Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible to two of four sampled residents (Resident 148 and Resident 18) reviewed under the accidents care area by:a. Failing to ensure Resident 148 was provided with a tab alarm (refers to a type of fall prevention device that utilizes a pull-string or cord to activate an alarm when a patient attempts to move, such as getting out of bed or a chair) while in bed as ordered by the physician. b. Failing to ensure Resident 18's side rails were the correct size as ordered by the physician.These deficient practices had the potential to result in increased risk of injuries for Resident 148 and Resident 18. Findings: a. During a review of Resident 148's admission Record, the admission Record indicated the facility admitted the resident on 7/24/2025 with diagnoses including history of falling and chronic kidney disease (kidneys are damaged and can't filter blood properly, leading to a buildup of waste in the body). During a review of Resident 148`s History and Physical (H&P- a comprehensive assessment performed by a healthcare provider to gather information about a patient's medical condition), the H&P indicated that the resident has the capacity to understand and make decisions. During the review of the Resident 148`s Order Summary Report (OSR), the OSR indicated a physician`s order dated 7/24/2025 for tab alarm while in bed to alert staff when resident attempts to get out of bed unassisted and monitor placement and function. During a concurrent observation and interview on 07/29/2025 at 3:18 p.m., with Registered Nurse 3 in Resident 148’s room, RN 3 stated Resident 148 has a physician`s order to use tab alarm as a fall prevention measure. RN 3 stated that a tab alarm is clipped to the resident`s gown, and it will sound off if the resident attempts to get out of bed unassisted. During an inspection to verify the presence of the tab alarm it was observed that Resident 148 did not have a tab alarm in place. RN 3 stated that it should be in place and without it the resident could get up from bed and the staff would not be alerted and the resident could fall resulting in injury. During a review of Resident 148`s Care Plan (CP-are written tools that outline nursing diagnoses, interventions, and goals) dated 7/24/2025, the CP indicated under the approach (intervention) section to provide tab alarm for the prevention of potential falls or injuries. During a review of the facility`s policy and procedure titled “Falls Management Program,” last reviewed on 5/27/2025, the policy indicated that “it is the policy of this facility to provide residents with a safe environment which is free from accident hazards as is possible, the facility will provide residents with adequate supervision and assistive devices to prevent accidents…”. During a review of the facility`s policy and procedure titled “Device Evaluation,” last reviewed on 5/27/2025, the policy indicated that the facility “will ensure that device provided to the resident(s) is functional and in good condition…sensor pad alarm in bed is to remind resident not to get out of bed unassisted and monitor placement and function…”. b. During a review of Resident 18’s admission Record, the admission Record indicated the facility admitted Resident 18 on 6/23/2025 with diagnoses that included but not limited to difficulty in walking, muscle weakness, dysphagia (difficulty swallowing) and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 18’s History and Physical (H&P) dated 6/23/2025, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/29/2025, the MDS indicated Resident 18 was usually understood and usually able to understand others. The MDS indicated Resident 18 was dependent on facility staff for activities such as oral hygiene, dressing, putting on or taking off shoes and personal hygiene. The MDS further indicated Resident 18 required partial assistance with walking up to 50 feet. During a review of Resident 18’s Order Summary Report dated 6/23/2025, the Order Summary Report indicated an order dated 6/23/2025 for Bilateral 1/4 side rails up to assist the resident when lying and repositioning in bed. During a review of Resident 18’s Side Rail Care Plan (CP) on 7 dated 6/23/2025, the CP indicated the resident’s bed has 1/4 length side rails. During a review of Resident 18’s Entrapment Risk Evaluation for Bed Rails dated 6/23/2025, the evaluation indicated the resident’s bed has 1/4 length side rails. During a concurrent observation and interview on 7/30/2025 at 9:24 am in Resident 18’s room with MDS Registered Nurse (MDS-RN), the MDS-RN observed the side rails and stated they were the much shorter, 1 1/12 length side rails that some residents have to help reduce entrapment. The MDS-RN stated that to use the shorter side rails, the residents should be able to understand the purpose of the side rails and not be confused. The MDS-RN stated the side rails present were not 1/4 in size. During a concurrent interview and record review of Resident 18’s Order Summery Report, Side Rail CP and Entrapment Risk Evaluation on 7/30/2025 at 9:35 am with the MDS-RN, reviewed Resident 18’s Order Summery Report, Side Rail CP and Entrapment Risk Evaluation. The MDS-RN stated the current side rails in Resident 18’s room were 1 1/12 in length and not the correct 1/4 length. The MDS-RN stated Resident 18 was never evaluated or had an order for 1 1/12 length rails. The MDS-RN stated this oversight should not have occurred and Resident 18 could have become confused and fall out of bed, possibly injuring herself During a review of the facility's policy and procedure (P&P) titled, Policy on Bed Side Rails, last reviewed on 5/27/2025, indicated the purpose of the bed rails was to aid the residents in turning and repositioning while in bed and reducing the risk of patients falling out of bed. Use of bed rails should be based on patients’ assessed medical needs and should be documented clearly and physician’s order should be obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent significant medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by giving hydralazine HLC (blood pressure medication) outside of the prescribed parameters (a fixed limit/range by the doctor to either give or hold a medication) for one of five sample Residents (Resident 12). This deficient practice placed Resident 12 at risk for potential hypovolemic shock (a critical condition resulting from a significant decrease in blood volume, leading to inadequate blood flow to the body's organs) or other adverse effects (unwanted, unintended result). Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted Resident 12 on 1/18/2023 and re-admitted the resident on 7/20/2025, with diagnoses including end stage renal disease (irreversible kidney failure), hypertension, and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing).During a record review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12's cognitive skills (thought processes) were intact. The MDS indicated Resident 12 required maximum assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves.) During a review of Resident 12's physician order dated 7/20/2025, the physician order indicated an order for hydralazine hydrochloride (medication for hypertension) oral tablet 25 mg, give one tablet by mouth every six hours for hypertension, hold for systolic blood pressure of 110 or less.During a review of Resident 12's MAR dated 7/2025, the MAR indicated on 7/30/2025 at 12:00 p.m., hydralazine 25 mg, one tablet was given (indicated by check mark) by Registered Nurse 1 (RN 1) when the recorded BP was 100/65 mmHg.During a concurrent interview and record review on 7/31/2025 at 8:10 a.m., with Licensed Vocational Nurse 1 (LVN) 1, reviewed Resident 12's physician orders and MAR dated 7/2025. LVN 1 stated Resident 12's physician order for hydralazine has systolic blood pressure parameters that need to be followed to avoid causing potential harm to Resident 12. LVN 1 stated a dose of hydralazine 25 mg was given to Resident 12 on 7/30/2025 at 12:00 p.m., for a systolic blood pressure of 100. LVN 1 stated that the dose should not have been given, and this is a medication error for Resident 12 since the parameters indicated to hold dose if SBP is 110 or less. LVN 1 stated that not following medication parameters could have potentially caused Resident 12 to become hypovolemic (decrease in the circulating volume of blood and other fluids in the body) and further complicating his health. During a concurrent interview and record review on 7/31/2025 at 10:14 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 12's physician orders and MAR dated 7/2025. RN 2 stated that it is important to follow medication parameters to avoid causing harm to the residents. RN 2 stated that parameters indicate if a medication dose needs to be adjusted, given as prescribed, or held. RN 2 stated that the dose of hydralazine given on 7/30/2025, at 12:00 p.m., should have been held since the systolic blood pressure was out of parameters. RN 2 stated that this medication error placed Resident 12 at risk for adverse effectsDuring a telephone interview on 7/31/25 at 2:45 p.m. with RN 1, RN 1 stated order parameters need to be followed to avoid causing harm to residents. RN 1 stated that if a blood pressure medication for high blood pressure is given outside the paraments, the medication can cause the blood pressure to drop below normal levels and can potentially lead to hypovolemic shock. RN 1 states Resident 12 should not have received the 12 pm dose of Hydralazine on 7/30/2025 because the blood pressure was 100/65 which is below the order parameters to hold medication when the systolic blood pressure is below 110. RN 1 stated this dose put Resident 12 at risk for hypovolemic shock. During a review of the facility's Policy and Procedure (P&P) titled, Specific Medication Administration Procedures, last reviewed on 5/27/2025, the P&P indicated to administer medications in a safe and effective manner, note any contraindications the resident may have prior to drug administration, and read medication label before administering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity and respect for three of seven residents (Residents 62, 120, and 83) observed during medication pass by failing to ensure:1. Licensed Vocational Nurse (LVN) 4 pulled the curtain closed when checking Resident 62's blood sugar and during administration of insulin (a natural hormone that turns food into energy and manages your blood sugar level) via injection.2. Registered Nurse (RN) 4 pulled the curtain closed or shut the door to the hallway while administering oral medications to Resident 120.3. Registered Nurse (RN) 4 fully pulled the curtain closed while checking Resident 83's blood pressure and administering oral medications and eyedrops.This deficient practice violated Residents 62, 120, and 83's right to be treated with respect and dignity and had the potential to affect the residents' sense of self-worth and self-esteem.Findings: 1. During a review of Resident 62's admission Record (AR), the AR indicated the facility admitted the resident on 10/19/2024 with diagnoses including muscle weakness and Type 2 Diabetes Mellitus (a group of diseases that result in too much sugar in the blood) During a review of Resident 62's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 7/04/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 62 was independent in performing activities of daily (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During a review of Resident 62`s physician`s orders dated 10/19/2024, the physician`s order included an order for Humulin (a short-acting insulin used to help manage blood sugar levels in individuals with type 1 or type 2 diabetes) R Injection Solution 100 Unit/milliliter as per sliding scale (one way to determine how much insulin to take before each meal.). During a concurrent medication pass observation and interview on 07/29/2025 at 4:39 p.m., observed LVN 4 enter Resident 62`s room, where the resident was sitting in her wheelchair with the privacy curtain open, visible from her roommates and from the hallway. LVN 4 proceeded to take the resident`s blood sugar by fingerstick ( a common method for monitoring blood glucose levels, especially for individuals with diabetes. It involves pricking the fingertip with a lancet to obtain a small blood sample, which is then applied to a test strip and read by a glucose meter), without drawing the privacy curtain. LVN 4 then went back to the medication cart and prepared the insulin injection and went back to the resident`s room and administered the insulin injection without drawing the privacy curtain around Resident 62’s bed. When LVN 4 was asked if the resident’s dignity and privacy were maintained during the blood sugar checks and medication administration, LVN 4 stated that she should have provided privacy to the resident by drawing the curtain. LVN 4 stated not providing privacy to the resident could result in the resident feeling embarrassed and exposed. During a review of the facility`s policy and procedures titled “Quality of Life-Dignity,” last reviewed on 5/27/2025, the policy indicated that “Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality…staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures…” 2. During a review of Resident 120’s admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including, but not limited to, acute kidney failure (when the kidneys suddenly can't filter waste products from the blood) and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 120’s Physician Progress Note dated 3/12/2025, the Physician Progress Note indicated the resident can make his needs known but cannot make medical decisions. During a review of Resident 120’s Minimum Data Set (MDS – a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 120 had moderate cognitive impairment (has trouble thinking, learning, and remembering clearly). The MDS further indicated Resident 120 was dependent on staff to complete most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 7/29/2025 at 8:47 a.m. with RN 4 at Resident 120’s bedside, RN 4 administered oral medications to Resident 120 while he was in bed. RN 4 did not pull Resident 120’s privacy curtain around his bed or shut the door to his room leaving Resident 120 visible inside his shared room and from the hallway while getting the resident’s medications. 