**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to be informed and make decisions about their care for one of four sample residents (Resident 1) when the facility did not obtain informed consent prior to increasing Resident 1's Seroquel (an antipsychotic medication that balances certain chemicals in the brain to help the person feel calmer and think clearly) dosage.This failure had the potential to result in Resident 1 receiving psychotropic medication (medication that affects brain activities associated with mental processes and behavior) without proper understanding or consent, compromising their right to participate in medical decision-making.Findings:During a review of Resident 1's admission Record (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including blindness, hypothyroidism (condition where a person's thyroid [small gland in neck] didn't make enough hormones), arthritis (condition that caused pain, swelling and stiffness in joints, depression, visual hallucinations (when a person saw things that weren't really there) and, anxiety.During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had no cognitive impairment.During a review of Resident 1's Medication Administration Record (MAR), it was noted Resident 1 had a dose increase of Seroquel. The previous order, in effect from 1/31/25 to 3/1/25, was for Seroquel 25 mg daily at 9:00 a.m. for psychotic features manifested by episodes of hallucinations, and 50 mg at 9:00 p.m. for the same indication. The current order started on 3/1/25-current reflected a change to 50 mg at 9:00a.m. and 9:00 p.m. for depression with psychotic features manifested by hallucinations.During a concurrent observation and interview on 6/25/25 at 12:04 p.m. with Resident 1 and her Responsible Party (RP) 5, Resident 1 was observed eating lunch with her husband and daughter. Resident 1 stated she enjoyed the meal and responded to questions appropriately. RP 5 stated Resident 1 had an appointment with her private psychiatrist from Sutter every two months via virtual meeting. She reported that the Social Services Director (SSD) arranged the virtual meetings, which she joined virtually.During a review of document titled Clinical Notes, dated 4/22/25, the Clinical Notes indicated Resident 1's psychiatrist recommended Resident 1's Seroquel dose be increased to 50 mg in the morning.During a concurrent interview and review of Resident 1's electronic health record on 6/26/25 at 12:09 p.m. with the Director of Nursing (DON), the DON stated the last informed consent for Seroquel was obtained on January 31, 2025. The DON stated there was no informed consent documented for the subsequent Seroquel dose increase to 50 mg twice daily. The DON stated it was important to ensure Resident 1 was aware that the medication dose was being increased and informed of the potential side effects associated with the medication.During an interview on 6/26/25 at 3:40 p.m. with the Registered Pharmacist (RPh), the RPh stated informed consent was required before increasing a medication dose. The RPh explained it was important for the residents to be aware of the potential adverse effects, understand the reason for the increase in the dose and have the opportunity to agree or disagree with the change.During a review of the facilities policy and procedure (P&P) titled, Psychotropic Medication Use, revised February 2025, the P&P indicated 3. Psychotropic medication management is an interdisciplinary process that involves the resident, family and or representative .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that four of four sampled residents (Resident 299, Resident 35, Resident 1, and Resident 18) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when:1. For Resident 299, Seroquel (an antipsychotic medication that balances certain chemicals in the brain to help the person feel calmer and think clearly), was initiated without an appropriate indication, the facility did not document, implement, or monitor resident specific non-pharmacological interventions (ways to help someone feel better or manage a health problem without using medicine) prior to the initiation and continued used of Seroquel, include objective measurable behavioral goals with timeframes on the care plan for adequate behavioral monitoring, , and adequately monitor, track and document behavioral episodes, and side effect monitoring.These failures placed Resident 299 at risk for unnecessary medication use, adverse side effects and a decline in psychosocial well-being.2. For Resident 35, the facility did not implement or monitor individualized non-pharmacological interventions, and did not adequately monitor, track, document behavioral episodes and side effects related to Resident 35's use of divalproex (a psychotropic medication used to help control mood and behavior), Lexapro (a psychotropic medication used to balance chemicals in the brain to improve mood and help them feel calmer), Rexulti (an antipsychotic medication used to calm the brain, making it easier for the person to feel more balanced and act normally), and lorazepam (a psychotropic medication used to slow down activity in brain so a person could relax and feel more in control).These failures placed Resident 35 at risk for prolonged and potentially unnecessary use of psychotropic medications without appropriate monitoring or oversight.3. For Resident 1, the facility did not implement or monitor individualized non-pharmacological interventions, and did not adequately monitor, track and document behavioral episodes for the use of Seroquel, Zoloft (a psychotropic medication used to balance chemicals in the brain to improve mood and help them feel calmer), and lorazepam. These failures placed Resident 1 at risk for inappropriate treatment decisions, continued use of psychotropic medication without adequate clinical oversight and potential adverse effects.4. For Resident 18, the facility did not implement or monitor individualized non-pharmacological interventions and did not adequately monitor, track and document behavioral episodes related to buspirone (medication that calmed certain parts of the brain, so the person didn't feel worried all the time), Lexapro, and Seroquel use.These failures place Resident 18 at risk for continued use of psychotropic medication without appropriate clinical justification or oversight.1. During a review of Resident 299's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission Record indicated, Resident 299 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), unsteadiness on feet, muscle weakness, anxiety, falling and hyperlipidemia (high amounts of fat in the blood ).During a review of Resident 299's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 3 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 299 had severe cognitive impairment.During a review of Resident 299's Hospital Progress Note, dated 6/11/25, the Hospital Progress Note indicated, .on the afternoon of 6/11/25 [Resident 299] became extremely agitated and combative, refused to take oral medications and removed her intravenous (IV) line . Although Seroquel 25 mg (milligram, a unit of measurement) daily was ordered, it was not administered to Resident 299.During a review of the facility's Physician Order Sheet, dated 6/27/25, the Physician Order Sheet indicated, active order for Quetiapine [Seroquel] 25mg, one tablet every 8 hours as needed for agitation, for fourteen days, starting on 6/16/25.During an observation on 6/25/25 at 11:57 a.m., Resident 299 was observed in her room, sitting in a chair and chatting with her husband. Resident 299 appeared pleasant and greeted the observer by saying hello.During an interview on 6/25/25 at 3:55 p.m. with the Infection Preventionist (IP), the IP stated her interactions with Resident 299 had been limited, due Resident 299 being newly admitted on [DATE]. However, the IP stated Resident 299 appeared pleasant and cooperative with care and was not currently exhibiting any complaints. The IP stated behaviors were monitored through Resident 299's Treatment Administration Record (TAR) and the documentation of behaviors and potential medication side effects would typically be completed at the end of each shift. The IP stated when a resident exhibited a behavior, staff would attempt to identify an underlying cause, emphasizing the presence of a behavior did not automatically indicate the need for medication.During an interview on 6/25/25 at 4:11 p.m. with the IP, the IP stated for both routine and PRN (as needed) psychotropic medications, staff selected the target behavior and documented it in the Electronic Health Record (EHR). The IP added staff could also document in the progress notes if a resident was exhibiting behaviors. The IP stated she did not recall ever being required to document the number of behaviors a resident was having, nor had she done so for any resident.During a concurrent interview and review of Resident 299's EHR on 6/25/25 at 4:16 p.m. with the IP, the IP stated behavioral interventions were actions taken to support a resident before administering medications; behaviors being anything that was safe and aiming to make the resident comfortable. The IP stated there was no documentation of behavioral interventions and did not see evidence that any behavioral interventions were implemented prior to the initiation of Seroquel or documentation explaining why Seroquel was started for Resident 299.During a concurrent interview and review of Resident 299's EHR on 6/26/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 299 became restless and forgetful when her husband left the room. LVN 1 stated behavioral interventions were used to redirect the resident and reassure Resident 299 that she was safe. LVN 1 stated Resident 299 was admitted to the facility with an order for Seroquel and acknowledged that Seroquel was not considered a first-line treatment for agitation. LVN 1 confirmed there was no documentation of non-pharmacological interventions prior to the initiation of Seroquel and no documentation of such interventions in Resident 299's care plan or MAR. LVN 1 stated the purpose of the care plan was to create a clear picture of why treatments were being provided, to inform staff of the residents' needs and to assist in assessing the behaviors the residents were exhibiting.During a concurrent interview and review of Resident 299's EHR on 6/26/25 at 10:07 a.m. with LVN 1, LVN 1 stated there was no monitoring of non-pharmacological interventions documented on Resident 299's MAR, dated June 1, 2025-June 30, 2025, while she was being administered Seroquel for agitation. LVN 1 stated it was important to implement and monitor non-pharmacological interventions for Resident 299 to reduce reliance on psychotropic medications, as these could cause side effects and adverse effects that the resident might experience.During a concurrent interview and review of Resident 299's EHR on 6/26/25 at 10:11 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated she was responsible for creating the resident's care plans. The MDSC stated she had previously been instructed to create care plans based only on the resident's diagnosis and not the medications. The MDSC stated she was recently informed that a care plan should also be developed for psychotropic medications. The MDSC stated it was important because it allowed monitoring of black box warnings, potential side effects, resident behaviors and efforts to reduce the use of psychotropic medications. The MDSC described the care plan as a personalized guide for how to care for the residents. The MDSC stated Resident 299's care plan did not include psychotropic medications or documentation of potential side effects. The MDSC confirmed awareness that antipsychotic medications carry black box warnings and stated this information should be included in the care plan, so nursing staff are informed and know what to monitor.During a concurrent interview and review of Resident 299's EHR on 6/26/25 at 10:18 a.m. with LVN 1, LVN 1 stated when monitoring for side effects, she reviewed the triggers for Seroquel listed on the electronic Medication Administration Record (MAR) dated June1, 2025-June 30, 2025, and determined if any were present. LVN 1 stated, if side effects present, she would select the specific side effect; if none were observed, she would enter none. LVN 1 stated that side effects listed on the MAR for Resident 299 were not specific to the medication being administered and were specific to the diagnosis of anxiety. A review of Resident 299's EHR did not specify whether Resident 299 displayed any side effects associated with the use of Seroquel.During a concurrent interview and review of Resident 299's EHR on 6/26/25 at 10:27 a.m. with LVN 1, LVN 1 stated she documented Resident 299's behaviors for the use of Seroquel, in Resident 299's daily skilled notes and MAR dated June 1,2025-June 30, 2025. LVN 1 was unable to provide documentation of Resident 299's behaviors of agitation in Resident 299's EHR, and confirmed the number of behaviors of agitation exhibited by Resident 299 was not monitored. LVN 1 stated tracking the number of Resident 299's behaviors were important because it allowed staff to see how many times per month the residents were experiencing behaviors and to identify any patterns. LVN 1 stated without monitoring the number of behaviors, it was not possible to determine whether Resident 299's behavioral goals were being met.During an interview on 6/26/25 at 3:22 p.m. with the Registered Pharmacist (RPh), the RPh stated the goal was to avoid medicating a resident if their condition could be managed without the use of medications. The RPh stated it was never the first choice to use Seroquel for agitation, as it was not considered a first-line therapy.2. During a review of Resident 35's admission Record, the admission Record indicated, Resident 35 was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia (difficulty swallowing), falling, hyperlipidemia, anxiety, depression, muscle weakness, violent behavior, and delusional disorder (mental condition where a person strongly believed things that weren't true).During a review of Resident 35's MDS the MDS indicated a BIMS score of 0, indicating Resident 35 had severe cognitive impairment.During a review of Resident 35's MAR for divalproex order and administration history, it was noted Resident 35 began the medication on 11/2/23 at a dose of 125 mg twice daily. The dosage was increased to 250 mg twice daily starting on 11/15/23 through 12/3/23, the dose was adjusted to 125 mg twice daily for behaviors related to dementia including hitting and striking. From 12/6/24 through 1/26/25 Resident 35 continued 125 mg twice daily for hitting and striking. As of the current review, Resident 35 remained on 125 mg twice daily for the same behaviors.During a review of Resident 35's MAR for Lexapro it was noted Resident 35 received 20 mg daily from 12/28/22 through 10/30/24. Beginning 10/30/24, the dosage was reduced to 10 mg daily for the treatment of major depression manifested by tearfulness and this remained the current dose at the time of review.During a review of Resident 35's MAR, it was noted that Rexulti was initiated on 4/20/25 at a dose of 0.5 mg daily for 7 days to address dementia-related behaviors, including hitting and striking. On 4/27/25, the dose was increased to 1 mg daily for the same behaviors. Beginning on 5/4/25, the dose was further increased to 2 mg daily for dementia manifested by hitting and striking, which remained the current dosage at the time of review.During a review of Resident 35's MAR, it was noted that lorazepam 0.5 mg every 8 hours as needed was administered from 5/13/24-11/13/24. The medication was prescribed to address behaviors manifested by impulsiveness