheter positioned in a large vein that carries blood into the heart), when used for long-term intravenous ([IV] into a vein) administration of antibiotics, nutrition or medications, and for blood draws, and not through the regular peripheral IV access line for one of 17 sampled residents (33). This deficient practice had the potential to cause burning, discoloration to the IV site, and damage Resident 33's veins. Findings: On 05/21/19 at 8:08 a.m., during observation, and interview, Resident 33 was observed with a peripherally inserted central catheter (PICC) line in the left upper arm. Resident 33's PICC line was not connected to any tubing or line and there was no fluids infusing at the time of observation. Concurrently, during the observation, there was TPN infusing at 150 milliliter per hour (ml/hr) in Resident 33's right arm. However, Resident 33's TPN was infusing through a regular IV line, connected to a saline lock (an intravenous catheter that is threaded into a peripheral vein, flushed with saline, and then capped off for later use). During the same time, Registered Nurse (RN 33) was observed to discontinue the TPN from the resident's right arm saline lock. During an interview RN 33 was asked if the TPN was administered through the peripheral saline lock and not the PICC line, RN 33 stated yes. When asked about Resident 33's left arm PICC line, RN 33 stated we do not use that. According to Resident 33's admission record, indicated the resident was admitted to the facility on [DATE], with diagnoses that included gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), and osteoporosis (thinning of the bones). According to Resident 33's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 05/05/19, indicated the resident had no impairment in cognitive skills for daily decision-making, and required limited to extensive assistance from staff for activities of daily living. A review of the active PICC audit report for Resident 33 indicated it was placed in the resident's left upper arm on 05/03/19. The audit report indicated PICC line was for medication/fluid administration. A review of Resident 33's TPN order from the pharmacy, dated 05/20/19 indicated to administer TPN on 05/20/19, to start at 8:00 p.m. A review of Resident 33's physician order indicated to administer TPN through the intravenous central route (PICC), administer over 14 hours, and for TPN to end on 05/21/19 at 10:03 am. A review of the licensed nurses progress notes for Resident 33, dated 05/18/19, indicated Registered Nurse (RN 31) changed the IV site from peripheral IV to the right forearm (RFA) due to single PICC. During an interview with RN supervisor at 9:30 am, in regards to Resident 33's TPN infusing in to a peripheral line, stated we do not infuse TPN via peripheral line. RN supervisor stated the vein was not able to tolerate TPN, and the facility always used central lines (PICC) line for TPN administration. During interview with RN 33 on 05/23/19 at 9:44 am stated she observed TPN infusing through the right arm peripheral IV line and as an RN she knew TPN should had been infused through the central line. During an interview with the facility's consulting pharmacist on 05/23/19 at 2:26 p.m., stated the registered nurses should check orders before administering any fluids or medications. The pharmacist stated infusing TPN through a peripheral line can cause vein irritation, and cause burning at the site.

Based on observation, interview and record review, the facility failed to ensure the staff did not wear a personal protective equipment (protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection), by wearing a disposable yellow gown outside of a contact isolation room (used for infections, diseases, or germs that are spread by touching the patient or items in the room). This deficient practice placed the resident's, staff, and visitors at for cross contamination. Findings: During an observation of the facility on 05/22/19 at 11:45 a.m., the environmental service (EVS) staff was observed coming outside of a contact isolation room, while still wearing the disposable yellow gown. The gown was exposed to barrels and a mop bucket cart, which was parked outside the isolation room. During an interview with Infection Control Nurse (ICN) on 05/22/19 at 11:47 am, stated EVS staff should not be coming out from the isolation room still wearing the PPE, yellow disposable gown. Concurrently, ICN instructed EVS staff to wipe down barrels, and the mop bucket, to prevent cross contamination throughout the facility. During an interview with EVS staff on 05/22/19 at 11:48 a.m., stated disposable yellow PPE gowns should be worn, the disposed inside the isolation rooms prior to leaving the room.