3. During a review of Resident 83’s admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, epilepsy (a brain disorder that causes seizures) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 83’s History and Physical (H&P) dated 10/4/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 83’s MDS, dated [DATE], the MDS indicated Resident 83 was cognitively intact (can think, learn, and remember clearly). The MDS further indicated Resident 83 was independent for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 7/29/2025 at 9:00 a.m. with RN 4 at Resident 83’s bedside, RN 4 checked Resident 83’s blood pressure while he was in bed. RN 4 then administered oral medications, and eye drops to Resident 83 while he was in bed. RN 4 did not pull Resident 83’s privacy curtain around his bed leaving Resident 83 exposed to a common area at the foot of his bed inside his shared room. During an interview on 7/29/2025 at 9:28 a.m. with RN 4, RN 4 stated she should have pulled the privacy curtain around the residents while providing care and giving medications. RN 4 stated the residents should have their curtains pulled around them when getting care because they have a right to privacy and it is important for their dignity. During an interview on 7/31/2025 at 2:48 p.m. with the Director of Nursing (DON), the DON stated residents should be provided privacy when getting their blood pressure checked. The DON stated if a resident is exposed to the hallway while getting medications they should have privacy. The DON stated the purpose of closing the curtain is because of dignity issues and to provide privacy if the resident wants it. During a review of the facility`s policy and procedure (P&P) titled “Quality of Life-Dignity,” last reviewed on 5/27/2025, the policy indicated that “Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality…staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures….”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan (CP-a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) by failing to:a. 1.Develop a care plan addressing the communication needs of one resident of one (Resident 2) residents reviewed under the communication and sensory care area. a.2.Develop a care plan addressing the risks associated with the use of Seroquel (medication used to treat various mental health conditions) which carries a Black Box Warning (warnings that are intended to provide critical information about a drug's potential risks) for one of four (Resident 2) reviewed under the dementia care area.b. Develop a care plan for floor mats for one of four residents (Resident 18) investigated under accidents. c. Develop a care plan to meet the resident`s needs for ambulation (walking) for one of four residents (Resident 148) investigated for position and mobility.These deficient practices had the potential to result in failure to deliver the necessary care and services.Findings: a.1&2 During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted the resident on 6/18/2025 with diagnoses that included muscle weakness and unspecified dementia (a group of symptoms that can affect thinking, memory, reasoning, personality, mood and behavior). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/22/2025, the MDS indicated the resident's primary language was not English. The MDS indicated that the resident had the ability to sometimes make self-understood and the ability to sometimes understand others. The MDS indicated that the resident was dependent on staff for activities of daily living (ADL-refers to basic self-care tasks that individuals typically perform independently). During a concurrent interview and record review on 7/30/2025 at 8:36 a.m., with Registered Nurse 3 (RN 3), Resident 2`s care plans, physician orders and MDS were reviewed. RN 3 stated that Resident 2`s primary language is not English, however, there was no care plan developed to address the resident’s communication needs, and there should have been one in place to ensure the resident needs are communicated to the staff and are met. RN 3 stated Resident 2 had an order dated 6/19/2025 for Seroquel Oral Tablet 25 milligrams (mg) two times a day for psychotic features manifested by screaming at others. RN 3 further stated there was no care plan developed to address Seroquel’s black box warning, and the risks associated with its use. RN 3 stated that the risks associated with the use of Seroquel include suicidal ideation and self-harming behavior and the care plan should indicate interventions that address these risks to ensure resident safety. During a review of the facility`s policy and procedure titled “ Care Plans, Comprehensive Person-Centered,” last reviewed on 5/27/2025, the policy indicated that “ A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident…” During a review of the facility`s policy and procedure titled “Communication with Non-English/Aphasic Resident,” last reviewed on 5/27/2025, the policy indicated that “it is the policy of this facility that all residents who are cognitively intact will be able to communicate their needs to facility staff, other residents, and other persons as desired by the resident. The facility will also provide interpreter for non-English speaking residents…”. During a review of the facility`s policy and procedure titled “Black Box Warnings,” last reviewed on 5/27/2025, the policy indicated that “a black box warning on a medication denotes that there is a serious or life threatening potential side effects associated with that medication…Nursing to document in the care plan the black box warning when a resident is on a medication with a black box warning…”. b. During a review of Resident 18’s admission Record, the admission Record indicated the facility admitted Resident 18 on 6/23/2025 with diagnoses that included but not limited to difficulty in walking, muscle weakness, dysphagia (difficulty swallowing) and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 18’s History and Physical (H&P) dated 6/23/2025, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/29/2025, the MDS indicated Resident 18 was usually understood and usually able to understand others. The MDS indicated Resident 18 was dependent on facility staff for activities such as oral hygiene, dressing, putting on or taking off shoes and personal hygiene. The MDS further indicated Resident 18 required partial assistance with walking up to 50 feet. During a review of Resident 18’s Physician’s Order dated 6/24/2025, the Physician Orders indicated an order for use of bilateral floor mat for injury prevention. During a concurrent observation and interview on 7/30/2025 at 9:54 am in Resident 18’s room with MDS Registered Nurse (MDS-RN), observed the bed length floormats on both sides of the bed. The MDS-RN stated the floor mats are there to help prevent resident injury if the resident were to fall. The MDS-RN stated that there should be a physician’s order and care plan for the floor mats. During a concurrent interview and record review of Resident 18’s Care Plans (CP) on 7/30/2025 at 10:05 am with the MDS-RN, reviewed Resident 18’s CPs. The MDS-RN stated there was no care plan developed to address the us of floor mats and licensed staff should have created one when they received the order from the physician. The MDS-RN stated without a CP, the resident could have been harmed if staff removed the floor mats or were unaware the floor mats needed to be in place, increasing the risk of injury in the event of a fall. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 5/27/2025, indicated the purpose of the P&P was to provide comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs for each resident. c. During a review of Resident 41’s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and difficulty walking. During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 5/07/2025, the MDS indicated Resident 41 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 41 required supervision or touching assistance (resident completes activity; helper assists only prior to or following the activity) with walking 150 feet (a unit of measure in walking, primarily used in the US customary and imperial systems of measurement). During a review of Resident 41’s Physician’s Orders, the Physician Orders indicated an order dated 8/26/2024 for Restorative Nursing Assistant (RNA-a specialized Certified Nursing Assistant who focuses on helping residents regain or maintain their highest possible level of physical function) for ambulation using front wheeled walker (FWW, a walking aide, features two wheels on the front legs) as tolerated, three times a week as tolerated every day shift every Monday, Wednesday, and Friday During a review of Resident 41’s Care Plan for High Risk for Decline in Ambulation, initiated 8/26/2024, the care plan indicated a goal that Resident 41 will maintain current ambulation function through the next review date. The care plan indicated the intervention to walk using FWW with RNA every day, three times a week as tolerated. During a review of Resident 41’s Restorative Nursing Weekly Summary, dated 7/20/2025, the weekly summary indicated the following: Resident 41 walked three times a week, 10 minutes routine, the resident walked 250 feet straight. Resident 41 needs supervision assistance while walking. Resident 41 tolerated the treatment well. Resident 41 needed verbal cues while walking. During an interview with Resident 41 on 7/28/2025 at 9:35 a.m., Resident 41 stated she has been in the facility a few years, and in the wheelchair most of the time but wants to walk so she can be discharged home. During an interview with Restorative Nursing Assistant 1 (RNA 1) on 7/29/2025 at 2:32 p.m., she stated Resident 41 walks in the hallway three times a week, walking approximately 200 feet each time. During an interview with the Director of Staff Development (DSD) on 7/31/2025 at 9:34 a.m., when asked about the resident’s care plan goal of maintain current ambulation function through the next review date, she stated the licensed nurses want Resident 41 to progress in terms of their function and to see how their progression is. The DSD stated her current ambulation rate is 150 feet each walking time. During an interview with RNA 2 on 7/31/2025 at 10 a.m., she stated she has walked with Resident 41 from her room to the front lobby and then back in the hallway, past her room to participate in activities in the back dining room. RNA 2 stated Resident 41 had no problems walking and no pain. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 7/31/2025 at 10:10 a.m., reviewed Resident 41’s Physical Therapy Discharge Summary (which indicates a resident’s current physical abilities such as walking, upon discharge from the physical therapy program), dated 8/21/2025. The DOR stated Resident 41’s physical abilities with walking 100 feet with a front wheeled walker, contact guard assist ( a level of assistance where a therapist provides minimal physical support to a patient, typically by maintaining light contact with their body during functional tasks like walking). Reviewed Resident 41’s Care Plan for High Risk for Decline in Ambulation with the DOR. The DOR confirmed that the care plan was created by one of the physical therapists. The DOR stated the goal could be more specific so that staff could see if Resident 41 is achieving the goal, not achieving the goal, or exceeding the goal. The DOR stated the care plan could include more interventions such as adding exercises or repetitions of exercises for the care plan. During an observation on 7/31/2025 at 10:20 a.m., observed Resident 41 walking in the hallway with RNA 1. Resident 41 walked from room [ROOM NUMBER] to the front door of the facility with a front wheeled walker. Resident 41 appeared to have no issues walking. Resident 41 stated they had no pain or problems walking. During a concurrent interview and record review with the Director of Nursing (DON) on 7/31/2025 at 11:53 a.m., reviewed Resident 41’s High Risk for Decline in Ambulation care plan. The DON stated the care plan should have a specific goal so that licensed nurses and RNAs will know if she is meeting the goals which could be a potential for evaluation by the physical therapy team. During a review of the facility’s policy and procedure (P&P) titled, “Comprehensive Person-Centered Care Plans,” last reviewed 5/27/2025, the P&P indicated the following: - The Interdisciplinary Team (IDT, a group of various disciplines, such as nursing dietary, and physical therapy, etc. who meet with a resident to help them establish health care goals), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The comprehensive, person-centered care plan will: o Include measurable objectives and time frames. o Include the resident’s stated goal upon admission and desired outcomes. During a review of the facility’s policy and procedure titled, “Restorative Nursing Services,” last reviewed 5/27/2025, the P&P indicated the following: - Restorative goals and objectives are outlined in the resident’s plan of care. - Restorative goals may include, but are not limited to supporting and assisting the resident in: o Adjusting or adapting to changing abilities; o Developing, maintaining or strengthening; o Maintaining his/her dignity, independence and self-esteem; and o Participating in the development and implementation of his/her plan of care.

Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (prn) opioid ([narcotic- used to treat moderate to severe pain) pain medication to a resident for one of four sampled residents (Resident 147). This deficient practice had the potential to place the resident at an increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the use of opioids. Findings: During a review of Resident 147's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2025 with diagnoses including cardiomegaly (also known as an enlarged heart, is not a disease itself, but rather a sign of an underlying heart condition) and difficulty in walking.During a review of Resident 147's History and Physical (H&P) dated 7/27/25, the H&P indicated that the resident has the capacity to understand and make decisions.During a review of Resident 147's Order Summary Report (OSR), the OSR indicated the following orders:- Provide non-pharmacologic intervention for pain as follows:1 - Repositioning 2 - Back Rub 3 - Relaxation Techniques 4 - Give Fluids 5 - Redirections 6 - Music 7 - Activity 8 - Adjust Room Temperature 9 - Dim light/ Quiet Environment 10 - Toilet 11 - Breathing Exercises 12 - Distraction/Activities 13 - Other (Refer to Nurses Notes), dated 7/25/2025.- Oxycodone hydrochloride (a strong prescription opioid pain reliever used to treat moderate to severe pain) oral tablet five (5) milligrams (mg- unit of measurement) give one (1) tablet by mouth every six (6) hours as needed for severe pain of 7-10/10 pain (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered dated 7/27/2025.During a concurrent interview and record review on 7/30/2025 at 11:09 a.m., with Registered Nurse 3 (RN 3), reviewed Resident 147's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). Resident 147's MAR indicated that Resident 147 was administered oxycodone five (5) mg one tab on 7/29/2025 at 12:15 a.m. for a pain scale of nine (9), 7/29/2025 at 7:02 a.m. for a pain scale of eight (8), and 7/29/2025 at 5:45 p.m. for a pain scale of nine (9). The review of the MAR also indicated that no non-pharmacological interventions were provided for the oxycodone administrations on 7/29/2025. RN 3 stated that non-pharmacological interventions should be attempted first to see if the pain is alleviated without the medication because the pain might just be caused by external factors that is causing the pain. RN 3 stated that the use of narcotic pain medication such as oxycodone can increase the risk of a resident experiencing adverse effects of the medication such as constipation (infrequent or difficult bowel movements) and respiratory depression (slow, shallow breathing rate) which is life threatening.During a review of the facility's policy and procedure titled, Pain Management, last reviewed and revised on 5/27/2025, the policy indicated that it is the policy of this facility to follow the plan of care for the management of pain as written in the resident`s care plan and the approach to be followed are.choose pain control option appropriate for the resident.any pertinent changes, intervention, and results of any intervention taken for pain relief shall be documented in the resident`s chart if indicated.

Based on observation, interview, and record review, the facility failed to:1. Ensure the licensed nurse documented the administration of Tramadol (a controlled substance with the potential for addiction- can treat moderate to severe pain) in the Medication Administration Record (a vital document in healthcare that accurately tracks and records all medications administered to a patient) right after the medication was administered to one of three residents (Resident 16) reviewed under the Medication Storage and Labeling task.2. Ensure the licensed nurse documented the administration of Norco (a controlled substance with the potential for addiction- used to relieve pain severe) right after the medication was administered for one of three (Resident 67) residents investigated under the Medication Storage and Labeling task.This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and that Residents 16 and 67 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: a. During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted the resident on 6/14/2025 with diagnoses including, muscle weakness and low back pain. During a review of Resident 16's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 6/19/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 16 was dependent on staff for toileting hygiene, dressing and putting on/taking off footwear. During a review of Resident 16`s Order Summary Report (OSR), the OSR indicated a physician order dated 6/20/2025 for Tramadol HCL Oral Tablet 50 milligram (mg), 1 tablet by mouth every 6 hours as needed for severe pain. b. During a review of Resident 67's admission Record (AR), the AR indicated the facility admitted the resident on 11/21/2023 with diagnoses including muscle weakness and hypertension (high blood pressure). During a review of Resident 67's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 5/15/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 67 was dependent on staff for toileting hygiene, dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 67`s Order Summary Report (OSR), the OSR indicated a physician order dated 8/23/2024 for Norco Oral Tablet 5-325 milligram (mg), 0.5 tablet by mouth every 6 hours as needed for moderate severe pain. During an inspection of Medication Cart 2 and review of Antibiotic and Controlled Drug Record (ACDR) and MAR on 7/29/2025 at 3:45 p.m., with Licensed Vocational Nurse 8 (LVN 8), the review indicated the following findings: - 1. Resident 16`s ACDR indicated that Tramadol 50 mg was signed out by a licensed nurse on 7/29/2025 at 9:00 a.m., however, the administration was not documented in the MAR. 2. Resident 67`s ACDR indicated that Norco 5-325 mg was signed out by a licensed nurse on 7/27/2025 at 8:00 a.m., however, the administration was documented in the MAR on 7/29/2025 at 4:09 p.m. (two days later). LVN 8 stated that he was not the nurse that removed Resident 16 and Resident 67's medications from the medication cart and signed the ACDR. LVN 8 stated that it is the facility’s policy for licensed nurses to return to their cart and document after administration of medication. During an interview and record review on 7/29/2025 at 3:55 p.m., with Licensed Vocational Nurse 9 (LVN 9), Resident 16 and Resident 67’s MAR and ACDR were reviewed. LVN 9 stated that she forgot to document the administration of Tramadol 50 mg and Norco 5-325 mg because she got distracted when another resident had a change of condition. LVN 9 stated that it is important to immediately document the administration of a narcotic pain medication because they (licensed nurses) are required to monitor the resident within a specific timeframe to reassess the effectiveness of the medication. During an interview on 07/31/2025 at 1:09 p.m., with the Director of Nursing (DON), the DON stated that after medications are administered the nurse should then document the medication administration in the ACDR and the MAR. The DON stated controlled drugs including narcotics are regularly audited to ensure the drugs are accounted for and there are no discrepancies between the MAR and the ACDR. The DON stated that if there are discrepancies, the discrepancies are reported to her. The DON stated that the audit is a way to prevent drug diversion. During a review of the facility`s policy and procedure titled “Specific Medication Administration Procedures,” last reviewed on 5/27/2025, the policy indicated that “after administration, return to cart and document administration on the MAR or TAR,”……. c. During a medication cart inspection observation and concurrent record review with Licensed Vocational Nurse 1 (LVN 3) on 7/29/2025 at 3:51 p.m., reviewed the facility’s Station 1 Medication Cart 1. Reviewed the Narcotic Control Sheet. There was a blank space on the Narcotic Control Sheet (a narcotic that is a controlled drug that is used to treat pain, the narcotic control sheet is signed by the incoming and outgoing licensed nurses after both nurses count the medications together) for the incoming licensed nurse’s signature for 7/29/2025 for the 3 p.m. time slot. LVN 3 stated she did not sign the sheet when she was counting medications with the 7 a.m. to 3 p.m. licensed nurse. LVN 3 stated she should have signed the form at the time she counted the controlled drugs with the morning nurse. LVN 3 stated it is important to sign the narcotic control sheet to make sure there are no discrepancies with the controlled drugs in the medication cart. During an interview on 7/29/2025 at 4:28 p.m. with the Director of Nursing (DON), she stated the facility policy indicates the narcotic control sheet should be signed by the incoming and retiring nurse at every shift change. The DON stated it was important to sign the form to verify that two nurses actually counted the narcotics when the medication cart was endorsed, and so the oncoming nurse knows what they are receiving and can resolve any discrepancies. The DON stated the completing the narcotic count is important to ensure that there is medication accuracy and accountability. During a review of the facility’s policy and procedure titled, “Policy on Narcotics”, last reviewed 5/27/2025, indicated narcotics must be counted by the oncoming and outgoing staff during each shift and sign the narcotic sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were properly stored and labeled in accordance with professional standards in two of three inspected medication carts by:1. Failing to label a box of Artificial Tears (eye drops that moisten dry eyes) with a resident's name but instead used a last name, during the investigation of Medication Cart 1, Station 1.2. Medication Cart 1, Station 2 had four loose, unlabeled pills left in the medication cart. These deficient practices had the potential for a resident to receive medication not intended for that resident or incorrect, contaminated, or expired medication.Findings: 1. During a review of Resident 98’s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure). During a review of Resident 98’s Minimum Data Set (MDS, a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 98 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 98 was dependent (helper does all the effort) on staff for personal hygiene. During a review of Resident 98’s Physician’s Orders, the Physician Orders indicated an order for Artificial Tears Ophthalmic Solution 0.200.2-1%, instill 1 drop in both eyes two times a day for dry eyes, dated [DATE]. During a review of Resident 98’s Care Plan for Eye Irritation, initiated [DATE], the care plan indicated a goal: “will be resolve without complication as possible for 90 days. The care plan indicated an intervention to apply medication as ordered to affected eye. During medication cart observation with Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 3:51 p.m., observed Medication Cart 1, Station 1. Observed a box of Artificial Tears with Resident 98’s last name on the box. LVN 3 stated the practice should be to label the medication box the room number, first name, and last name. LVN 3 stated this is important as to not get it mixed up with another resident with the same last name. During an interview with the Infection Prevention Nurse (IPN) on [DATE] at 11:21 a.m., she stated that the licensed nurses should have labeled Resident 98’s Artificial Tears with the resident’s first name, and last name to ensure proper identification. The IPN stated this is important to not get the medication mixed up with another resident with the same last name. During a concurrent interview and record review with