and grabbing at people.During an observation on 6/25/25 at 12:01 p.m., Resident 35 was observed in the dining room being assisted with lunch. Resident 35 was seated in a wheelchair at a table with another resident and a feeding assistant. No violent or aggressive behaviors were noted during the observation.During a concurrent interview and review of Resident 35's EHR on 6/25/25 at 3:39 p.m. with LVN 4, LVN 4 stated Resident 35 liked to hit, pinch and roll out of bed. LVN 4 explained Resident 35 would exhibit these behaviors toward anyone walking by and would swing her arms and attempt to pinch. LVN 4 stated she could document Resident 35's behaviors in a progress note. LVN 4 stated she did not believe there was a section in Resident 35's EHR to document non-pharmacological interventions prior to administering Resident 35's psychotropic medications (divalproex, Lexapro, Rexulti and lorazepam). LVN 4 stated behavior documentation for the use of Resident 35's psychotropic medications could only be entered once per shift, and the system did not allow for specifying the number of behaviors-only whether the target behaviors were present or not. LVN 4 stated side effects were documented at the end of the shift and the system would ask whether side effects were present or not. LVN 4 stated she had not seen a list of potential side effects associated with the use of Resident 35's psychotropic medications appear in Resident 35's EHR for documentation. LVN 4 also stated Resident 35 had dementia and was not verbal, making it difficult to determine whether the resident experienced delusions due to her cognitive impairment associated with dementia.During a concurrent interview and review of Resident 35's Care Plans on 6/26/25 at 1:39 p.m. with the DON, the DON stated side effects of Resident 35's psychotropic medications were not included in the care plans for nursing staff to implement and monitor. The DON acknowledged Resident 35's care plan did not have objective goals for target behaviors associated with the use of Resident 35's psychotropic medications and stated that having clear objective goals for behaviors associated with Resident 35's psychotropic medications in the care plan was important to guide care and to evaluate whether medications were effective, warranted or therapeutic. The DON stated nursing staff did not track the number of residents' behavioral episodes, only the presence of behaviors. The DON stated the facility relied on nurses' documentation to determine whether a medication needed to be changed or adjusted, but acknowledged this was not an effective method of tracking and documentation of behaviors for evaluating medication effectiveness. The DON was unable to provide documentation of non-pharmacological interventions implemented and documented for the use of Resident 35's psychotropic medications and stated that the facility did not have a system for monitoring non-pharmacological interventions.During a concurrent interview and review of Resident 35's EHR on 6/26/25 at 1:55 p.m. with the DON, the DON stated the purpose of a Gradual Dose Reduction (GDR) was to slowly decrease the medication dosage when a resident demonstrated a decrease in behaviors. The DON acknowledged not having an objective goal for number of behaviors and documenting number of behaviors made it difficult to determine whether a medication was effective and warranted a GDR.During an interview on 6/26/25 at 3:33 p.m. with the RPh, the RPh noted having clearly defined goals helped guide care by identifying what outcomes the team was striving to achieve. The RPh stated the expectation was for nursing staff to document and monitor non-pharmacological interventions for residents receiving psychotropic medications, to determine what strategies were effective and beneficial. The RPh highlighted the importance of utilizing non-pharmacological interventions to help reduce the need for medications. Additionally, the RPh explained it was important to document behavioral episodes quantitively (a way to count or measure using numbers), as this allowed staff to determine whether a resident was improving or declining. The RPh confirmed tracking the number of behaviors helped inform whether a dose increase or decrease was appropriate. The RPh stated adverse effects of psychotropic medications had been compiled in a binder but were not available in the EHR. Monitoring for side effects was identified as essential, as the presence of side effects may indicate the need to reduce the dosage or change the medication.3. During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including blindness, hypothyroidism (condition where a person's thyroid [small gland in neck] didn't make enough hormones), arthritis (condition that caused pain, swelling and stiffness in joints, depression, visual hallucinations (when a person saw things that weren't really there) and, anxiety.During a review of Resident 1's MDS, the MDS indicated a BIMS score of 13 indicating Resident 1 had no cognitive impairment.During a review of Resident 1's MAR dated 6/1/25 to 6/30/25 it was noted Resident 1 received Seroquel for various psychiatric symptoms over multiple time periods. Seroquel 12.5 mg daily was initiated on 2/21/24 and continued through 7/17/24 for depression and visual hallucinations occurring at lunchtime. From 12/23/22 through 7/19/24 Resident 1 also received Seroquel 25 mg twice daily for depression and visual hallucinations. Between 7/17/24 and 8/13/24, the dosage was adjusted to 12.5 mg twice daily for psychotic features manifested by episodes of hallucinations. From 8/14/24 through 9/25/24, Resident 1 received Seroquel 25 mg daily as needed for depression with psychotic symptoms for a duration of 90 days. Currently the ordered dose is Seroquel 50mg daily at 9am for depression with psychotic features m/b hallucinations 5/19/25 to current.During a review of Resident 1's MAR dated 6/1/25 to 6/30/25, the MAR indicated an order for Zoloft 100 mg daily at 9pm for depression, starting 3/1/25.During a review of Resident 1's MAR, it was noted Resident 1 was started on lorazepam 0.5 mg every six hours as needed for anxiety from 4/8/23 through 8/8/23. Resident 1 resumed lorazepam 0.5 mg every six hours as needed for anxiety from 2/11/24 through 3/11/24 and again from 3/24/24 through 6/9/24 for the same indication. From 6/9/24 through 7/17/24 Resident 1 continued lorazepam 0.5 mg every six hours as needed for anxiety. From 7/23/24 through 8/5/24 Resident 1 received lorazepam 0.5 mg every twelve hours as needed for anxiety manifested by agitation and increased hallucinations, for a duration of fourteen days. Two separate orders for lorazepam 0.5 mg every six hours as needed for anxiety manifested by agitation and increased hallucinations were in place from 8/6/24 through 8/14/24 for thirty days. Resident 1 continued lorazepam 0.5 mg every six hours as needed for anxiety manifested by agitation and increased hallucinations from 8/14/24 through 11/12/24 for a ninety-day duration. From 11/11/24 through 5/11/25, lorazepam 0.5 mg every six hours as needed was administered for anxiety manifested by agitation and increased hallucinations under a six-month order. As of 5/13/25 through the current review date Resident 1 remained on lorazepam 0.5 mg every six hours as needed for anxiety manifested by agitation and increased hallucinations.During a concurrent observation and interview on 6/25/25 at 12:04 p.m. with Resident 1 and Responsible Party (RP) 5, Resident 1 was observed eating lunch with her husband and daughter. Resident 1 stated she enjoyed the meal and responded to questions appropriately. Resident 1's daughter stated Resident 1 had an appointment with her private psychiatrist from a local hospital every two months via virtual meeting. RP 5 stated the Social Services Director (SSD) arranged the virtual meetings which she also joined remotely.During an interview on 6/25/25 at 2:47 p.m. with LVN 4, LVN 4 stated Resident 1 was blind and experienced episodes of confusion. LVN 4 explained that staff attempted to redirect Resident 1 when she became confused, noting that confusion often led to increased anxiety. LVN 4 described instances when Resident 1 believed she was positioned high off the ground, requiring staff to reorient her and reassure her that her feet were on the floor. LVN 4 stated she was unsure of specific reasons for Resident 1 being prescribed Zoloft, Seroquel and lorazepam particularly regarding their use when the resident became anxious.During a concurrent interview and review of Resident 1's EHR on 6/25/25 at 3:10 p.m. with LVN 4, LVN 4 stated she did not know if individualized non-pharmacological interventions for Resident 1 were documented in Resident 1's EHR. LVN 4 was unable to provide documentation for implementation and monitoring of individualized non-pharmacological interventions for Resident 1's use of psychotropic medications (Zoloft, Seroquel and lorazepam). LVN 4 explained nursing staff were expected to document whether a behavior was present or not during the shift, along with the type of behavior observed. LVN 4 stated the EHR system prompted staff to enter this information once per shift. LVN 4 confirmed it was not possible to document the number of behavioral episodes, only a yes or no response as to whether the target behavior was observed. LVN 4 acknowledged nursing staff documented Resident 1's target behaviors for Zoloft, Seroquel and lorazepam on Resident 1's EHR as yes or no.During a concurrent interview and review of Resident 1's EHR on 6/26/25 at 11:45 a.m. with the DON, the DON stated Resident 1 was seen by her psychiatrist via a virtual meeting, and the provider faxed treatment recommendations to the facility. The DON stated the SSD was present during the virtual meetings. The DON stated the psychiatrist was informed of the number of days Resident 1 exhibited behaviors but was not provided with details on the specific types of behaviors.During a continued review of Resident 1's' EHR, a telephone order dated 5/19/25, Resident 1's EHR indicated an order was placed by Registered Nurse (RN) 1 without any associated behavioral monitoring count. A review of Resident 1's care plan indicated there were no care plans in place for Zoloft, lorazepam or Seroquel. Additionally, Resident 1's care plans did not address non-pharmacological interventions. The DON stated care plans help the facility meet the needs of the residents and if a care plan was not resident-specific, it could lead to issues such as adverse effects and unmet needs. The DON stated non-pharmacological interventions were important for reducing the use of medications by trying other options first. The DON explained behaviors were not tallied by the number of episodes per day but rather monitored for overall trends to evaluate medication effectiveness. The DON stated if a resident showed an increase in behaviors, it might indicate the need for different non-pharmacological interventions or a dose adjustment. If medication was shown to be effective, a GDR could be considered. The DON acknowledged the current monitoring of behaviors associated with psychotropic medications was not adequate and did not provide accurate information needed for the provider to make an informed decision as to whether the resident's psychotropic medications were effective. The DON confirmed the goal was to maintain the lowest effective dose. The DON also stated monitoring the number of behavioral episodes was necessary, and that simply noting that a resident reported having behaviors was not an appropriate justification for increasing a medication dose. The DON was unable to provide documentation of non-pharmacological interventions implemented and documented for the use of Resident 1's psychotropic medications and stated that the facility did not have a system for monitoring non-pharmacological interventions.During an interview on 6/26/25 at 3:33 p.m. with the RPh, the RPh stated having clearly defined goals helped guide care by identifying what outcomes the team was striving to achieve. The RPh stated the expectation was for nursing staff to document and monitor non-pharmacological interventions for residents receiving psychotropic medications, to determine what strategies were effective and beneficial. The RPh highlighted the importance of utilizing non-pharmacological interventions to help reduce the need for medications. Additionally, the RPh explained it was important to document behavioral episodes quantitively, as this allowed staff to determine whether a resident was improving or declining. The RPh confirmed tracking the number of behaviors helped inform whether a dose increase or decrease was appropriate. The RPh stated adverse effects of psychotropic medications had been compiled in a binder but were not available in the electronic health record. Monitoring for side effects was identified as essential, as the presence of side effects may indicate the need to reduce the dosage or change the medication.4. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and depression.During a review of Resident 18's MDS indicated a BIMS score of 3 indicating Resident 18 had severe cognitive impairment.During a review of Resident 18's MAR, it was noted Resident 18 was started on buspirone 5 mg daily from 4/28/25 through 5/6/25. The dose continued at 5 mg daily from 5/6/25 through 6/18/25. Beginning on 6/18/25 the dosage was increased to buspirone 5 mg three times daily for dementia manifested by anxious and worried behavior, which remained the current order at the time of review.During a review of Resident 18's MAR, it was noted Resident 18 was started on Lexapro 15 mg daily from 12/10/24 through 1/29/25. Resident 18 continued Lexapro at 15 mg daily from 1/29/25 through 4/2825. As of 4/28/25 the current order reflected Lexapro 10 mg daily for depression manifested by sadness and tearfulness.During a review of Resident 18's MAR, It was noted Resident 18 was started on Seroquel 50 mg at bedtime from 12/10/24-12/16/24 for unspecified dementia. Additionally, from 12/11/24-12/16/24 Resident 18 received Seroquel 25 mg daily at 9:00 a.m. for unspecified dementia without behavioral disturbance. Beginning 12/16/25 through 1/29/25, Resident 18 administered Seroquel 25 mg twice daily at 9:00 a.m. and 5:00 p.m. for unspecified dementia without behavioral disturbances. From 1/29/25 through 6/18/25, Resident 18 continued Seroquel 25 mg at 9:00 a.m. and 5:00 p.m. for unspecified dementia manifested by feeling fearful and scared and expressing thoughts that someone was going to hurt her. As of 6/18/25 to the current review date, Resident 18 has been receiving Seroquel 25 mg daily at 5:00 p.m. for unspecified dementia without behavioral disturbance, manifested by feeling fearful, scared and thinking someone is going to hurt her.During an observation on 6/25/25 at 12:00 p.m. Resident 18 was observed during lunch. Resident 18 was seated at a table with another resident and was eating finger foods. Resident 18 was quiet throughout the meal observation.During an interview on 6/25/25 at 3:39 p.m. with LVN 4, LVN 4 stated Resident 18 was confused, scared easily and was easily redirected. LVN 4 described Resident 18 as an easy individual to care for. LVN 4 stated she did not believe there was a way to document non-pharmacological interventions prior to medication administration, as the EHR did not contain a designated area for that information. LVN 4 explained resident behaviors were documented once per shift for the entire shift.During a concurrent interview and review of Resident 18's EHR on 6/26/25 at 2:09 p.m. with the DON, a progress note dated 4/21/25 at 4:51 p.m., indicated buspirone 5 mg daily was initiated based on Resident 18 exhibiting behaviors such as reaching out, attempting to get out of her chair and displaying a worried or concerned expression on her face. The DON acknowledged nursing staff documented Resident 18's behaviors for the use of psychotropic medications (buspirone, Lexapro, Seroquel) by documenting yes or no at the end of shift and stated there was no quantitative tracking of Resident 18's anxious or worried behaviors.During a concurrent interview and review of Resident 18's EHR on 6/26/25 at 2:17 p.m. with the DON, the DON stated Resident 18's care plans did not include an objective goal for the number of behaviors associated with the use of buspirone, Lexapro and Seroquel. The DON stated the care plans were not specific to the medications and did not contain resident-specific non-pharmacological interventions for behaviors related to anxiety or depression, for nursing staff implementation and monitoring. Additionally, the DON stated nursing staff did not implement or document non-pharmacological interventions and that there was inadequate monitoring of behavioral symptoms related to the use of these medications.During an interview on 6/26/25 at 3:33 p.m. with the RPh, the RPh stated having clearly defined goals for behaviors associated with the use of psychotropic medications helped guide care by identifying what outcomes the team was striving to achieve. The RPh stated the expectation was for nursing staff to document and monitor non-pharmacological interventions for residents receiving psychotropic medications, to determine what strategies were effective and beneficial. The RPh highlighted the importance of utilizing non-pharmacological interventions to help reduce the need for medications. Additionally, the RPh explained it was important to document behavioral episodes quantitively, as this allowed staff to determine whether a resident was improving or declining. The RPh confirmed tracking the number of behaviors helped inform whether a dose increase or decrease was appropriate.During a review of the facilities policy and procedure (P&P) titled, Medication Therapy, revised April 2007, the P&P indicated 2. all decisions related to medications shall include appropriate elements of the care process such as a. adequately detailed assessments, b. review of causes of symptoms, c. consideration of the clinical relevance of symptoms and abnormal diagnostic test results e. each residents wishes, values, goals, conditions and prognosis. 3 upon admission and periodically thereafter staff will review individuals' current medication regimen, to identify whether: a. there is a clear indication for treating that individual with the medication b. the dosage is appropriate c. the frequency of administration and duration of use are appropriate and d. potential side effects are present. 5. The physician will identify situations where medications should be tapered, discontinued or changed to another medication a. when medication is being given in excessive doses for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rational.During a review of the facilities policy and procedure (P&P) titled, Psychotropic Medication Use, revised February 2025, the P&P indicated psychotropic medication management is an interdisciplinary process that involves the resident, family and or the representative and includes: a. determining adequate indication for use, c. adequate monitoring for efficacy

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person centered Care Plan (a document that outlines a personalized approach to an individual's healthcare and support needs) for two of two sampled (Residents 6 and 20) when:1. Resident 20 had no Care Plan created for the use of their mobility rails (rails on the side of the bed which help a resident turn and move in bed)This failure had the potential to cause Resident 20's use of mobility rails to not receive proper monitoring or support to ensure they were used safely.2. Resident 6 did not have a care plan developed for ordered padded side rails.This failure had the potential to result in harm to Resident 6 if the padded side rails were removed.Findings: 1. During an observation on 6/23/25 at 3:31 p.m. in Resident 20's room, Resident 20 had mobility rails raised on the left and right side of his bed. During a review of Resident 20's Face Sheet (FS- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/25/25, the FS indicated, Resident 20 was admitted to the facility with a diagnosis of spastic hemiplegia of the right side (a condition where the muscles on one side of the body are stiff and experience involuntary contractions, leading to weakness and difficulty with movement) and muscle weakness (a reduced ability to generate force in one or more muscles) During a concurrent interview and record review on 6/24/25 at 3:44 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 20's Care Plan dated 6/24/25 was reviewed. LVN 1 stated Resident 20 did not have a care plan created for his use of mobility rails. LVN 1 stated Resident 20's use of mobility rails should have had their own fully developed Care Plan. LVN 1 stated mobility rails are an assistive device, and care planning was necessary in order to monitor and ensure their safe usage. During a concurrent interview and record review on 6/26/25 at 3:16 p.m. with the Minimum Data Set Nurse (MDSN), Resident 20's Care Plan dated 6/26/25 was reviewed. The MDSN stated Resident 20 did not have a specific Care Plan created for his use of mobility rails. The MDSN stated an appropriate and complete person centered care plan was important in order to properly monitor Resident 20's use of assistive equipment and ensure their safety. During an interview on 6/26/25 at 9:38 a.m. with the Director of Nursing (DON), the DON stated Resident 20's Care Plan needed to be specific, and person centered. The DON stated Resident 20 had the use of his rails listed as an intervention for another care plan, but it needed to be its own specific care plan in order to better monitor his use of the assistive device. During a review of the facility's MDS Nurse, Job Description, dated 6/2/25, the Job Description indicated . The MDS Nurse . is ultimately responsible for the oversight and coordination of the federally mandated resident assessment instrument (RAI) process, which includes the MDS assessment, care area assessment, and care plan development and revision . During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 3/22, indicated, . 7. The comprehensive person-centered care plan: a. includes measurable objective and timeframes. b. describes the service that are to be furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being including: (1) services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights including the right to refuse treatment . c. includes the residents stated goals upon admission and desired outcomes; d. build on the resident's strengths; and e. reflects currently recognized standard of practice for problem areas and conditions . 2. During an observation on 6/23/25 at 3:38 p.m. in Resident 6's room, observed Resident 6 awake in bed with head of bed raised. Observed padded upper left and upper right side rails. During an observation on 6/24/25 at 9:15 a.m. in Resident 6's room, observed Resident 6 awake in bed and covered with a blanket. Observed padded upper left and upper right side rails. During a concurrent observation and interview on 6/26/25 at 8:29 a.m. with Certified Nursing Assistant (CNA) 2 in Resident 6's room, Resident 6 observed in bed awake, with head of bed raised and both left, and right upper side rails padded. CNA 2 stated Resident 6's upper right and left side rails are padded so the resident does not hit herself when she moves around. During a review of Resident 6's Face Sheet dated 6/26/25, the Face Sheet indicated Resident 6 was admitted into the facility on 2/27/17. During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) Section C - Cognitive Patterns dated 6/5/25, the MDS Section C - Cognitive Patterns indicated Resident 6's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 3 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) which indicated Resident 6 had a severe cognitive impairment. During a review of Resident 6's MDS Section I- Active Diagnosis dated 6/5/25, MDS Section I- Active Diagnosis indicated in the neurological section, Resident 6 had an active diagnosis of seizure disorder (sudden, temporary disruption in brain activity that causes involuntary changes in behavior, movement, sensation or consciousness) or epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures). During a review of Resident 6's June 2025 Physician Order Set dated 6/26/25, the June 2025 Physician Order Set indicated Resident 6 had seizure precautions in place with notes, . monitor for seizures [related to] levetiracetam [antiseizure medication], padded rail . The June 2025 Physician Order Set indicated this was ordered on 2/4/2025. During a concurrent interview and record review on 6/26/25 at 1:57 p.m. with LVN 1, Resident 6's Care Plan Report (undated), was reviewed. The Care Plan Report indicated Problem: [Resident 6] is at risk for injuries related to seizure activity. Status: Active (Current). Goals: [Resident 6] will be free from seizure activity through the next 90 days. Status: Active (Current) Goal Date: 9/29/2025. Interventions: Administer medications per physician orders-monitor side effects and adverse reactions associated with medication use-observe for any signs/symptoms indicated in black box warnings--- Status: Active (Current) . LVN 1 stated unable to locate padded side rails in the care plan and stated it should be included in the care plan. LVN 1 stated it is important to include padded side rails for Resident 6 because it is a person-centered care plan and if this is not included the nurse or staff will not know Resident 6 would require this intervention. LVN 1 stated the padded side rails are there so the resident does not hurt herself. During an interview on 6/27/25 at 9:01 a.m. with the DON, the DON stated the expectation is for Resident 6 to have padded side rails included in the care plan. The DON stated it is important to have padded side rails included in the care plan for staff to know what the resident requires for care. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated, .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' condition change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure care and services were provided in accordance with professional standards of quality for three of five sampled residents (Resident 8, Resident 5 and Resident 12) when:1.For Resident 8, there was no documented evidence of the removal of the previously applied medication patches from the residents' back.This failure to track and document patch removal had the potential to result in overmedication and adverse effects.2. Social Service Director (SSD) did not have a system in place to monitor Resident 8 for a follow up dental appointment.This failure had the potential to result in Resident 8's dental care to not be completed.3.Resident 5 did not have a running total of daily fluid intake calculated and documented.This failure had the potential to prevent a clear assessment of hydration status and overall fluid balance.4. Resident 12's potassium lab result was not communicated to the prescriber, and there was no evidence of clinical follow-up or intervention.This failure had the potential to place the resident at risk for complications related to abnormal potassium levels.Findings:1. During a review of Resident 8's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission Record indicated, Resident 8 was admitted to the facility on [DATE] with a diagnoses including hypertension (HTN-high blood pressure), and pain in both left and right shoulders. During an observation on 6/24/25 at 9:09 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed applying a lidocaine 4% (topical medication used to treat pain) patch to Resident 8's right shoulder. LVN 1 did not date, time or initial the medication patch at the time of administration. During a concurrent interview and record review of Resident 8's chart on 6/24/25 at 12:02 p.m. with LVN 1, LVN 1 stated she did not know when the lidocaine 4% patch applied on 6/23/25 was removed. The Medication Administration Record (MAR) indicated a patch was applied on 6/23/25 at 9:00 a.m.; however, there was no documentation of its removal. LVN 1 stated lidocaine 4% patches had a 12-hour duration to be applied on the skin and stated she had never dated or initialed patches upon application. LVN 1 stated there was no clear way to determine when the patch was removed since the patches were not time and date marked. During a review of the Medication Guide Instructions for lidocaine 4% patch last revised February 2025, the instructions indicated, the patch may be left on the skin for up to 8 or 12 hours .do not leave any patch on for longer than the stated time period .During an interview on 6/24/25 at 3:04 p.m. with the Director of Nursing (DON), the DON stated that staff should have an order to remove the medication patch. The DON stated the expectation is for nurses to have a time, date and initial of when medication patches are applied. The DON stated the nurse applying the patch is also expected to generate a corresponding removal order in the MAR to ensure patches are not left on the skin for an extended period, as this could increase the risk of skin irritation. During a review of the Specialist Pharmacy Service (SPS) article, Using Transdermal Patches Safely in Healthcare Settings, published 5/3/22, the article indicated, Healthcare staff should use a consistent method for recording patch application and removal, including date and time and site rotation, to mitigate medication errors and skin. 2. During a concurrent observation and interview on 6/23/25 at 3:36 p.m. with Resident 8 in room, Resident 8 observed to be awake, well groomed and in wheelchair. Observed Resident 8 to be missing two upper front teeth. Resident 8 stated had partial upper denture (removable dental appliance designed to replace multiple missing teeth while some nature teeth remain) prior to admission but no longer had them. Resident 8 stated the dentist did a mold for new partial upper dentures but that was months ago and had not heard anything since. Resident 8 stated not having upper partial dentures had not affected eating but was annoying to not have teeth. During a review of Resident 8's Face Sheet dated 6/27/25, the Face Sheet indicated Resident 8 was admitted into the facility on 4/4/2024. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool) Section C - Cognitive Patterns dated 3/7/25, the MDS Section C - Cognitive Patterns indicated Resident 6 ' s Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 10 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) which indicated Resident 8 had a moderate cognitive impairment. During a concurrent interview and record review on 6/25/25 at 1:35 p.m. with SSD, Resident 8's dental note dated 2/12/25 was reviewed. The dental note indicated, .Prosthetic [device designed to replace a missing part of the body] Evaluation: NOA [notice of authorization], PUD [partial upper denture]/FUD [full upper denture] (F/U [follow up] on framework) . SSD stated it appeared the note stated the dentist would follow up with Resident 8 but stated she was not familiar with the verbiage used by the dentist. SSD stated she should know how to read the dental notes since she is the one responsible for coordinating resident care. SSD stated she was not informed Resident 8 required a follow-up. SSD stated, when informed by the dentist a follow up is needed for a resident it would be her responsibility to do a follow-up but stated she does not maintain a list of residents who require a follow-up visit. SSD stated she had not kept track of what needs to be done for residents and what residents had been seen. SSD stated a note will not be written when documents are uploaded but will only upload the document completed by the dentist. During an interview on 6/27/25 at 9:38 a.m. with the Director of Nursing (DON), the DON stated SSD should be putting in notes for all updates regarding residents medical care in their chart. The DON stated SSD ensures follow-ups are done but they are not written down. The DON stated SSD needs to document any referrals, consults and follow-ups because if this is not done, there is no proof they occurred. The DON stated it is best practice to document anything about patient care because there needs to be some record that staff and the facility did something. During a review of the job description Director of Social Services dated 10/1/24, the Director of Social Services indicated, . Position Summary .This position is responsible for directing the social service functions which include the planning, development and implementation of appropriate programs designed to address the emotional and psychological needs of campus residents in multiple levels of care and their families. This position is responsible for actively participating in the resident assessment process . This position serves as a resident advocate within the campus . The Director of Social Services indicated, .Major Responsibilities . Provide regular contacts with families and act as a liaison for families with the resident care team . Maintain current documentation in resident ' s health record as it related to the social services care component of the comprehensive care plan for each resident as identified by the interdisciplinary team. Assure that appropriate care plan documentation as required by regulations and need is complete . 3. During a review of Resident 5's admission Record, the admission Record indicated, Resident 5 was admitted to the facility on [DATE] with a diagnoses including dysphagia (difficulty swallowing), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a concurrent observation and interview on 6/24/25 at 7:59 p.m., during the medication administration task, LVN 2 poured 30 ml of water into Resident 5's gastrostomy tube (g-tube -a small tube that goes directly through the skin into the stomach, and is used to give food, water or medicine to someone who can't eat normally), administered three medications and flushed 30 ml of water between each medication. Following the medication administration, LVN 2 administered Resident 5's bolus (a set amount of liquid) tube feeding of 240 ml of Jevity (brand of liquid nutrition) and completed the feeding with a final 30 ml water flush. During an interview on 6/24/25 at 2:23 p.m. with LVN 2, LVN 2 stated Resident 5 received 240 ml per g-tube feeding. LVN stated the total daily fluid intake was not being calculated. LVN 2 stated there was no formal policy on flushing, but leadership had instructed staff to administer 30ml of water with each medication. LVN 2 acknowledged this practice could contribute to fluid overload (when the body had too much water or other fluids in it) in Resident 5, who had a diagnosis of CHF. LVN 2 stated Resident 5 did not have any monitoring in place for edema (swelling) and did not have an order for diuretic (medicine that helped the body get rid of extra water) medication. During a concurrent interview and review of Resident 5's electronic health record, Resident 5's fluid orders were reviewed. Registered Nurse (RN)1 stated Resident 5 received her g-tube feedings six times per day, which totaled 1,440 ml of fluid daily. RN 1 stated the current order indicated 240 ml every 4 hours. During an interview on 6/24/25 at 3:27 p.m. with the DON, DON stated that nurses were expected to calculate the total volume of enteral feedings, including free water, and document it directly in the resident's chart. The DON stated input and output are tracked, and all fluid intake is calculated based on the MD's order. The DON stated that while there was an order for enteral flushes, there was no specific order for the total volume of enteral feed and free fluid. The DON stated there should be an order for the total daily volume of enteral feed and free fluid to ensure Resident 5 is receiving the correct amount of fluid. The DON stated that because Resident 5 has CHF, receiving too much fluid could result in fluid overload, while not receiving enough could lead to dehydration. The DON added the MD typically provided an order for the total volume to be administered each day. During a concurrent interview and review of Resident 5's electronic health record on 6/25/25 at 1:42 p.m. with the Registered Dietitian (RD), the RD stated she was responsible for making recommendations for the resident's total daily fluid intake. The RD explained that free water came from the formula itself, as well from flushes administered before and after feedings and between medications. The RD stated Resident 5 was NPO (nothing by mouth). The RD stated the last full nutritional assessment was completed on 4/30/25 by the consultant dietitian while she was on leave The consultant RD's 4/30/25 assessment was based on Resident 5's weight of 46 kg and recommended a total fluid intake of 1,610 ml per day. At that time Resident 5 received Jevity 1.2 at 60ml/hour as a continuous feeding, along with 160 ml of free water every 8 hours. The calculated free water from the Jevity 1.2 at 60ml/hr was 1,162 ml, plus an additional 480 ml from flushes, totaling 1,642. On 5/15/25, the feeding order was changed from continuous to bolus. The current regimen included Jevity 1.2 at 240ml every four hours, providing approximately 1,162 ml of free water daily. The RD stated additionally, Resident 5 received 30 ml flushes totaling 360 ml and 30 ml flushes before and after each medication administration (total approximately 360ml), bringing the estimated total daily fluid intake to approximately 1,882 ml. During a continued interview on 6/25/25 at 2:19 p.m. with the RD, the RD stated the amount of medication Resident 5 receives can impact overall flid intake. The RD stated there should be a goal for Resident 5's estimated fluid needs to ensure she is receiving an adequate amount without exceeding her requirements. The RD stated signs of fluid overload, such as edema, could indicate excessive fluid intake. The RD stated she was aware of Resident 5's diagnosis of CHF which further emphasized the importance of carefully managing total fluid volume. During an interview on 6/25/25 at 2:52 p.m. with the RD, the RD stated her goal for total daily fluid intake would have been 1,645 ml based on Resident 5's weight of 104 pounds at the time the Jevity order was changed to bolus feedings on 5/15/25. The RD stated Resident 5's actual calculated fluid intake was 1,882 ml per day, which exceeded the fluid goal. The RD stated the fluid goal would be adjusted if the resident exhibited signs of CHF such as fluid overload. The RD stated Resident 5's current weight was 110 pounds. During a review of Resident 5's Clinical Notes Report, dated 6/25/25, the Clinical Notes Report indicated, RD recommendation on 5/20/25 at 9:09 a.m. for Jevity 1.2 bolus feeds: 240 ml every 4 hours six times per day for a total volume of 1440 ml. Flush with 30 ml water before and after each feeding. This will provide 1728 kcal and 79 g protein daily. The RD recommendations did not account for the additional volume of water Resident 5 would receive with each medication administration, which contributes to Resident 5's total daily fluid intake. During a review of Resident 5's June 2025 Physician Order Sheet, dated 6/25/25, the June 2025 Physician Order Sheet indicated, Jevity 1.2. Cal 0.06 gram-1.2 kcal/ml oral liquid (240 ml) LIQUID (ML) G-tube. Notes: indication total volume 1440/ml day bolus feed 240 ml every 4 hours six times per day. The MD recommendations did not account for the additional volume of water Resident 5 would receive with each medication administration, which contributes to Resident 5's total daily fluid intake.During a review of Resident 5's June 2025 Physician Order Sheet, dated 6/25/25, the June 2025 Physician Order Sheet indicated, flush with 30 ml water before and after each feeding to provide 1728 KCAL starting on 5/20/25. Enteral tube flush. Notes: flush 30 ml of water before and after each medication starting on 4/12/25. During a review of Resident 5's June 2025 Physician Order Sheet, dated 6/25/25, the June 2025 Physician Order Sheet indicated, intake and output (I &O) monitoring to be done three times daily at 5:00 a.m., 1:00 p.m. and 9:00p.m.During a review of Resident 5's June 2025 Treatments, dated 6/25/25, the June 2025 Treatments indicated the only the Jevity feedings were being recorded. Although Resident 5 is NPO and received all fluids through g-tube, additional fluid intake-such as water flushes and water given with medications-were not included in the documented intake totals. During a review of Resident 5's Care Plan Report, dated 6/25/25, the Care Plan Report for CHF did not include interventions for monitoring total daily fluid volume. The only fluid-related intervention documented was to monitor intake at every meal. During a review of Merck Manual-Professional Edition, a widely recognized professional reference, the Manual indicated, water administered with medications should be included in the resident's total daily fluid calculation. Failing to account for all sources of fluid-such as medication flushes and enteral water-can lead to inaccuracies in fluid management and potentially impact resident safety and clinical outcomes. 4. During a review of Resident 12's admission Record, the admission Record indicated, Resident 12 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high blood pressure), heart failure, and acute myocardial infarction (MI-heart attack).During a review of Resident 12's Lab Report, dated 6/19/25 at 4:12 p.m., the Lab Report indicated, Resident 12's blood was drawn on 6/18/25 at 2:05 p.m. The potassium (a mineral in the body that helps the heartbeat normally) level was reported as 5.3, which was above the reference range of 3.5-5.1. This result indicated a high and out of range value. During a review of Resident 12's Clinical Notes Report dated 6/20/25 at 11:00 p.m., the Medical Doctor (MD) ordered Resident 12 to receive a one dose of Kayexalate (medication to decrease potassium level) 15 grams and for the potassium level to be redrawn on 6/22/25, in response to the elevated potassium level of 5.3.During a review of Resident 12's Lab Report, dated 6/23/25 at 2:49 p.m., the Lab Report indicated, Resident 12's blood redrawn on 6/22/25 at 8:45 p.m. The potassium result showed hemolysis (occurs when red blood cell breaks and spills their contents into the blood, which could occur if blood sample was handled too roughly or not stored right). During a concurrent interview and review of Resident 12's electronic health record, LVN 1 stated on 6/22/25 at 1:00p.m., Resident 12's MD placed an order for Resident 12's potassium level to be redrawn. LVN 1 acknowledged the lab results from 6/22/25 indicated the specimen was hemolyzed. LVN 1 confirmed there were no new orders for the potassium to be redrawn, and the physician had not been notified of the hemolyzed result. A nursing note dated 6/23/25 at 10:11 p.m. indicated potassium level back from lab, no critical values. Placed in MD binder. LVN 1 stated that after receiving lab results, the process was to send a picture of the lab result via text message to the MD and then place the lab sheet in the lab sheet binder for the MD to review and sign later. LVN 1 stated a picture of the lab result was not texted to the MD. LVN 1 stated it was important to communicate lab results to the MD, as a high potassium level could affect Resident 12's heart and kidneys. LVN 1 acknowledged Resident 12 had a history of heart problems. During an interview on 6/24/25 at 3:27 p.m. with the DON, the DON stated the process for lab draw (obtaining and analyzing blood sample) was t for a nurse to input the order, and the lab personnel come to draw the resident's blood. The DON stated, once results were received, the nurse was responsible for acknowledging them, notifying the MD and placing the lab sheet in the lab binder. The DON stated the expectation was the nurse should have notified the MD of the hemolyzed result and obtained a new order for the labs to be redrawn. The DON emphasized the importance of this step was to prevent any potential heart issues for Resident 12.During a review of the facilities policy and procedure (P&P) titled, Lab Diagnostic Test Results-Clinical Protocol, revised November 2018, the P&P indicated, when test results are reported to the facility, a nurse will first review the results .3.a nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality and the individual current condition .4. A nurse will try to determine whether the test was done c. (2) if the reason for performing the test cannot be identified, the nurse should proceed as though the tests were ordered to assess a condition change or recent onset of signs and symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure proper pharmaceutical services were provided to meet the needs of residents when the facility did not have an effective system in place to periodically reconcile all controlled substances in the facility.This failure had the potential for diversion, mismanagement, or unaccounted medication, and the potential not to meet the needs of the residents in the facility.Findings:During an interview on [DATE] at 3:13 p.m. with the Director of Nursing (DON), the DON stated that residents were typically discharged with their medications. DON stated that if a resident was deceased or a medication was discontinued, nursing staff would inform her, and the medications would be stored in a locked box in her office until destruction by both her and the consultant pharmacist. The DON stated she and the nurse would sign the disposition log and date it at the time the medication was handed to her for destruction. The DON stated she does not periodically reconcile medications in the facility and did not have a system in place. The DON stated it would be important to have a system such as that in place to ensure that no drugs go missing in the building. During an interview on [DATE] at 3:00 p.m. with the Registered Pharmacist (RPh), the RPh acknowledged the facility did not have a process in place to periodically reconcile all controlled substances in the facility and stated it was important to periodically reconcile controlled substances in order to ensure all medications were properly accounted for.During a review of the facility's Policy and Procedure (P&P) titled, Controlled Substances, revised [DATE], the P&P indicated, policies and procedures for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist .During a review of the facility's Policy and Procedure (P&P) titled, Dispensing and Reconciling Controlled Substances, revised [DATE], the P&P indicated, controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 8 percent. There were 25 opportunities for errors and two medication errors occurred for two of four sampled residents (Resident 28, and Resident 12) when:1. Resident 28's diclofenac 1% gel (topical pain medication) dose was not correctly measured.2. Resident 12's Refresh Classic 1.4-0.6% eye drops (medication used to treat dry eye disease) were administered incorrectly in both dosage amount and technique. The quantity exceeded the prescribed amount in the left eye and the drops were placed directly in the center of the eye.These failures to follow proper medication administration practices had the potential to result in reduced