the Director of Nurses (DON) on [DATE] at 7:56 a.m., reviewed the policy and procedure titled, “Labeling of Medication Containers,” last reviewed [DATE], which indicated labels for each single unit dose package shall include all necessary information, such as the resident name. The DON stated resident name refers to first and last name. The DON stated this is important to ensure that it is the right patient and is not a medication error. During a review of the facility’s policy and procedure titled, “Labeling of Medication Containers,” last reviewed [DATE], indicated labels for each single unit dose package shall include all necessary information, such as the resident name. 2. During a concurrent observation and interview on [DATE] at 2:27 p.m. with Licensed Vocational Nurse 7 (LVN 7) at Station 2 Medication Cart 1, one white round pill, one green round pill, and two white oblong pills were observed unlabeled and unpackaged inside the medication cart. LVN 7 stated the medication should not be stored like that because they cannot identify what the medication is. LVN 7 stated the medication should be disposed of in the biohazard box. During an interview on [DATE] at 2:48 p.m. with the Director of Nursing (DON), the DON stated all medications should be labeled and stored correctly. The DON stated all medications should be properly labeled so they know the type of medication and who it belongs to. During a review of the facility’s policy and procedure (P&P) titled, “Medication Storage in the Facility,” last reviewed [DATE], the P&P indicated the provider pharmacy dispenses medications in containers that meet legal requirements, and medications should be kept in these containers. During a review of the facility’s policy and procedure (P&P) titled, “Labeling of Medication Containers,” last reviewed [DATE], the P&P indicated all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations.

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when the Swedish meat ball portions were four (4) ounces (oz, a unit of measurement) instead of three (3) oz portions.This failure had the potential to decrease nutrient intake of protein resulting in unplanned weight loss to 78 of 122 residents on regular texture (texture of food with no restrictions and modifications) diet and ineffective diet therapy of 38 of 122 residents on consistent carbohydrate (CCHO, diet consisting of the same amount of carbohydrate each meal), renal diet (diet consisting of food with limited amount of protein, sodium, potassium and phosphorus) getting food from the kitchen.Findings:During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 7/28/2025, the spreadsheet indicated residents on regular texture diet would include the following foods on the tray: Swedish meatballs 2 pcs Gravy 1-2 oz Over egg noodles 1/2 cup (c, household measurement) Fresh zucchini and carrots 1/2 c Orange slice Wheat roll 1 Margarine 1 teaspoon Raspberry parfait square 2x2 1/2 inches Milk 4 oz During a concurrent observation and interview on 7/28/2025 at 11:47 a.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate) lunch service with [NAME] 1, [NAME] 1 weighed the Swedish meatballs and got the following weights using the facility food scale: Swedish meatballs weight 1: 4 oz Swedish meatballs weight 2: 4 oz Swedish meatballs weight 3: 4 oz Swedish meatballs weight 4: 4 oz Swedish meatballs weight 5: 4.2 oz Swedish meatballs weight 6: 4 oz [NAME] 1 stated she made the Swedish meatballs from scratch using ground turkey and used the green number 16 scoop to portion each meatball.During an interview on 7/28/2025 at 12:15 p.m. with [NAME] 1, [NAME] 1 stated she portioned the Swedish meatballs using green scoop which was number 16.During a concurrent observation and interview on 7/28/2025 at 12:46 p.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of a regular diet with the Dietary Supervisor (DS), the DS stated the portion of meatballs was 2 pcs with a weight of 3 oz total. DS stated if residents got 4 oz of Swedish meatballs, they would get more protein which was not following the recipe. The DS stated residents would get excess protein for the day causing unplanned weight gain as a potential outcome. The DS stated residents on Renal and CCHO diets would get more protein and carbohydrates and would not follow their diets resulting in ineffective diet therapy. The DS stated the green scoop is number 12 (1/3 c) and the blue scoop is number 16 (1/4 c). The DS stated [NAME] 1 used the wrong scoop and the portion was more.During a review of the facility's policies and procedures (P&P) titled Food Preparation dated 5/27/2025, the P&P indicated, Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.During a review of the facility's P&P titled Menu Planning dated 5/27/2025, the P&P indicated, (4) The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the facility Registered Dietitian prior to the beginning of each quarterly menu cycle.During a review of the facility's standardized recipe titled Recipe: Curry Lemon Chicken dated 5/27/2025, the recipe indicated portion size: 2 meatballs (3 oz protein). Directions: 1. Wash onions well under cool running water. Combine breadcrumbs and milk-let milk absorb crumbs. Then add nutmeg, onions, and eggs. Add ground turkey.2. Mix slowly until blended. Shape into balls using number 16 scoops, rounded. Place meatballs into serving pans.During a review of the facility's P&P titled Portion Control dated 5/27/2025, the P&P indicated Policy: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food. 1. Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed in the RDs for healthcare recipe book.2. Ladles are sized according to their capacity. 3. A diet scale should be used to weigh meats.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve temperature when raspberry parfait was at 52 degrees Fahrenheit ( F, a degree of temperature) and puree raspberry parfait was at 59 F.This deficient practice placed 121 of 122 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.Findings:During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 7/28/2025, the spreadsheet indicated residents on regular texture diet would include the following foods on the tray: Swedish meatballs 2 pcs Gravy 1-2 oz Over egg noodles 1/2 cup (c, household measurement) Fresh zucchini and carrots 1/2 c Orange slice Wheat roll 1 Margarine 1 teaspoon Raspberry parfait square 2x2 1/2 inches Milk 4 oz During a review of the facility's daily spreadsheet titled Summer Menus, dated 7/28/2026, the spreadsheet indicated residents on modified texture diet would include puree raspberry parfait number 12 scoop (1/3 c).During a concurrent observation and interview on 7/28/2025 at 12:28 p.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of a regular diet with the Dietary Supervisor (DS), observed the DS took the temperature of the raspberry parfait square using the facility thermometer. The DS stated the temperature of the raspberry parfait square was at 52 F. During a concurrent observation and interview on 7/28/2025 at 12:28 p.m. of the test tray of a puree diet with the DS, observed the DS took the temperature of the puree raspberry parfait square using the facility thermometer. The DS stated the temperature of the raspberry parfait square was at 59 F. During an interview on 7/28/2025 at 12:35 p.m. with the DS, the DS stated the raspberry parfait temperature was high, and it should be at least 40 F. The DS stated the raspberry parfait and puree raspberry parfait waited on the serving area in trayline causing its temperature to go up. The DS stated the raspberry parfait should have been stored in the refrigerator a little bit longer or there should have been an ice in the raspberry parfait container to keep it cold. The DS stated residents could get sick of food borne illnesses and could have diarrhea, stomach pain and vomiting upon consuming food items not meeting the temperature of at least 40 F. The DS stated residents would not eat the food and it could cause them dissatisfaction and complaints because the food was not cold. The DS stated residents would not be eating the parfait and would not be meeting the calories the residents need and could lead to weight loss. During a review of the facility's policies and procedures titled Food Preparation, dated 5/27/2025, the P&P indicated Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. (7) Hold food prior to service for as short time as practical. A maximum 1 hour holding time is recommended. Hot food should be held prior to service at 140 F or above and cold foods at 41 F or below. Keep foods covered during holding.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not cleaned and sanitized.a. Reach in freezer bottom shelves had boxes particles and dirt debris.b. The ice cream reach-in freezer had dirt and dust debris.c. The bread refrigerator had dried juice and milk sticky food spill.d. Reach in refrigerator vent had dust buildup.e. Walk in refrigerator vent had dust buildup.f. Ice buildup in the walk-in freezer door.g. [NAME] particles on the dry storage room floorh. Can opener container have had dust and dirt buildup.i. The condiment container had salt, pepper, sugar, artificial sweetener and dust debris.j. Hood and hood light where the staff cook food had dust and dirt particles.k. Mixer had dust and was not cleaned after use. l. The rack for clean pans storage had dust particles. m. The vending machine used for residents had dust particles.2. There is no thermometer inside the bread reach-in refrigerator.3. One (1) dented can was stored with non-dented cans.4. Staff failed to perform handwashing and hand hygienea. Dietary Aide 1 (DA 1) did not wash hands after touching the faucet knob and proceeded to go to work.b. Dietary Aide 2 (DA 2) did not wash hands after using the same paper towel turn off the faucet knob then dry their hands.c. Dietary Aide 3 (DA 3) went to dirty area and touched the clean dishes without changing gloves and washing hands5. Kitchen utensils were not air dried.a. Scoops were not air dried and not stored in the same orientation and direction.b. Pots and pans were stacked wet and not air dried.6. The strainer had amber discoloration.7. Plastic ware containers were divided using a carton box which was not a cleanable surface.8. Resident's freezer shelves had rust.9. The crack and broken refrigerator surface was covered with flexi tape and was not a cleanable surface. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 121 of 122 medically compromised residents who received food and ice from the kitchen. Findings: 1. a. During an observation on 7/28/2025 at 8:33 a.m. of the reach-in freezer, observed dirt debris at the bottom shelves. b. During an observation on 7/28/2025 at 8:39 a.m. of the ice cream reach-in freezer, observed dirt debris on the shelves. c. During an observation on 7/28/2025 at 8:42 a.m. of the bread reach-in refrigerator, observed dirt, dried up food spill on the shelves. d. During an observation on 7/28/2025 at 8:47 a.m. of the reach-in refrigerator in the preparation area, observed dust particles and buildup on the refrigerator vent. During a concurrent observation and interview on 7/28/2025 at 8:53 a.m. with the Dietary Supervisor (DS), the DS stated there was dirt debris on the bottom shelves of the reach-in freezer and ice cream reach in freezer. The DS stated there were dry juice and milk spills in the bread reach-in refrigerator and dust buildup on the vent of the reach in refrigerator. The DS stated all the refrigerators and freezers were not free from dirt and it was not okay due to potential cross-contamination of dirt and dust to food. The DS stated residents could get sick of diarrhea, stomach pain, vomiting and food poisoning as a potential outcome. e. During an observation on 7/28/2025 at 9:19 a.m. of the walk-in refrigerator, observed dust buildup on the vent of the walk-in refrigerator. During an interview on 7/28/2025 at 9:26 a.m. with the DS, the DS stated the vent in the walk-in freezer was dusty and she would need to inform the maintenance to clean it. The DS stated it was not okay that the vent was dusty as it could go to the food and could cause physical contamination. f. During an observation on 7/28/2025 at 9:24 a.m. of the walk-in freezer, ice buildup observed on the door of the freezer. During a concurrent observation and interview on 7/28/2025 at 9:28 a.m. of the walk-in freezer door with the DS, the DS stated the walk-in freezer door was hard to close because of the ice buildup and it was not okay because the air coldness in the freezer would not properly circulate. The DS stated there would be a tendency that food would not meet the freezing temperatures and residents could get sick of food poisoning as a potential outcome. g. During an observation on 7/28/2025 at 9:32 a.m. of the dry storage area, observed rice particles on the floor. During a concurrent observation on 7/28/2025 at 9:47 a.m. of the dry storage floor, the DS stated the white residue on the floor was paint. The DS stated there were rice particles on the floor and it was important to maintain the cleanliness of the floor to prevent roaches and other insects in the food storage. h. During an observation on 7/28/2025 at 8:19 a.m. of the can opener holder, observed the can opener holder had dust and sticky black dirt buildup. During an interview on 7/29/2025 at 9:01 a.m. with the DS, the DS stated they do deep clean every Thursday. The DS stated there was a dust buildup on the can opener holder and it was not okay because it was touching the can opener used to open canned foods and dust could be transferred to food. The DS stated residents could have food borne illness because of cross-contamination as a potential outcome. i. During an observation on 7/28/2025 at 8:28 a.m. of the condiment containers by trayline (an area where foods were assembled from the steamtable to residents' plate), observed salt container with salt residues and dirt debris, pepper container had pepper residues and dirt debris, sugar container had sugar residues and dirt debris, and sweetener container had sweetener residues and dirt debris. During an interview on 7/28/2025 at 9:10 a.m. with the DS, the DS stated there was salt, sugar, black pepper, sweetener and dirt particles in each individual container and it had to be cleaned to prevent cross-contamination. j. During an observation on 7/29/2025 at 8:31 a.m. of the kitchen hood by the stove, dust and dirt observed on the light and surfaces of the hood. During a concurrent observation on 7/29/2025 at 9:14 a.m. of the kitchen hood with the DS, the DS stated they cleaned the hood every Tuesday night. The DS stated there was dust in the kitchen hood and it was not okay because it could fall directly to the food where the cook prepares and cook foods. k. During a concurrent observation and interview on 7/29/2025 at 8:38 a.m. of the mixer with [NAME] 1, observed dust on the mixer external parts. [NAME] 1 stated last time the mixer was used was last night and the person responsible for cleaning it was the one who used it last night. During an interview on 7/29/2025 at 9:18 a.m. with the DS, the DS stated the mixer was used last night and the staff clean it every after use. The DS stated there was a flour residue on the mixer external parts and it was not okay due to cross-contamination of food. l. During a concurrent observation and interview on 7/29/2025 at 9:17 a.m. of the pan's storage area with the DS, the DS stated the rack for storing pans was dusty and it was not okay due to cross-contamination. m. During a concurrent observation and interview on 7/29/2025 at 9:52 a.m. of the vending machine with Certified Nursing Assistant 2 (CNA 2) and the DS, CNA 2 stated they used the vending machine for the alert residents. The DS stated the vending machine was dusty and it was the outside company who maintains it. The DS stated it was not okay to have a dusty vending machine because it could cause contamination of food. During a review of the facility's policies and procedures (P&P) titled Sanitation dated 5/27/2025, the P&P indicated (2) The FNS Director is responsible for instructing Food and Nutrition Services personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area. (6) The maintenance department will assist Food and Nutrition Services as necessary in maintaining equipment and doing janitorial duties which the Food and Nutrition employees cannot do and maintain maintenance records on all equipment. During a review of the facility's P&P titled Refrigerator and Freezer, dated 5/27/2025, the P&P indicated maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. For the best cleaning results, always refer to your owner's manual (1) Refrigerator and freezer should be on a weekly cleaning schedule. (2) Wipe up spills immediately. (6) Remove all the items and clean the shelves. Wipe with sanitizer. During a review of the facility's P&P titled Storeroom dated 5/27/2025, the P&P indicated The general cleanliness and care of the storeroom and supplies are important to ensure safe wholesome food. (1) The floor, walls, ceiling, lights, shelves and equipment must be kept clean by setting up, maintaining, and monitoring a regular cleaning schedule. Routine inspections must be made to ensure cleanliness and high standards of sanitation. (3) All will be cleaned weekly and noted on the cleaning schedule. Best to clean prior to food delivery. During a review of the facility's P&P titled Hoods, Filters, and Vents dated 5/27/2025, the P&P indicated Hoods must be cleaned every month and must be free of dust and grease. During a review of the facility's P&P titled Electrical Food Machines dated 5/27/2025, the P&P indicated Keep and maintain all food machines in good operating, sanitary condition. This includes the mixer, grinders slicers and toasters. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. During an observation on 7/28/2025 at 8:39 a.m. of the ice cream reach-on freezer, observed no thermometer inside the freezer. During a concurrent observation and interview on 7/28/2025 at 9:05 a.m. of the ice cream freezer with the DS, the DS stated there was no thermometer in the ice cream freezer. The DS stated they have an outside temperature gauge and inside thermometer and it was important to have two thermometers in the freezers and refrigerator. The DS stated she must double-check why they need to have a second thermometer in the refrigerators and freezers. During an interview on 7/29/2025 at 8:42 a.m. with the DS, the DS stated they placed the thermometer inside for accuracy of the refrigerator and freezer temperatures. The DS stated if there was not a thermometer inside the refrigerator and freezer, it would be possible the temperature would not be in the right temperature and ice cream could melt. The DS stated residents could get foodborne illnesses if proper temperature was not achieved as a potential outcome. During a review of the facility's P&P titled Sanitation dated 5/27/2025 the P&P indicated (19) Correct temperatures for the storage and handling of foods are used. Thermometers will be used to check temperatures of refrigerators, freezers and in food storeroom. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display. 3. During a concurrent observation and interview on 7/28/2025 at 9:47 a.m. of the dry storage room canned foods with the DS, observed one (1) dented can stored with non-dented canned foods. The DS stated they have a separate area to store the dented cans as it needed to be returned to the vendor because they could not use it for residents. The DS stated a little dent on the can would not be acceptable as the food inside could be spoiled or expired. During an interview on 7/29/2025 at 8:45 a.m. with the DS, the DS stated dented cans should not be used for resident's consumption and should be returned to vendor as it is spoiled and could cause botulism (a rare but serious poisoning caused by bacteria in dented cans) to residents upon consumption of food as a potential outcome. During a review of the facility's P&P titled Storeroom dated 5/27/2025, the P&P indicated (2) Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods. If damaged when delivered, return them to the purveyor for credit. During a review of the facility's P&P titled Food Storage-Dented Cans dated 5/27/2025, the P&P indicated Policy: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victims to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 4. a. During an observation on 7/29/2025 at 8:16 a.m. of the Dietary Aide 1 (DA 1) handwashing, observed DA 1 washed her hands then turn off the faucet knob with bare hands then went back to work. b. During an observation on 7/29/205 at 8:18 a.m. of the Dietary Aide 2 (DA 2) handwashing, observed DA 2 washed her hands turned off the faucet knob using a paper towel then wiped and dried her hands using the same paper towel she used to turn off the faucet knob. During an interview on 7/29/2025 at 8:50 a.m. with the DS, the DS stated handwashing should be done when staff comes in the kitchen, change gloves and touch things. The DS stated the staff needed to use a paper towel when turning off the faucet knob because after handwashing the hands are clean, and the knob is dirty. The DS stated the hands would be contaminated upon touching the dirty knob. The DS stated staff should be washing their hands if they touched the faucet knob before returning to work to prevent cross-contamination of food. The DS stated the staff should not use the same paper towel after turning off the faucet knob then use the same paper towel to dry their hands due to cross-contamination. The DS stated the process of drying hands was to use paper towel first to dry the hands then turn off the faucet knob. c. During a concurrent observation and interview on 7/29/2025 at 9:35 a.m. of the dishwashing process with the DS, observed Dietary Assistant 3 (DA 3), observed DA 3 wore gloves, removed the soiled dishes from the cart, loaded the racks with domes then unloaded the clean plates using the same gloves. The DS stated DA 3 needed to wash his hands and change gloves from going dirty to the clean area to prevent cross-contamination of plates and clean dishes. During a review of the facilities P&P titled Sanitation dated 5/27/2025, the P&P indicated (15) All Food and Nutrition service staff shall know the proper hand washing technique. The FNS Director is responsible for the proper training of this. The handwashing sink shall have running hot and cold water, soap, paper toweling and appropriate receptacles for wastepaper. (20) A minimum of two employees will be used when dishes are machine washed. One will handle the soiled area and the other will handle the clean side. If an employee does need to go from soiled end to clean end, a strict handwashing routine must be followed. During a review of the facilities P&P titled Hand Washing Procedure dated 5/27/2025, the P&P indicated Handwashing is important to prevent the spread of infection. When hands need to be washed: (1) before starting work in the kitchen. (2) After handling soiled dishes and utensils. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. 