effectiveness of treatment or harm to Residents 28 and 12.Findings:1. During a concurrent observation and interview on 6/24/25 at 8:34 a.m. with Licensed Vocational Nurse (LVN) 2, during a medication administration task, LVN 2 was observed filling a medication cup with diclofenac 1% to the second dram (a unit of measurement) line. LVN 2 stated the medication cup did not have gram measurements labeled on it, so she estimated the amount to be administered. The physician order was to apply 2 grams of the topical gel to Resident 28's left knee. LVN 2 was unaware that a measuring stick was included inside the medication box for accurately measuring the prescribed dosage. Additionally, LVN 2 stated she was unsure what a dram represented as a unit of measure.During a review of Resident 28's Physician Order Sheet, dated 6/25/25, the Physician Order Sheet indicated, Resident 28 had an active order for diclofenac 1% topical gel, with instructions to apply 2 grams to the left knee twice a day.During a review of the Medication Guide Instructions for diclofenac 1%, last revised May 2024, the instructions indicated, to measure the right dose, use the dosing card provided with the medication. Place a dosing card on a flat surface so that you can read the print on the card. Squeeze an even line of the medication from the tube onto the dosing card, using the marks on the card to measure the prescribed dose.During an interview on 6/24/25 at 3:04 p.m. with LVN 2, she stated it was important to ensure accuracy and to follow the physician's orders. LVN stated that staff need to match the doctor's orders and refer to the package inserts when administering medications.During an interview on 6/24/25 at 3:13 p.m. with the Director of Nursing (DON), the DON stated that a ruler should be used to measure the dose in accordance with the physician's order. The DON stated it was not the standard of practice to squeeze the medication gel into a medicine cup, as this method does not align with the prescribed dosage. The DON stated that the incorrect dosing could result in Resident 28 not receiving adequate pain control or, if too much is given, could potentially cause bruising and bleeding.During an interview on 6/26/25 at 3:00 p.m. with the Registered Pharmacist (RPh), the RPh stated the expectation when following prescriber's orders is to do so completely and accurately. The RPh stated this was important because the medication is intended to treat pain in the specific location where it is applied.2. During a concurrent observation and interview on 6/24/25 at 9:22 a.m. with LVN 1, during medication administration task, LVN 1 was observed assisting Resident 12 in opening her eyes and administering Refresh Classic 1.4-0.6% eye drops. LVN 1 placed one drop in Resident 12's right eye and two drops in the left eye, aiming for the center of each eye. LVN 1 realized she had administered an extra drop in the left eye and stated she would contact the physician. LVN 1 stated the medication is intended to moisturize the eye, and therefore, it does not matter where the drops are placed.During a review of Resident 12's Physician Order Sheet, dated 6/25/25, the Physician Order Sheet indicated, Resident 12 had an active order for Refresh Classic 1.4-0.6% eye drops to be administered as one drop in each eye three times per day.During a review of the Medication Guide Instructions for diclofenac 1%, last revised September 2024, the instructions indicated, tilt your head back, look up and pull down the lower eye lid to make a pouch.During an interview on 6/24/25 at 2:14 p.m. with LVN 1, LVN 1 stated she looked up the information and learned that it is most effective to administer the eye drop into the conjunctival sac (small pocket between the inside of the lower eyelid and surface of the eye). LVN 1 stated she informed the physician of the incorrect dose of eye drops administered to Resident 12's left eye, and Resident 12 was placed on alert charting to monitor for any potential side effects.During an interview on 6/24/25 at 3:27 p.m. with the DON, the DON stated eye drops should not be placed directly in the center of the eye, as this could potentially damage the eye or result in loss of the medication. The DON stated it was not her expectation of staff to administer drops in this manner. The DON stated eye drops are to be placed in the conjunctival sac of the eye.During an interview on 6/26/25 at 3:00 p.m. with the RPh, the RPh stated the expectation for administering eye drops is they are placed in the conjunctival sac.According to [NAME] and [NAME] (2023) in Nursing Rights of Medication Administration, Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures when:1. One bottle of Resident 17's latanoprost (medication used to decrease blood pressure in the eye) was stored in the Station 1 (Whispering [NAME]) medication cart did not have resident-specific label.This had the potential to result in medication administration errors, including administration to the wrong resident, which may adversely affect resident safety.2. Discontinued medications for Resident 17, Resident 28 and Resident 32 were stored in in the active medication section of the Station 1 medication cart.This had the potential to result in the administration of discontinued medications, placing residents at risk for receiving unnecessary or inappropriate treatment.3. A bottle of house stock medication (over the counter medication available for administration to any resident in the facility) in the Station 1 medication room was expired as of 5/2025 and was not removed from active stock.This failure had the potential to result in administration of expired medication, which could affect the safety and effectiveness of treatment provided to residents.4. A partially used multi-dose tuberculin vial (a sterile liquid used in a skin test to diagnose tuberculosis [TB- serious bacterial infection of the lungs] infection) in the medication refrigerator of station 1 was opened but did not have an open date or an expiration date.This failure had the potential to result in the use of compromised or ineffective medication, which could lead to inaccurate tuberculosis skin test results and negatively impact resident and staff safety.5. An opened and partially used bottle of sterile normal saline for irrigation (saltwater solution used to clean wounds or body parts. It's made in a way to make sure it had no germs in it), labeled for single use only, was stored in the active medication section of the treatment cart of Station 2 (Heartland Place).This failure had the potential to result in contamination and posed a risk to resident health and safety.6. Two bottles of nystatin powder (medication used to treat certain skin infections caused by fungi) were found in the treatment cart of Station 2 without resident-specific labels.This had the potential to result in medication administration errors, including administration to the wrong resident, which may adversely affect resident safety.Findings:1. During a concurrent observation and interview on 6/23/25 at 1:56 p.m. with Licensed Vocational Nurse (LVN) 3, the medication cart for Station 1 was inspected. Resident 17's latanoprost 0.005%) was stored inside a medication box without a resident identifier label on the bottle. LVN 3 acknowledged Resident 17's latanoprost bottle did not have resident-specific identifier and stated the medication bottle should be labeled because the box could be lost, and without the label on the bottle, staff would not know to whom the medication belong.During an interview on 6/24/25 at 3:27 p.m. with the Director of Nursing (DON), the DON stated the expectation of staff was the medication bottles should be labeled with a patient identifier because medications are intended for use only by the specific resident for whom they are prescribed.During an interview on 6/26/25 at 3:00 p.m. with Registered Pharmacist (RPh), the RPh stated the policy required a smaller label to be applied directly to the medication container itself, not just on the medication box as this is to prevent accidental administration.2. During an observation 6/23/25 at 2:10 p.m., the medication cart for Station 1 was inspected. For Resident 17, Rocklatan 0.02%-0.005% (medication used to decrease blood pressure in the eye) were observed stored in the medication cart. For Resident 28, and Resident 32, Zofran ODT (an oral disintegrating tablet medication used to treat nausea) 4 milligrams (mg- unit of measure) tablets were individually packaged and stored in separate clear bags and labeled with each resident's identifier.During a concurrent interview and record review on 6/23/25 at 2:35 p.m. with LVN 3, Residents 17, 28 and 32's physician orders were reviewed.A review of Resident 17's Medication Administration Record (MAR), dated June 2025, indicated the Rocklatan 0.002%-0.005% eye drops had been discontinued since 6/13/25. LVN 3 stated discontinued medications should be removed from the medication cart and added, You don't want to give discontinued medications.During a review of Resident 17's June 2025 Physician Order Sheet, dated 6/25/25, the orders indicated Resident 17's Rocklatan 0.02%-0.005% eye drops were ordered 1/17/2020 and discontinued on 6/13/25.During a review of Resident 28's Treatment/Order Update/Change in Condition, dated 3/6/25, the order indicated Resident 28's Zofran ODT 4mg every 8 hours as needed was to begin on 3/7/25 and end on 3/11/25.During a review of Resident 32's Physician Medication Orders, dated 3/12/25, the order indicated Resident 32's Zofran ODT 4mg every 8 hours as needed was to being on 3/12/25 and end on 3/19/25.LVN 3 acknowledged the medication orders reviewed for Residents 17, 28 and 32 were discontinued. LVN 3 stated the medications should have been removed from the medication cart and placed in the discontinued medication box when the physician order completed.During an interview on 6/24/25 at 3:27 p.m. with the DON, the DON stated the expectation was for discontinued medications to be placed in the locked drawer in the medication room once an order to discontinue is received. The DON stated there should not be any discontinued medications stored in a medication cart alongside active medications.During an interview on 6/26/25 at 3:00 p.m. with RPh, the RPh stated discontinued medications should not be stored in the active medications cart, to prevent accidental administration.3. During a concurrent observation and interview on 6/23/25 at 2:37pm at Station 1 with Registered Nurse (RN) 1, a medication bottle of Geri-Lanta regular strength 366ml (medication used to treat upset stomach) was observed stored in a cabinet with active medication house stock. Upon review, the medication was found to be expired as of May 2025. RN 1 stated the medication should have been removed and placed in the discontinued medication box. RN 1 stated this was important to prevent medication errors and to ensure residents did not receive expired medications, as it was a matter of resident safety.During an interview on 6/24/25 at 3:27 p.m. with the DON, the DON stated her expectation was for expired medications to be removed from active house stock in the medication room. The DON stated expired medications should be removed to prevent the risk of someone accidentally selecting and administering them to a resident.During an interview on 6/26/27 at 3:00 p.m. with RPh, the RPh stated expired medications should not be stored with active medication stock in storage rooms to prevent the risk of expired medications being administered to residents.During a review of facilities policy and procedure (P&P) titled, Storage of Medications, dated 11/2020, the P&P indicated, discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.4. During a concurrent observation and interview on 6/23/25 at 2:47pm at the Station 1 RN 1, a tuberculin 1 ml vial was observed stored in the medication refrigerator. The vial had been previously opened and punctured; however, there was no date indicating when it was opened or when it should expire. RN 1 confirmed the vial had been opened and acknowledged the open and expiration dates had not been written on the vial. RN 1 stated once the vial is opened, it must be discarded after 30 days.During an interview on 6/24/25 at 3:27 p.m. with the DON, the DON stated it was her expectation that an open date be documented on the tuberculin solution vial. The DON stated the solution could only be used for up to 30 days once opened. The DON stated the risk of not documenting the open date is that staff could administer expired tuberculin solution, which could result in an inaccurate reading.During an interview on 6/26/25 at 3:00 p.m. with RPh, the RPh stated the tuberculin vial should have been labeled with an open date, as it expired 30 days after opening. The RPh stated labeling with an open date was important to ensure the accuracy of the test results.During a review of the manufacturer information package insert for tuberculin date unknown, the storage recommendations indicated vials in use for more than 30 days should be discarded due to possible oxidation [breakdown of the medication] and degradation, which may affect the potency of the solution.5. During a concurrent observation and interview on 6/23/25 at 2:57 p.m. with LVN 4, a partially used 100 ml bottle of sodium chloride irrigation solution was observed in the treatment cart of station 2 . LVN 4 stated the bottle was labeled as sterile and, therefore, should not be reused. LVN 4 stated it should be disposed of after initial use, as it is considered a one-time use item.During an interview on 6/24/25 at 3:27 p.m. with the DON, the DON stated the bottle is sterile and should be for one-time use. The DON stated the bottles should be discarded after use and not stored back in the treatment cart. The DON stated it was important because, once opened, the bottle is no longer considered sterile.During an interview on 6/26/25 at 3:00 p.m. with RPh, the RPh stated the sodium chloride irrigation was labeled for single use only and should not be returned to the treatment cart after being opened.During a review of the manufacturer information package insert for sodium chloride-sodium chloride irrigation dated 9/23, the package insert warning indicated, after opening container, its contents should be used promptly to minimize the possibility of bacterial (germs) growth.discard unused portion of irrigating solution since it contains no preservatives.6. During a concurrent observation and interview on 6/23/25 at 2:57 p.m. with LVN 4, two nystatin powder bottles (60 grams and 30 grams, were observed in the treatment cart of station 2. The bottles did not have a resident identifier on them. LVN 4 acknowledged the nystatin bottles did not have resident-specific identifiers and stated the bottles should have a resident identifier to ensure the medications were not administered to the wrong resident.During an interview on 6/24/25 at 3:27 p.m. with the DON the DON stated the expectation of staff was the medication bottles should be labeled with a patient identifier because medications are intended for use only by the specific resident for whom they are prescribed.During an interview on 6/26/25 at 3:00 p.m. with RPh, the RPh stated the nystatin powder bottles in the treatment cart should have resident-specific identifiers to ensure the medications were being used only for the intended residents.During a review of facilities policy and procedure (P&P) titled, Labeling of Medication Containers, dated 4/2019, the P&P indicated, medication labels must be legible at all times.any medication packaging or containers that are inadequately or improperly labeled are returned .labels for individual resident medications include all necessary information, such as a. the residents name.