5. a. During an observation on 7/29/2025 at 8:22 a.m. of the scoop drawer, the scoops were stored in different directions and had water particles. During a concurrent observation and interview on 7/29/2025 at 9:03 a.m. the DS stated the scoops were not stored in the same orientation and it should be in one direction so staff could avoid touching the lip of the scoop to avoid cross-contamination. The DS stated all dishes and utensils should be air dried as the last step of the dishwashing process. The DS stated there were still water particles and the scoops were stored in the drawer not completely air dried. The DS stated dishes and utensils are to be air dried to prevent chemical contamination of food and the sanitizer needed to be completely dry for it to be effectively clean the scoops. During a review of the facility's P&P titled Dishwashing dated 5/27/2025, the P&P indicated flatware will be rinsed and separated into cylinders and washed in dishmachine two times. Flatware will then be handled by the handle end of the utensil, not the mouth end. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-904.11 Kitchenware and Tableware (A) Single-service and Single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food-and lip-contact surfaces is prevented. b. During a concurrent observation and interview on 7/29/2025 at 9:24 a.m. of the pots and pans by the preparation area, the DS stated the pots and pans were stacked wet, and it was not okay because the water could get stuck inside and could cause cross contamination. During a review of the facility's P&P titled Dishwashing dated 5/27/2025, the P&P indicated (5) Dishes are to be air dried in racks before stacking and storing. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.6. During an observation on 7/29/2025 at 8:24 a.m. of the strainer, observed the strainer had amber discoloration.During an interview on 7/29/2025 at 9:25 a.m. with the DS, the DS stated the original color of the strainer was amber, but she will replace it due to the discoloration as it could cause cross contamination of food. During a review of the facility's P&P titled Sanitation dated 5/27/2025, the P&P indicated (9) All utensils, counters, shelves and equipment shall be kept cleaned in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas.During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. 7. During an observation on 7/29/2025 at 8:28 a.m. of the plastic utensils container, observed a cut out box divider taped into it. During an observation on 7/29/2025 at 9:10 a.m. with the DS, the DS stated the plastic spoon containers had cartoon dividers and it was not a cleanable surface. The DS stated having cartoon dividers was not okay because it could attract rodents and cause physical contamination of food. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-101 Characteristics. Materials that are used in construction of utensils and food-contact surfaces of equipment may not allow the mitigation of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be (a) safe; (b) durable, corrosion-resistant, and non-absorbent; (c) sufficient in weight and thickness to withstand repeated warewashing; (d) Finished to have a smooth, easily cleanable surface. 8. During a concurrent observation and interview on 7/29/2025 at 10:06 a.m. of the residents' refrigerator in the activity room with the DS, the DS stated the refrigerator shelves were rusted, and it was not okay due to cross contamination. During a review of the facility's P&P titled Refrigerator and Freezer dated 5/27/2025, the P&P indicated (9) Periodically inspect shelves and replace if coating is chipped away exposing metal shelves. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 9. During a concurrent observation and interview on 7/29/2025 at 10:06 a.m. of the resident's refrigerator in the activity room with the DS and the Maintenance Supervisor (MS), the DS stated there was a flexi tape at the bottom of the refrigerator as it was cracked. The MS stated the refrigerator has cracks and needed to be replaced. The DS stated roaches could go to the cracks and the flexi tape was not a cleanable surface and could harbor bacteria. During a review of the facility's P&P titled Sanitation dated 5/27/2025, the P&P indicated (4) Employees are to alert the FNS Director immediately to any equipment needing repair. (5) The FNS Director (and/or cook in his absence) will report any equipment needing repair to the maintenance man. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-101 Characteristics. Materials that are used in construction of utensils and food-contact surfaces of equipment may not allow the mitigation of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be (a) safe; (b) durable, corrosion-resistant, and non-absorbent; (c) sufficient in weight and thickness to withstand repeated warewashing; (d) Finished to have a smooth, easily cleanable surface.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when two (2) of 2 dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not covered while not actively being used and there were soiled gloves and food juices on the floor. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 121 of 122 facility residents. Findings:During a concurrent observation and interview on 7/29/2025 at 9:54 a.m. of the dumpster with the Dietary Supervisor (DS), observed one dumpster was overfilled with trash, not completely covered, the other dumpster's lid was opened and there were liquid drippings and soiled gloves on the dumpster floor. The DS stated the dumpsters were full of trash and it was not completely closed and covered. The DS stated there were flies going in and out already and it needed to be closed to prevent flies and pest. The DS stated flies and insects could spread diseases and infection to residents as a potential outcome.During a concurrent observation and interview on 7/29/2025 at 10 AM of the dumpster with the Maintenance Supervisor (MS), MS stated the dumpster was overflowing with trash and it was not fully closed, and the other dumpster was left open by the gardener. The MS stated it was important to keep the dumpster close to prevent insects and pests from coming into the facility due to infection control. The MS stated he cleaned the area every Saturday however he needed to clean it due to the soiled gloves and juice food spills on the floor. The MS stated he would talk to the gardener to close the dumpster lid after using it. During a review of the facility's policies and procedures (P&P) titled Miscellaneous Areas dated 5/27/2025, the P&P indicated Trash Procedure: (2) Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. Trash Collection Area: The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. (1) The area must be swept and washed down by maintenance with a detergent on a regular basis.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:a. Ensure pain assessments were accurately documented for two out of three residents investigated under the pain care area (Residents 11 and 111) when the site of pain was not correctly documented as a part of the pain assessment. This failure resulted in Residents 11 and 111 having incorrectly and incompletely documented pain assessments.b. Clarify hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) orders were clear and accurate for one of five sample residents (Resident 12).This deficient practice placed Resident 12 at risk for unnecessary dialysis treatment and potential for electrolyte imbalance. c. Ensure accuracy of records when Licensed Nurse 3 (LVN 3) who did not sign controlled drug count sheet at the shift change time on 7/29/2025, signed afterwards, but did not document the entry as a late entry (documentation made after the time of the event).This had the potential for the record to not accurately reflect what has occurred.d. Ensure a licensed nurse accurately documented the administration of a hypertension medication (medication used to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) in accordance with the physician's prescribed parameters (a fixed limit/range to either give or hold a medication) for one of one sampled residents (Resident 13).This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services for Resident 13Findings: a. 1. During a review of Resident 11’s admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including, but not limited to, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) in both knees, chronic pain (pain that lasts longer than three months), and difficulty in walking. During a review of Resident 11’s History and Physical (H&P) dated 6/23/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 11’s Minimum Data Set (MDS – a resident assessment tool), dated 6/20/2025, the MDS indicated Resident 11 was cognitively intact (can think, learn, and remember clearly). The MDS further indicated Resident 11 needs partial or substantial assistance from staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 11’s Physician’s Orders, the Physician’s Orders indicated an order dated 6/29/2025 for one Roxicodone (an opioid medication used to treat pain) 30 milligram oral tablet to be given every 12 hours as needed for moderate to severe pain. During a review of Resident 11’s care plan (a document that outlines a patient’s healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team), titled “Alteration in comfort due to pain .,” dated 7/13/2025, the care plan indicated to observe and assess Resident 11’s pain, location, duration, frequency, and strength. During a review of Resident 11’s Administration Notes accessed on 7/30/2025 at 2:28 p.m., the following Administration Notes indicated Roxicodone was administered without a complete pain assessment documented including the site of pain prior to administration: 7/2/2025 9:50 a.m., 7/17/2025 at 4:48 p.m., 7/19/2025 at 5:00 a.m., 7/20/2025 at 5:00 a.m., 7/27/2025 at 6:15 a.m., and 7/27/2025 at 6:15 p.m. During a concurrent interview and record review on 7/31/2025 at 12:23 p.m. with LVN 1, Resident 11’s Administration Note dated 7/2/2025 at 9:50 a.m. indicated a late entry from LVN 1 that the resident was experiencing generalized body pain prior to pain medication administration. LVN 1 stated she added a late entry regarding the resident’s site of pain today (7/31/2025) after she heard Resident 11 talking to the pain specialist and she remembered she had not documented the resident’s site of pain on a prior assessment. LVN 1 stated she knew where the resident’s pain was on 7/2/2025 because she asked Resident 11 today where her pain normally is and Resident 11 told her it is always all over her body. LVN 1 reviewed the Administration Note dated 7/29/2025 which indicated Resident 11 was experiencing back pain, not generalized body pain and stated other pain assessments indicated the resident experiences pain in specific body sites like back pain at times and not always generalized body pain. LVN 1 stated it was not the correct process for her to ask the resident about her pain today to include in the pain assessment on 7/2/2025. LVN 1 stated the site of pain shouldn’t be documented later because something could be overlooked. LVN 1 stated there is no way to ensure generalized body pain is 100% accurate on 7/2/2025 due to the late assessment and documentation. LVN 1 stated the pain assessment should be accurate to make sure the resident’s pain is treated appropriately. a.2 During a review of Resident 111’s admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted [DATE] with diagnoses including, but not limited to, myocardial infarction (MI-heart attack), rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly potentially causing pain, weakness, and harm to the kidneys), and generalized muscle weakness. During a review of Resident 111’s H&P dated 6/24/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 111’s MDS, dated [DATE], the MDS indicated Resident 111 had moderate cognitive impairment (had trouble with thinking, learning, and remembering clearly). The MDS further indicated Resident 111 needs total or substantial assistance from staff for most ADLs. During a review of Resident 111’s Physician’s Orders, the Physician’s Orders indicated an order dated 6/23/2025 for two Tylenol 325 mg oral tablets to be given every six hours as needed for mild pain. During a review of Resident 111’s care plan, titled “Alteration in comfort manifested by pain .,” dated 6/23/2025, the care plan indicated to assess for pain and medicate per standing order During an interview on 7/28/2025 at 10:09 a.m. with Resident 111, Resident 111 stated she had a headache and was waiting for a nurse to bring her Tylenol. During a concurrent interview and record review on 7/31/2025 at 12:23 p.m. with LVN 1, Resident 111’s Administration Notes, dated 7/28/2025, indicated Tylenol was administered on 7/28/2025 at 10:37 a.m. without a complete pain assessment documented including the site of pain prior to administration. LVN 1 stated she asked Resident 111 where her pain was, and Resident 111 told her it was a headache, but she did not document it. LVN 1 said the site of pain should be documented so you can track the resident’s episodes of pain and see if she is having pain at the same site. During a concurrent interview and record review on 7/31/2025 at 2:48 p.m. with the Director of Nursing (DON), Resident 11’s MAR dated July 2025 and Administration Notes dated 7/2/2025 9:50 a.m., 7/17/2025 at 4:48 p.m., 7/19/2025 at 5:00 a.m., 7/20/2025 at 5:00 a.m., 7/27/2025 at 6:15 a.m., and 7/27/2025 at 6:15 p.m. were reviewed. The Administration Notes dated 7/17/2025 at 4:28 p.m. did not indicate the site of pain during the assessment. The Administration Notes dated 7/2/2025 9:50 a.m., 7/19/2025 at 5:00 a.m., 7/20/2025 at 5:00 a.m., 7/27/2025 at 6:15 a.m., and 7/27/2025 at 6:15 p.m. indicated late entries with the site of pain documented on the pain assessment prior to the administration of Roxicodone. Resident 111’s Administration Notes, dated 7/28/2025, indicated Tylenol was administered on 7/28/2025 at 10:37 a.m. without a complete pain assessment documented including the site of pain prior to administration. The DON stated prior to administering pain medication the nurse should assess the pain and document the assessment. The DON stated the site of pain should be included in the assessment because if for example the resident’s arm hurts, they would need to assess the arm prior to giving medication and do nonpharmacological interventions (strategies to reduce pain that don’t involve medications). The DON stated it is not a best practice to document the pain assessment after the assessment is completed because they could forget where the location of the pain is and the documentation could be incomplete. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” last reviewed 5/27/2025, the P&P indicated pain will be assessed following any pain medication administration including the location of the pain and results of the reassessment. During a review of the facility’s P&P titled, “Charting and Documentation,” last reviewed 5/27/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. b. During a record review of Resident 12’s admission Record (front page of the chart that contains a summary of basic information about the resident) the admission Record indicated the facility originally admitted Resident 12 on 1/18/2023 and re-admitted the resident on 7/20/2025, with diagnoses including end stage renal disease (irreversible kidney failure), hypertension (high blood pressure), and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review of Resident 12’s Minimum Data Set (MDS- a resident assessment tool), dated 3/19/2025, the MDS indicated Resident 12’s cognitive skills were intact. The MDS indicated Resident 12 required maximum assistance from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves.) During a record review of Resident 12’s physician order dated 7/23/2025, the physician order indicated an order for Hemodialysis (Monday – Friday) with a chair time of 9:40 a.m. – 1:45p.m. During an observation on Monday, 7/28/2025 at 9:07 a.m., outside of Resident 12’s room, was observed on the ambulance gurney being taken to the hemodialysis center for treatment. During an interview on 7/28/2025 at 2:22 p.m. with Resident 12, Resident 12 stated he receives hemodialysis every Monday and Friday. During a concurrent interview and record review on 7/30/2025 at 10:32 a.m. with Registered Nurse (RN) 1, Resident 12’s physician orders were reviewed. RN 1 stated the hemodialysis order was not accurately entered and it did not reflect Resident 12’s hemodialysis schedule correctly. RN 1 stated Resident 12’s receives hemodialysis Monday and Friday and does not receive hemodialysis Monday through Friday. RN 1 stated it is important to accurately enter physician orders to avoid harming the resident or avoid providing unnecessary treatments to the residents. RN 1 stated unnecessary dialysis to Resident 12 has the potential to cause electrolyte imbalances and/or a decrease in blood pressure leading to potential resident harm. During a concurrent interview and record review on 7/31/25 at 10:14 a.m. with Registered Nurse (RN) 2, Resident 12’s physician orders were reviewed. RN 2 stated when orders are received from physicians the orders must be entered correctly into the resident’s chart. RN 2 stated that if an order is not clear, the order needs to be clarified with the physician before being entered. RN 2 stated Resident 12’s hemodialysis order indicated Resident 12 received hemodialysis Monday thought Friday. RN 2 stated that the order for hemodialysis should read, “hemodialysis Monday and Friday.” RN 2 stated this incorrect order can potentially cause Resident 12 to receive unnecessary hemodialysis and increase the risk of adverse effects for Resident 12. RN 2 stated the order should have been clarified with the physician for accuracy before providing dialysis treatment to Resident 12. During a review of the facility’s policy and procedure (P&P) titled “Physician’s Orders,” dated 9/2024, the P&P indicated “The staff is responsible to query and verify with the doctor the order for accuracy.” c. During a medication cart inspection observation and concurrent record review with Licensed Vocational Nurse 1 (LVN 3) on 7/29/2025 at 3:51 p.m., reviewed the facility’s Station 1 Medication Cart 1 and Narcotic Control Sheet. There was a blank space on the Narcotic Control Sheet (a narcotic that is a controlled drug that is used to treat pain, the narcotic control sheet is signed by the incoming and outgoing licensed nurses after both nurses count the medications together) for the incoming licensed nurse’s signature for 7/29/2025 for the 3 p.m. time slot. LVN 3 stated she did not sign the sheet when she was counting medications with the 7 a.m. to 3 p.m. licensed nurse. LVN 3 stated she should have signed the form at the time she counted the controlled drugs with the morning nurse. LVN 3 stated it is important to sign the narcotic control sheet to make sure there are no discrepancies with the controlled drugs in the medication cart. During a concurrent interview and record review on 7/30/2025 at 1:42 p.m. with the Director of Nursing (DON), the DON stated the facility policy indicates the narcotic control sheet should be signed by the incoming and retiring nurse at every shift change. The DON stated it was important to sign the form to verify that two nurses actually counted the narcotics when the medication cart was endorsed, and so the oncoming nurse knows what they are receiving and is able to resolve any discrepancies. The DON stated the completing the narcotic count is important to ensure that there is medication accuracy and accountability. Reviewed Medication Cart 1, Station 1 Narcotic Control Sheet with the DON. The Narcotic Control Sheet indicated LVN 3’s initials in the slot for the 7/29/2025 3 p.m. time for the outgoing and incoming nurse initials. The DON stated the incoming initials were those of LVN 3. When asked if the entry should have been recorded as a late entry, the DON stated the entry should be recorded as a late entry to ensure the accuracy and timeliness of the record. During a review of the facility’s policy and procedure titled, “Policy on Narcotics”, last reviewed 5/27/2025, indicated narcotics must be counted by the oncoming and outgoing staff during each shift and sign the narcotic sheet. During a review of the facility’s policy and procedure titled, “Charting and Documentation,” last reviewed 5/27/2025, indicated late entries are allowed and documented immediately as the events are recalled with no time frame. The policy indicated to not erase any entries, and the staff may draw one line through the entry and write error and sign the entry. d. During a review of Resident 13’s admission Record, the admission Record indicated the facility admitted the resident on 12/5/2022 with diagnoses that included, but is not limited to difficulty in walking, dysphagia (difficulty swallowing), and a history of falling. During a review of Resident 13’s History and Physical (H&P) dated 7/12/2025, the H&P indicated Resident 13 did have the capacity to understand and make decisions. During a review of Resident 13’s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/23/2025, the MDS indicated Resident 13 understood others and was able to make themselves understood. The MDS indicated Resident 13 was dependent on staff for activities such as toileting, dressing, and putting on/taking off footwear. During a review of Resident 13’s Order Summary Report, the Order Summary Report indicated an order for metoprolol tartrate (medication for hypertension) oral tablet 25 milligram (mg – a unit of measurement), give one tablet by mouth two times a day for hypertension, give with food, hold the medication when at least one of the vital signs is present: systolic blood pressure (SBP – the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) is less than 110 millimeters of mercury (mmHg- unit of measure), pulse [heart] rate is less than 60 beats per minute (bpm), ordered 4/19/2024. During a review of Resident 13’s Medical Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications given to a resident) dated 6/2025, the MAR indicated: - On 6/28/2025 at 5:00 p.m., metoprolol was given (indicated by a check mark) when the recorded BP was 100/62 mmHg and HR was 74 bmp by Licensed Vocational Nurse 6 (LVN 6). During a concurrent interview and record review on 7/30/2025 at 3:40 p.m., with LVN 6, reviewed Resident 13’s MAR dated 6/2025. LVN 6 stated that a check mark represents that the medication was given. LVN 6 stated on 6/28/2025, she did not remember if she administered the metoprolol or not, but with a BP reading of 100/62 mmHg, metoprolol should have been held because the SBP was below 110 and the physician order indicated to hold the medication if SBP was below 110. LVN 6 stated as a licensed nurse, she must follow the physician’s orders as written to ensure the safety of the resident. LVN 6 stated Resident 13 could have become hypotensive (low blood pressure) and fainted. During a concurrent interview and record review on 7/31/2025 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 13’s MAR dated 6/2025 and 7/2025. The DON stated all licensed nurses must follow the standards of practice when giving medication, for example identifying the resident and checking for dosage and parameters. The DON stated Resident 13’s MAR indicated that metoprolol was given as indicated by a checkmark on 6/3/2025, 6/28/2025, and 7/5/2025, when the vital signs were outside the parameters. The DON stated the parameters are given by the physician so licensed nurses can follow them to ensure safety for the residents. The DON stated Resident 13 could have become hypotensive and possibly hurt themselves if they fainted or fell. During a review of the facility’s Policy and Procedure (P&P) titled, “Specific Medication Administration Procedures,” last reviewed on 5/27/2025, the P&P indicated to administer medications in a safe and effective manner and to note any contraindications the resident may have prior to drug administration. During a review of the facility’s P&P titled, “Charting and Documentation,” last reviewed 5/27/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:1. Ensure facility staff donned (put on) and doffed (took off) an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) when entering and exiting a resident's room who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of seven sampled residents (Resident 6).This deficient practice had the potential to increase the risk of spreading infection to other residents and staff. 