Based on observation, interview and record review, the facility failed to ensure proper sanitation of equipment when two of two ice machines for resident use had brown and yellow discoloration in the machines. This failure had the potential to contaminate the ice distributed to residents and the potential for residents to become ill.Findings: During a concurrent observation and interview on 6/23/25 at 2:34 p.m. with Director of Facilities Management (DFM) in the kitchen at the ice machine, DFM removed the front panel of the ice machine and observed brown and yellow staining around the perimeter of the inside of the ice machine. Surveyor conducted a tissue swipe of the areas with brown and yellow staining and brown debris was observed on tissue. Confirmed the brown debris seen on tissue with DFM. DFM stated the debris should not be there. DFM stated the ice machine is deep cleaned once a month. During a concurrent observation and interview on 6/24/25 at 9:50 a.m. with DFM at nurses' station one utility room, the ice machine was inspected. DFM removed front panel of the ice machine and brown staining was noted around the perimeter of the inside of the machine. [NAME] staining observed in water drop off area. Surveyor conducted tissue swipe of brown areas and brown debris was observed on tissue. Confirmed brown debris on tissue with DFM. DFM stated the expectation is to have all parts of the inside of the ice machine cleaned. During a concurrent observation and interview on 6/24/25 at 9:59 a.m. with Maintenance Technician (MT) in the nurses' station one utility room, MT confirmed the brown staining observed inside ice machine. MT stated both ice machines have not been cleaned in the month of June and are due to be cleaned. During an interview on 6/24/25 at 10:02 a.m. with DFM, DFM stated both ice machines are cleaned monthly but there is not a set date when they need to be cleaned. DFM stated both ice machines just need to be cleaned within the month. During an interview on 6/24/25 at 10:08 a.m. with Certified Nursing Assistance (CNA) 1, CNA 1 stated the ice from the ice machine in nurses' station one utility room is used for residents. CNA 1 stated the ice is used to keep items cold and ice placed in residents' drinks. During a concurrent interview and record review on 6/25/25 at 3:44 p.m. with Assistant Director, Facilities Management Assistant Director (FMAD) Maintenance Work Order #130824 dated 5/5/25 was reviewed. The Maintenance Work Order #130824 indicated the assignment to clean the ice machines in May was assigned on 5/5/25 and the MT completed the job of cleaning both ice machines on 5/9/25. FMAD confirmed the last time both ice machines were cleaned was on 5/9/25. FMAD stated once the MT has cleaned the ice machines, FMAD will come in and inspect the machine and ensure they are cleaned and there is no residue. FMAD stated the machines can be up and running before he comes in to inspect the machines. FMAD stated the work order for the ice machines to be cleaned is generated the first of the month and they will need to be cleaned within the month. FMAD stated it is important for the ice machines to be clean because they are used for residents and residents can get sick if not clean. During an interview on 6/25/25 at 3:48 p.m. with MT, MT stated both ice machines will be cleaned when he has time, and they are not cleaned on a specific day. MT stated it is important for the ice machines to be cleaned because ice goes to all residents, and they could get sick. During an interview on 6/27/25 at 8:59 a.m. with the Director of Nursing (DON), the DON stated the expectation is for the ice machines to be monitored by facility maintenance for cleanliness and to follow protocol. The DON stated both ice machines are used for residents. The DON stated it is important to ensure the ice machines are cleaned because residents can get sick. During a review of job description titled Maintenance Technician III dated 10/1/24, the Maintenance Technician III description indicated, .Position Summary: Provide high quality and specialized maintenance in the following areas: physical plant, machinery and equipment, and preventative and corrective maintenance. Includes specialized responsibilities in the areas of heating and cooling (HVAC), refrigeration . and other environmental services functions .During a review of job description titled Assistant Director, Facilities Management dated 10/1/24, the Assistant Director, Facilities Management description indicated, .Position Summary .Responsible for assuring compliance with all applicable local, state and federal statues and conformance with campus safety programs .Major Responsibilities: Assign and manage facilities management work order scheduling to ensure satisfactory and timely completion. Must be able to prioritize work and be proactive in noticing problem areas or jobs that need to be done in order to maintain organization standards .During a review of job description titled Director of Facilities Management dated 10/1/24, the Director of Facilities Management description indicated, .Position Summary . The facilities management director is responsible for assuring compliance with all applicable local, state and federal statues and conformance with campus safety programs .Major responsibilities . Responds to all staff and resident work requests and the appropriate follow up .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow proper infection control practices for 1 of 4 sampled residents (Resident 5) when the nurse did not use Enhanced Barrier Precautions (EBP as gown, and gloves), while administering medications and a bolus feeding through a gastrostomy tube (G-tube- a small, soft tube that is inserted through the skin directly into the stomach, and is used to give food, water or medicine).This failure increased the risk of spreading germs amongst all residents in the facility.Findings:During a review of Resident 5's admission Record (AR- a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), Resident 5's AR indicated, Resident 5 was admitted to the facility on [DATE] with a diagnosis which included dysphagia (difficulty swallowing), cerebrovascular accident (CVA-a stroke, loss of blood flow to a part of the brain), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During an observation on 6/24/25 at 8:25 a.m. with Licensed Vocational Nurse (LVN) 2 during medication administration observation task, LVN 2 administered medications and a bolus feeding via G-tube to Resident 5 and only wore gloves during the task.During an interview on 6/24/25 at 2:16 p.m. with LVN 2, LVN 2 stated the purpose of EBP was to prevent infections, reduce the spread of germs and protect the resident. LVN 2 stated EBP, which included wearing a gown and gloves, were used when caring for residents such as Resident 5 was at high risk for infection during such procedures due to her G-tube. During an interview on 6/24/25 at 3:13 p.m. with the Director of Nursing (DON), the DON stated EBP were required for any resident with wounds, catheters, IV's or G-tubes. The DON stated her expectation for staff was to wear EBP when providing direct care to residents with these conditions or devices. The DON stated wearing only gloves was not sufficient. The DON stated following EBP was important to prevent the spread of infections to others and to avoid exposing the resident to potential infections. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated, EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .examples of high contact resident care activities requiring the use of gown and gloves for EBP's include: g device care or use ( feeding tube) .EBP remain in place remain in place for the duration of the residents stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk .

Based on interview, record review, document review, and facility policy review, the facility failed to act upon the Pharmacist's recommendation to add a specific duration to as needed psychotropic medication for 2 (Resident #11 and Resident #37) of 5 residents sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Regimen Review and Reporting, dated 01/2024, indicated, 6. Resident-specific MRR [medication regimen review] recommendations and findings are documented and acted upon by nursing care center and/or physician. The policy indicated, 8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. a. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record. 1. A Face Sheet revealed the facility admitted Resident #37 on 12/28/2022. According to the Face Sheet, the resident had a medical history that included diagnose of right femur fracture, major depressive disorder, and anxiety. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident received an antianxiety medication during the assessment period. Resident #37's Care Plan Report, effective 12/28/2022 to present, indicated the resident had a diagnosis of anxiety manifested by feelings of inability to breathe, and received ant-anxiety medications on an as needed basis. Resident #37's June 2024 Physician Order Sheet contained an order dated 02/21/2024 for lorazepam (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every eight hours as needed for anxiety. The order did not include a stop/discontinue date. The Pharmacist's Note to Attending Physician/Prescriber dated 03/22/2024, indicated, Resident #37 was currently on lorazepam 0.5 mg every eight hours as needed for anxiety. Per the Note to the Attending Physician/Prescriber, as needed psychotropic orders must have a duration per our regulations. The Pharmacist's Recommendations Pending from Last Month's Report for the timeframe 06/01/2024 to 06/11/2024, indicated, Resident #37 was currently on lorazepam 0.5 mg every eight hours as needed for anxiety and our regulation specify that we must have a specific duration for as needed anxiolytics. During an interview on 06/12/2024 at 8:37 AM, the Nurse Practitioner (NP) stated there should be a stop date within 14 days on PRN [pro re nata, as needed lorazepam, and the Pharmacist normally sent recommendations for a stop date if one was not included in the original order. The NP stated she did not know why there was not a stop date on Resident #37's PRN lorazepam order. During an interview on 06/12/2024 at 9:23 AM, the Pharmacist stated when she did medication reviews, she recommended to the physicians that PRN antianxiety medications needed a specified duration included in the order. The Pharmacist stated she recommended in March 2024 for the physician to add a duration or stop date to Resident #37's PRN lorazepam, but the physician had not yet responded to the recommendation. The Pharmacist stated she was in the facility on 06/11/2024 and again made a recommendation to the physician to add a stop date to Resident #37's PRN lorazepam because the regulation required a specified duration for a PRN psychotropic. The Pharmacist stated she told the facility to just call the physician because the physician was not responding to their recommendations. During an interview on 06/12/2024 at 10:54 AM, the Director of Nursing (DON) stated orders for PRN antianxiety medications required a stop date or duration to be included in the order per the regulations. The DON stated she knew there were orders for PRN antianxiety medications in use, but was not aware there was no specified duration included in the order and added that the recommendations for a stop date must have been overlooked until now. During an interview on 06/12/2024 at 11:00 AM, the Administrator stated she expected her staff to follow the policy on PRN psychotropic use and expected the physician to follow up on all pharmacy recommendations. 2. A Face Sheet revealed the facility admitted Resident #11 on 01/19/2024. According to the Face Sheet, the resident had a medical history that included chronic pain syndrome, spinal stenosis, and atrial fibrillation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received an antianxiety medication during the assessment period. Resident #11's Care Plan Report, effective 01/19/2024 to present, indicated the resident had a diagnosis of anxiety manifested by restlessness and agitation. Resident #11's June 2024 Physician Order Sheet contained an order dated 03/25/2024 for Ativan (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every six hours as needed for anxiety. The order did not include a stop/discontinue date. The Consultant Pharmacist's Medication Regimen Review, for Resident #11 for the timeframe 04/06/2024 to 04/17/2024, indicated, PRN psychotropic orders need a 14 day stop date. At that time physician will need to re-evaluate the continued need for the psychotropic. Duration greater than 14 days will need physician rationale. The Pharmacist's Nursing Recommendations for the timeframe 06/01/2024 to 06/11/2024, indicated, PRN psychotropic orders need a 14 day stop date. At that time physician will need to re-evaluate the continued need for the psychotropic. Duration greater than 14 days will need physician rationale. During an interview on 06/12/2024 at 9:23 AM, the Pharmacist stated when she did medication reviews, she recommended to the physicians that PRN antianxiety medications needed a specified duration included in the order. The Pharmacist stated she recommended in April 2024 for the physician to add a duration or stop date to Resident #11's PRN Ativan but the physician had not yet responded to the recommendation. The Pharmacist stated she was in the facility on 06/11/2024and again made a recommendation to the physician to add a stop date to Resident #11's PRN Ativan because the regulation required a specified duration for the PRN psychotropic. The Pharmacist stated she told the facility to just call the physician because the physician was not responding to their recommendations. During an interview on 06/12/2024 at 10:54 AM, the Director of Nursing (DON) stated orders for PRN antianxiety medications required a stop date or duration to be included in the order per the regulations. The DON stated she knew there were orders for PRN antianxiety medications in use, but was not aware there was no specified duration included in the order and added that the recommendations for a stop date must have been overlooked until now. During an interview on 06/12/2024 at 11:00 AM, the Administrator stated she expected her staff to follow the policy on PRN psychotropic use and expected the physician to follow up on all pharmacy recommendations. During an interview on 06/12/2024 at 11:45 AM, the Physician stated he used PRN antianxiety medications for 14 days but then reassessed the resident's need for the medication. The Physician stated Resident #11 was on PRN Ativan prior to admission so he kept the order in place due to the family's reluctance to change the resident's medication regimen. The Physician stated he reviewed the pharmacy recommendations each month and did not follow up on the recommendation to input a stop date on Resident #11's PRN Ativan due to the family's preference. The Physician stated it was not documented in the resident's chart that he chose to keep Resident #11 on the PRN Ativan with no stop date.

Based on interview, record review, and facility policy review, the facility failed to indicate the duration of an as needed antianxiety medication for 2 (Resident #11 and Resident #37) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, dated 07/2022, indicated, 12. Psychotropic medications are not prescribed or given on a PRN [pro re nata, as needed] basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. A Face Sheet revealed the facility admitted Resident #37 on 12/28/2022. According to the Face Sheet, the resident had a medical history that included diagnose of right femur fracture, major depressive disorder, and anxiety. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident received an antianxiety medication during the assessment period. Resident #37's Care Plan Report, effective 12/28/2022 to present, indicated the resident had a diagnosis of anxiety manifested by feelings of inability to breathe, and received ant-anxiety medications on an as needed basis. Resident #37's June 2024 Physician Order Sheet contained an order dated 02/21/2024 for lorazepam (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every eight hours as needed for anxiety. The order did not include a stop/discontinue date. 2. A Face Sheet revealed the facility admitted Resident #11 on 01/19/2024. According to the Face Sheet, the resident had a medical history that included chronic pain syndrome, spinal stenosis, and atrial fibrillation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received an antianxiety medication during the assessment period. Resident #11's Care Plan Report, effective 01/19/2024 to present, indicated the resident had a diagnosis of anxiety manifested by restlessness and agitation. Resident #11's June 2024 Physician Order Sheet contained an order dated 03/25/2024 for Ativan (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every six hours as needed for anxiety. The order did not include a stop/discontinue date. During an interview on 06/12/2024 at 8:37 AM, the Nurse Practitioner (NP) stated there should be a stop date within 14 days on PRN lorazepam, and the Pharmacist normally sent recommendations for a stop date if one was not included in the original order. The NP stated she did not know why there was not a stop date on Resident #37's PRN lorazepam order. During an interview on 06/12/2024 at 9:23 AM, the Pharmacist stated when she did medication reviews, she recommended to the physicians that PRN antianxiety medications needed a specified duration included in the order. During an interview on 06/12/2024 at 10:54 AM, the Director of Nursing (DON) stated orders for PRN antianxiety medications required a stop date or duration to be included in the order per the regulations. The DON stated she knew there were orders for PRN antianxiety medications in use, but was not aware there was no specified duration included in the order and added that the recommendations for a stop date must have been overlooked until now. During an interview on 06/12/2024 at 11:00 AM, the Administrator stated she expected her staff to follow the policy on PRN psychotropics. According to the Administrator, the Physician ordered the medications, and she was not aware the facility used PRN Ativan with no stop date or specified duration.

2. A facility policy titled, Enhanced Barrier Precautions, revised 08/2022, indicated, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy indicated, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). A Face Sheet indicated the facility admitted Resident #33 on 11/14/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of malignant neoplasm of stomach and rhabdomyolysis. Resident #33's June 2024 Physician Order Sheet contained an order dated 06/06/2024, for wound honey topical paste to the resident's left lower back wound after cleaned with wound cleanser then cover with gauze island border dressing daily. During a concurrent observation and interview on 06/11/2024 at 1:07 PM, Licensed Vocational Nurse (LVN) #1 and Registered Nurse (RN) #2 provided wound care for Resident #33's wound on their left lower back. LVN #1 and RN #2 did not use EBPs while providing the wound care. LVN #1 indicated Resident #33 did not need EBP because the wound was small with no drainage. During an interview on 06/12/2024 at 7:20 AM, the Infection Control Prevention Officer (ICPO) indicated Resident #33 had a small area that kept opening and closing. The ICPO indicated if a wound required a daily dressing change, then EBP should be utilized. The ICPO stated staff should use EBP for Resident #33. The ICPO indicated she was not at the facility the previous week when the wound opened back up, but the nurse should have initiated the EBP set up because they knew if a daily dressing change was needed then EBP was required. During an interview on 06/12/2024 at 8:26 AM, LVN #1 stated she had been informed that EBP should have been used during the wound care that was provided on 06/11/2024. During an interview on 06/12/2024 at 10:49 AM, LVN #3 indicated EBP was utilized for residents with indwelling urinary catheter, dialysis access, peripherally inserted central catheter line, and wounds, to protect from body fluids. During an interview on 06/12/2024 at 11:18 AM, the Director of Nursing (DON) indicated any resident who had any type of wound or skin injury should have EBPs. The DON indicated EBP required a sign outside the room and personal protective equipment (PPE) cart outside the room. The DON stated the sign informed staff what PPE to wear. The DON stated staff should have utilized EBP during the wound care for Resident #33. The DON stated she expected EBP to be used for Resident #33's wound care and any resident who needed EBP. During an interview on 06/12/2024 at 11:32 AM, the Administrator indicated staff should have followed the policy for EBP during the wound care for Resident #33. The Administrator indicated she expected staff to follow the EBP policy. Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff stored respiratory equipment per the facility policy when not in use for 1 (Resident #3) of 1 sampled resident reviewed for respiratory care. The facility also failed to ensure enhanced barrier precautions were utilized during the provision of wound care for 1 (Resident #33) of 12 sampled residents. 1. A facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, specified, 8. Keep the oxygen cannulae and tubing used PRN [pro re nata, as needed] in a plastic bag when not in use. A Face Sheet revealed the facility admitted Resident #3 on 03/24/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD) with exacerbation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition. The MDS revealed the resident used oxygen therapy. Resident #3's Care Plan Report, effective 03/24/2022 to present, revealed the resident had a diagnosis of COPD and respiratory failure with hypoxia and was at risk for impaired gas exchange. Interventions directed the staff to administer supplemental oxygen as ordered. Resident #3's June 2024 Physician Order Sheet, revealed an ordered dated 03/20/2024, for supplemental oxygen at three liters per minute per nasal cannula. During an observation on 06/11/2024 at 12:42 PM, Resident #3's oxygen tubing was seen resting on the concentrator and not in the empty bag attached to the concentrator. During an interview on 06/11/2024 at 1:13 PM, Licensed Vocational Nurse (LVN) #3 stated oxygen tubing should be placed in a plastic bag when not in use. During an interview on 06/11/2024 at 1:58 PM, CNA #4 stated oxygen tubing should be placed in a bag on the compressor unit when being stored. During an interview on 06/12/2024 at 9:30 AM, the Director of Nursing (DON) stated she expected oxygen tubing be stored in a bag by the concentrator when not in use. According to the DON, proper storage of the oxygen tubing was important to avoid infections. During an interview on 06/12/2024 at 9:32 AM, the Administrator stated it was her expectation that staff follow the policy regarding storage of respiratory care equipment.

Based on observation, interview and record review, the facility failed to accommodate personal privacy for one of 10 sampled residents (Resident 4) when: Resident 4's privacy curtain was not drawn around his bed while he rested and exposed his undressed body below the waist line. This failure violated Resident 4's right to be treated with dignity and respect. Findings: During an observation on 6/13/19, at 7:54 a.m., in Resident 4's room, Resident 4 laid in bed while asleep, he was undressed from the waist down and was uncovered. Resident 4's brief, naked legs and feet were visible to those who passed by his room. Resident 4's privacy curtain was not drawn around Resident 4 to provide him with privacy. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, on 6/13/19, at 8:05 a.m., CNA 1 stated Resident 4 was uncovered and was not provided with privacy. CNA 1 stated anyone who passed by Resident 4's room could see his brief and undressed lower body. CNA 1 stated Resident 4's privacy curtain was not drawn around his bed to provide him with privacy and should have been drawn around his bed to provide him with privacy. During an interview with the Director of Nursing (DON), on 6/13/19, at 3:45 p.m., the DON stated staff should have made sure all residents were covered and provided with privacy in order to not violate their dignity. The facility policy and procedure titled, Resident Rights . undated, indicated As a resident of this nursing facility, you have the right to a dignified existence . You have the right to be treated with respect and dignity.

Based on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when: there were 82 medication pass opportunities for error and 10 errors resulted in a medication error rate of 12.2 percent. This failure resulted in the significant medication error for Resident 15. Findings: During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 6/12/19, at 11:39 a.m., during a morning medication pass, LVN 3 prepared medications for Resident 15. LVN 3 prepared and administered the following medications: amitriptline hydrochloride (hcl) (medication used to treat major depression) (mood disorder) 50 milligram (mg) (dry unit of measurement), carbidopa-levodopa (used to treat Parkinson) (disease of the brain causes involuntary body movements) 25-100 mg, duloxetine hcl (medication to treat depression) (mood disorder ) 30 mg capsule, isosorbide mononitrate 10 mg (mediction used to prevent chest pain), losartan potassium 50 mg tablets (medication to lowers blood pressure), metoprolol succinate 50 mg 1 tablet (high blood pressure medication), ferrous sulfate 325 mg (iron supplement) 1 tablet, vitamin D (supplement) 1 tablet, dabigatran etexilate 150 mg (medication to prevent blood clots), fluticasone propionate (allergy relief medication) 50 microgram (MCG) (unit of measurement) 2 sprays in each nostril, fexofenadine180 mg (allergy medication) 1 tab daily. LVN 3 stated she would not administer glipizide 5 mg tablet (anti-diabetic medication) because the medication indicated an expiration date of 5/2019. LVN 3 stated the medications administered at 11:39 a.m., were all due at 9 a.m., and were considered late. LVN 3 stated Resident 15 was asleep and she did not want to wake him up at 9 a.m. During a review of the clinical record for Resident 15's Nurses notes dated 6/12/19, at 12:46 p.m., LVN 3 entered and electronically signed a nurses note and indicated Resident 15's 9:00 a.m., medications were not given because the resident was sleeping. During an interview with Resident 15, on 6/13/19, at 2:34 p.m., he stated it was not a problem for him to wake up the morning. Resident 15 stated he wanted to take his medication and he did not mind being woken up by the nurses. Resident 15 stated he would never refuse to take his medications. During a Review of the Minimum Data Set (MDS) assessment (an evaluation of a residents cognitive, physical abilities and needs) dated 3/28/19, indicated Resident 15 had no cognitive impairment with a BIMS (Brief interview for mental status) score of 13 of 15. During a medication reconciliation of the Medication Administration record (MAR), on 6/13/19, at 8:15 a.m., Resident 15's morning medications which included amitriptline hcl 50 mg, carbidopa-levodopa 25-100 mg, duloxetine hcl 30 mg, isosorbide mononitrate 10 mg, losartan potassium 50 mg, metoprolol succinate 50 mg, ferrous sulfate 325 mg 1 tablet, vitamin D 1 tablet, dabigatran etexilate 150 mg, fluticasone propionate, 50 microgram 2 sprays in each nostril, fexofenadine180 mg 1 tab daily and glipizide 5 mg tablet were ordered to be administered at 9 a.m. Resident 15's, MAR indicated medications were initialed as administered by LVN 3 at 9 a.m., and not 11:39 a.m. LVN 3 initialed glipizide 5 mg as being administered on 6/12/19 at 9 a.m. During an interview with the Director of Nursing (DON), on 6/13/19, at 2:54 p.m., she stated LVN 3 should have woken Resident 15 to administer his medication. The facility policy and procedure titled, Administering Medications dated 12/12, indicated, Medications shall be administered in a safe and timely manner, and as prescribed .4. Medications must be administered with one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 6. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving a medication .

Based on observation, interview, and record review, the facility failed to ensure Resident 15 was free of a significant medication error when Licensed Vocational Nurse (LVN) 3 did not administer a morning dose of glipizide (medication used to treat high blood sugar). This failure placed Resident 15 at risk for complications from elevated blood sugar. Findings: During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 6/12/19, at 11:39 a.m., during a morning medication pass, LVN 3 prepared medications for Resident 15. LVN 3 prepared all 9 a.m., medications ordered except for glipizide 5 mg tablet. LVN 3 stated she was not going to administer Resident 15's glipizide because the medication indicated an expiration date of 5/2019. During a concurrent observation and interview with LVN 3, on 6/12/19, at 11:45 a.m., LVN 3 checked Resident 15's blood sugar. Resident 15's blood sugar was 187 and required 2 units of novolin insulin (medication used to help control blood sugar) injection based on a sliding scale (ordered amount of insulin given according to the blood sugar reading) ordered by the physician. LVN 3 drew up and administered 2 units of insulin to Resident 15. During a telephone interview with the Pharmacy Supervisor (PS), on 6/13/19, at 2:33 p.m., the PS stated the expiration date for glipizide was 5/2019. The PS stated the glipizide was an intermediate acting dose that would act similar to insulin by lowering the blood sugar. The PS stated Resident 15 might not have required the regular insulin administration if glipizide was administered in the morning. During an interview with the Director of Nursing (DON), on 6/13/19, at 2:54 p.m., she stated there was a possibility Resident 15 might not have required his insulin injection if he had received the glipizide in the morning. The facility policy and procedure titled, Administering Medications dated 12/12, indicated, Medications shall be administered in a safe and timely manner, and as prescribed .4. Medications must be administered with one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 6. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving a medication .

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety when: undated, opened bags of spices, hot dog buns, waffles, sugar, mayonnaise, chunk light tuna, chopped onions and an expired 1/4 milk gallon container were stored and available for use in the walk-in freezer, refrigerator and dry food storage areas. These failures to ensure effective dietetic service operations placed residents that received meal from the kitchen at risk for food borne illness and the growth of microorganisms. Findings: During a concurrent observation and interview with the Kitchen Director (KD), on 6/11/19, at 9:07 a.m., in the dry storage area, an undated and unlabeled 40 ounce opened bag of parsley flakes, an opened undated and unlabeled bag of basil leaves, an opened undated and unlabeled 8 ounce bag of white sugar with an expiration date of 5/1/19 were stored and available for use. The KD stated the items should have been dated with open date and used by date by the kitchen staff. During a concurrent observation and interview with the KD, on 6/11/19, at 9:35 a.m., in the kitchen's walk in freezer, four undated opened unlabeled bags of hotdog buns, two undated opened unlabeled plastic bags of cooked waffles were stored and ready for use in the walk in freezer. The KD confirmed the bags were not dated. The KD stated the items in the kitchen needed to have opened and used by date on the package label. During a concurrent observation and interview with KD, in the kitchen's freezer, on 6/11/19, at 9:55 a.m., an expired 1/4 fat free milk gallon with an opened date of 6/9/19 and used by 6/10/19 was available for use. An undated opened jar of mayonnaise was available for use. An undated opened plastic bag of chunk light tuna (prepared by kitchen staff on 5/23/19) and an undated bag of chopped onions were stored and ready for use. The KD reviewed the items and was unable to locate open or used by dates for the mayonnaise, chunk light tune and chopped onions. The KD confirmed the milk should have been discarded on 6/10/19 and the packed chunk tuna should have been labeled with use by date. The KD stated expired food items could cause food borne illness and elderly residents were susceptible to illness. The facility policy and procedure titled .Food and Nutrition Services, section 11: Sanitation and Infection control Labeling and Dating dated 1/2016, indicated Policy: All foods will be appropriately wrapped, labeled and dated based on food storage guidelines .Procedures: All foods are labeled, dated, and securely covered and use by dates are monitored and followed . All products are rotated using the first in, first out (FIFO) inventory method . The facility policy and procedure titled Food products Shelf Life Guidelines dated 1/12/17, indicated Purpose of the food Product shelf life guidelines To provide .general guideline for the shelf -life for food products .Product Description .spices, ground .dry storage .6-12 months .sugar confectioners or powdered 18 months .breads and rolls .Freezer .2 months . Pancakes and waffles .Freezer .1 month .Milk: whole, Reduced and low fat and fat free .Refrigerator . 7 days . Mayonnaise, commercial, refrigerate after opening . Refrigerator . 1 year unopened, 2 months opened .Deli meat/ Salads . store-prepared (or homemade) eggs, chicken, ham, tuna .Refrigerator . 3-5 days .

Based on observation, interview and record review, the facility failed to follow the recipe portion size for five of five sampled residents (Resident 21, Resident 37, Resident 18, Resident 193, Resident 22) when: the Dietary [NAME] (DC) served 2.2 ounces (dry unit of measurement) of braised Swiss steak instead of serving four ounces for one lunch meal. This failure placed Resident 21, Resident 37, Resident 18, Resident 193 and Resident 31 at risk for nutritional inadequacy. Findings: During a concurrent observation and interview with the DC, on 6/12/19, at 11:50 a.m., in the kitchen, the DC served the residents with the lunch of the day. The DC served braised Swiss steak, cheese tortellini with pesto sauce, sliced apples and a cucumber salad with ginger vinaigrette to Resident 18, Resident 21, Resident 22, Resident 37, and Resident 193. The DC did not measure the braised Swiss steak prior to serving. The DC stated the braised Swiss steak weighed four ounces prior to cooking. The DC stated she would weigh the braised Swiss steak and should have weighed the braised Swiss steak prior to serving. The DC calibrated the weighing scale, then took a slice of braised Swiss steak and weighed the braised Swiss steak on the scale. The braised Swiss steak weighed 2.2 ounces. DC stated, I should have served two slices of meat to make it 4 ounces. The DC stated she did not serve four ounces of braised Swiss steak to the five residents which could have lead to a protein inadequacy and weight loss. During a concurrent observation and interview with the Kitchen Director (KD), on 6/12/19, at 12:15 p.m., in the kitchen, the KD adjusted the weighing scale and re-weighed the braised Swiss steak for the second time. The KD validated the braised Swiss steak per slice weighed 2.2 ounces. The KD stated she should have instructed the staff to weigh the meat after cooking before serving to residents. The KD stated the residents should have been served 4 ounces of braised Swiss steak as indicated in the diet spreadsheet to prevent the risk of weight loss. During a concurrent interview and record review with the Registered Dietitian (RD), on 6/12/19, at 12:15 p.m., the RD reviewed the facility document titled Diet Spreadsheets dated 6/12/19, indicated .Regular .Braised Swiss Steak .Portions .4 [ounces] oz .'' The RD stated residents did not meet the posted amount of 4 ounces of meat that should have been provided to residents who were on a regular diet. The RD stated if less than 4 ounces of Swiss steak was served to residents there was not enough protein served and that could be a reduced nutritional supplement which could lead to weight loss and impaired wound healing. The facility policy and procedure titled, Menu Planning guidelines dated 5/22/17, indicated Policy .Procedure .2. Menu content is planned to be nutritionally adequate to meet most resident populations on regular diets. Modified diets are restricted to their specific guidelines and may or may not meet dietary guidelines RDA/DRI [Recommended Dietary Allowances/Dietary Reference Intakes] .7. Dietitian is responsible for ensuring menu meet nutritional adequacy,signs and dates the menu spreadsheet or individual diet plan .

3. During an observation on 6/11/19, at 2:45 p.m., in Resident 20's room, Resident 20 laid in bed, awake,with a kinked indwelling urinary catheter. Resident 20's catheter tubing was kinked where the tube connected to the catheter bag and did not allow urine to drain into the collection bag. During a concurrent observation and interview with LVN 1, on 6/11/19, at 3:37 p.m., LVN 1 stated Resident 20's catheter bag was kinked and did not drain urine into the bag. LVN 1 stated urine needed to flow freely without any kinks in the tubing. LVN stated there could be urine retained in the bladder that could lead to a urinary tract infection if the line was kinked. During an interview with Certified Nursing Assistant (CNA) 1, on 6/12/19, at 9:18 a.m., CNA 1 stated she cared for Resident 20 on 6/11/19 during the morning shift. CNA 1 stated she should have checked Resident 20's catheter tubing and verified that it was free of kinks and did not do so. CNA 1 stated a kink in the catheter could back up to the bladder and cause infection to Resident 20. During an interview with Director of Staff Development (DSD), on 6/12/19, at 9:25 a.m., DSD stated staff should have checked the patency (unlinked tubing) of the catheter during the catheter care. DSD stated the kinks in the catheter could cause urinary tract infection and discomfort to Resident 20. During an interview with Director of Nursing (DON), on 6/13/19, at 3:45 p.m., the DON stated staff should make sure that catheter lines were patent (open) so that urine flow will run freely to prevent urine backflow that could lead to discomfort and urinary tract infection The facility policy and procedure titled, Catheter Care, Urinary dated 7/2014, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infection . Maintaining Unobstructed urine Flow 1. Check the resident frequently to be sure he or she is lying on the catheter and to keep the catheter and tubing free of kinks . 4. During a concurrent interview and observation with LVN 1, on 6/11/19, at 3:37 p.m., in Resident 20 and Resident 4's restroom, LVN 1 found soiled briefs, one unbagged and the other brief was on top of the trash can in Resident 20 and Resident 4's room. LVN 1 stated, I do not know who forgot to toss it in the trash can. LVN 1 stated soiled briefs left on top of trash was an unsanitary practice. During an interview with the DSD, on 6/12/19, at 9:25 a.m., the DSD stated staff should have checked the restroom during their rounds with residents and before their shift ended. The DSD stated the soiled briefs on top of the garbage could cause cross contamination to residents who used the restroom left with soiled briefs. The facility policy and procedure titled Infection Control and Prevention dated 11/1/16, indicated, Policy: It is the policy of Covenant Retirement Communities to maintain an infection control and prevention program within the facility as well as an Antibiotic Stewardship Program. The facility will provide a safe, sanitary, and comfortable environment designed to prevent as possible and improve control of transmittable pathogens [germs], disease and infection . 5. During a concurrent observation and interview with Dietary [NAME] (DC) and Dietary Staff (DS), on 6/12/19, at 11:29 p.m., in the kitchen during the trayline meal preparation, DC and DS partially covered their hair and exposed hair from their forehead. DC stated all of their hairs should have been covered with the hair net. DC stated it was important to cover all of their hair to prevent hair from falling into the food being prepared. During an observation on 6/12/19, at 11:29 in the kitchen. DC was working in the preparation meal table with exposed hair from her forehead not covered by the hairnet. During a concurrent observation and interview with DC, on 6/13/19, at 6:53 a.m., in the kitchen. DC had uncovered and exposed hair from her forehead while she prepared breakfast. DC stated, My hair is too thick and heavy its always pulling down. I should have .checked my hair if it was all covered before going into the kitchen. The DC stated covering her hair would prevent her hair from falling into the food. During an interview with Registered Dietitian (RD) on 6/13/19, at 4:25 p.m., RD stated staff needed to make sure to cover all of their hair during food preparation. RD stated uncovered hair was a potential risk for food contamination to residents. The facility policy and procedure titled Hair Restraint Policy dated 1/4/19, indicated, Policy: Hair restraints must be worn in the kitchen at all times to ensure food safety. Procedure: 1. Hair restraints (hairnets, hats, or caps) must cover hair sufficiently to effectively keep hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single- service and single- use articles as well as to minimize hand contact with hair . The facility policy and procedure titled, Infection Control and Prevention dated 11/1/16, indicated, Policy: It is the policy of [facility] to maintain an infection control and prevention program within the facility . The facility will provide a safe, sanitary and comfortable environment . Based on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program to prevent cross contamination (the transfer of germs from one surface to another) when: 1. A used nebulizer mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) laid on top of Resident 9's nebulizer machine. The mask was unmarked. 2. An out dated nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient) laid on top of a concentrator (a medical device used to deliver oxygen which purifies the surrounding air) dated 6/2/19. These failures had the potential for bacteria to grow. 3. Resident 20's indwelling catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) was kinked at the lower end of the catheter line and catheter urinary bag. This failure had the potential to place the resident at risk for discomfort and could lead to urinary tract infection. 4. Soiled briefs were found on top of a trash can in Resident 20 and Resident 4's restroom. These failures had the potential to place the residents at risk for cross contamination and exposure to infectious organisms. 5. Two dietary staff had hair exposed during meal preparation. These failures placed residents at risk for food borne illness. Findings: 1. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, on 6/11/19, at 10 a.m., Resident 9's uncovered and unmarked nebulizer mask laid on top of the nebulizer. LVN 2 stated she did not change Resident 9's nebulizer mask because it was changed by the night shift nurse. LVN 2 stated the night shift were supposed to change the masks on Sunday nights and label them after being changed. 2. During a concurrent observation and interview with Resident 1, on 6/11/19, at 11:21 a.m., in Resident's 1 room, a nasal cannula used by Resident 1 was inside a plastic bag dated 6/2/19. Resident 1 stated he used the nasal cannula every night. During an interview with LVN 2, on 6/11/19, at 11:26 a.m., LVN 2 stated the oxygen tubing was changed every week on Sunday night by the night nurse. LVN 2 stated Resident 1's tubing was out dated, the date on the bag was 6/2/19. LVN 2 stated Resident 1 used his oxygen on a as needed basis. LVN 2 stated the tubing should have been changed on 6/9/19 by the night nurse. LVN 2 stated it was an infection control issue and the resident could get sick from germs on the tubing. During an interview with the Director of Nursing (DON), on 6/12/19, at 10:00 a.m., the DON stated there was no bag to store Resident 9's nebulizer mask. The DON stated Resident 1's oxygen cannula tubing was out date and should have been changed on Sunday night [6/9/19] by the night nurse. The DON stated it was an infection control issue and the residents could get sick from having germs on the out dated nasal cannula and the unbagged mask. The Facility policy and procedure titled Respiratory Therapy - Prevention of Infection dated 11/2011, indicated Purpose The purpose to this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, 4. Change the oxygen cannula and tubing every seven (7) days, or as needed. 5. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use.