2. Ensure the nebulizer (changes medication from a liquid to a mist so you can inhale it into your lungs) tubing was not touching the floor for one of two sampled residents (Resident 16) investigated for Respiratory Care.This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. Findings: a. During a review of Resident 6’s admission Record, the admission Record indicated the facility admitted the resident on 7/19/2024 and re-admitted the resident on 3/10/2025 with diagnoses that included dysphagia (difficulty swallowing), and attention to a gastrostomy (a surgical opening to allow feedings to be administered directly to the stomach, common for people with swallowing problems). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool) dated 6/19/2025, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent (helper does all the effort) on staff for oral hygiene. During a review of Resident 6’s physician orders, the physician orders indicated an order for enteral feed (tube feeding) every shift for enteral feeding, crush medications and provide liquid medications as indicated via enteral tube (gastrostomy tube or G- Tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach), dated 3/10/2025. During a concurrent observation and interview on 7/30/2025 at 7:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed LVN 2 preparing medications to administer to Resident 6. Observed LVN 2 and Certified Nursing Assistant 1 (CNA 1) go into Resident 6’s room to pull Resident 6 up in the bed. LVN 2 and CNA 1 were wearing gloves but not an isolation gown. LVN 2 then put on new gloves and an isolation gown and entered the room to take Resident 6’s blood pressure. LVN 2 took Resident 6’s blood pressure and exited the room, removing the gloves but not the isolation gown and observed the isolation gown brush up against the medication cart. LVN 2 was asked about exiting the room while still wearing an isolation gown and then LVN 2 removed the gown and started preparing Resident 6’s G-tube medications at the medication cart. LVN 2 prepared the medications and entered Resident 6’s room. LVN 2 exited the room in the isolation gown to retrieve a stethoscope (a medical instrument used for listening to sounds produced in the body) that was on the medication cart. LVN 2 returned to the room and gave the medications. LVN 2 then exited the room while still wearing the isolation gown to retrieve an injectable medication (medication given through the skin by a needle). LVN 2’s isolation gown came into contact with the medication cart. LVN 2 returned to Resident 6’s room to give the injectable medication. LVN 2 was asked why she did not remove her isolation gown before exiting the room and stated she should have removed the gown before exiting the room but did not. LVN 2 stated it is important to follow EBP to prevent the spread of infection to others. During an interview on 7/30/2025 at 9:20 a.m., with CNA 1, CNA 1 stated she (CNA 1) thought LVN 2 needed help immediately, so she entered the room without a gown. CNA 1 stated she would have to walk back to the silver supply cart in the opposite hallway in front of Station 2 to retrieve an isolation gown. Observed Resident 6’s hallway with CNA 1. There were no PPE supplies available in the hallway outside Resident 6’s room. CNA 1 stated she should have worn an isolation gown when assisting LVN 2 earlier. During an interview on 7/30/2025 at 11:04 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated the practice is to remove the isolation gown and gloves before leaving a resident’s room after staff have provided care for residents who are on EBP. The IPN stated LVN 2 should have removed the gown before exiting Resident 6’s room. The IPN stated this was important to prevent the spread of infection. During a review of the facility’s policy and procedure titled, “Enhanced Barrier Precaution,” last reviewed 5/27/2025, the policy indicated, enhanced barrier precautions (EBP) – used in conjunction with standard precautions (a set of infection control practices used in healthcare to prevent the transmission of diseases, regardless of the resident's suspected or confirmed infection status) and expand the use of PPE to donning (putting on) of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, bodily fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs to staff hands and clothing to reduce transmission…Indwelling medical devices with or without secretions or excretions even if the resident is not known to be infected with a MDRO (such as G-tubes)…Gowns and gloves shall be removed, and hand hygiene will be performed before leaving the room and avoid touching potentially contaminated environmental surfaces with clothing after contaminated PPEs are removed and discarded. b. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 6/14/2025 with diagnoses including muscle weakness and acute kidney failure (a sudden and rapid decrease in kidney function). During a review of Resident 16's MDS dated [DATE], the MDS indicated that the resident`s cognitive skills for daily decision making was intact and dependent on staff for toileting hygiene, dressing and set-up assistance for eating and oral hygiene. During a review of the Resident 16`s Order Summary Report, the Order Summary Report indicated a physician`s order for ipratropium-albuterol solution (used to hep relieve shortness of breath) 0.5-2.5 milligram (mg- unit of measurement) per three (3) milliliter (ml- unit of measurement) inhale orally every four (4) hours as needed for shortness of breath or wheezing via nebulizer. During a concurrent observation and interview on 7/28/2025 at 9:38 p.m., with the IPN, observed Resident 16`s nebulizer tubing on the floor. The IPN stated that the tubing should not be touching the floor since the floor is dirty and we do not know what germs are on the floor. The IPN stated that the resident can acquire a respiratory infection and removed the tubing and stated it will be replaced with a new one. During a review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.

Based on interview and record review that facility failed to implement their policy on homelike environment by failing to provide documented evidence that the facility checked residents ' room temperatures daily from 1/26/2025-1/28/2025. This deficient practice had the potential to keep residents from being provided a homelike environment and having comfortable room temperatures. Findings: During an interview with the Maintenance/Housekeeping Director (MHD) on 1/28/2025 at 11:52 am, the MHD stated that the facility checks the temperatures of residents ' room, three times a day. The first temperature should be taken by 9:00 a.m. The MKD stated that the facility temperatures are then documented in the facility ' s temperature log. During an interview and concurrent facility records review with the MHD on 1/28/2025 at 12:02 p.m., the MHD reviewed the facility documents titled, Air Temperature Monitor Log, dated 11/1/2024-1/25/2025. The MHD stated that there is no documented evidence that facility temperatures were checked on 1/26/2025-1/28/2025, for three (3) days. During an interview with Maintenance Assistant 1 (MA 1) on 1/28/2025 at 12:05 p.m., MA 1 stated that MA 1 was assigned to check the residents ' room temperatures. MA 1 stated that MA 1 did not check residents' room temperatures from 1/26/2025-1/28/2028 because MA 1 forgot to check the residents' ' room temperatures and because MA 1 got busy. During a follow up interview with the MHD on 1/28/2025 at 12:32 p.m., the MHD stated that it is important for the facility to check residents ' room temperatures on a daily basis for residents ' comfort. The MHD stated that the temperatures should be documented to show proof that the temperatures were checked. During a review of the facility provided policy and procedure titled Homelike Environment (Temperature Log), 5/2024, indicated residents are provided with a safe, clean, comfortable and homelike environment- specifically to have comfortable temperatures. The facility staff and management shall take the temperature once a day in various rooms to ensure comfortable temperatures to the extent possible.

Based on observation, interview and record review, the facility failed to remove two unidentified and unlabeled medication tablets found in one of five medication carts (Nursing Station 1 Medication Cart Two [2]). This deficient practice had the potential for the residents to receive medications with improper efficacy due to improper storage condition of medications. Findings: During a concurrent medication storage observation and interview on 8/28/2024 at 12:29 p.m. with the Infection Prevention Nurse (IPN), observed one unidentified and unlabeled pink tablet and one unidentified and unlabeled white tablet in Nursing Station 1 Medication Cart Two. The IPN stated that all medications must be labeled indicating the name of the resident, name of medication, medication dose, and the expiration date of the medication. During an interview on 8/28/2024 at 1:13 p.m., Licensed Vocational Nurse 1 (LVN1) stated unlabeled and contaminated medications should have been immediately removed from the medication cart to prevent any medication error. LVN 1 further stated that she forgot to discard both unidentified and unlabeled medications found in Nursing Station 1 Medication Cart Two. During an interview on 8/28/2024 at 3:05 p.m., the Director of Nursing (DON) stated that all medications must be stored according to the facility's policy and manufacturer's recommendations to ensure the effectiveness of the medication. A review of the facility's policy and procedure titled Medication Storage in the Facility last revised in August 2020, indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedure for medication disposal, and reordered from pharmacy if current order exists.

Based on interview and record review, the facility failed to ensure a facility staff knocked and asked permission prior to entering a resident's room for one of five sampled residents (Resident 413). This deficient practice violated the resident's rights to be treated with respect and dignity which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 413's admission Record, the document indicated the facility admitted the resident on 8/8/2024 with diagnoses including muscle weakness, history of falling, and chronic kidney disease (kidneys are damaged and can't filter blood the way they should). During a review of Resident 413's History and Physical (a formal assessment that a physician performs on a resident, which includes a medical history, physical exam, and documentation of findings) dated 8/9/2024, the document indicated that the resident had the capacity to understand and make decisions. During a concurrent observation and interview on 8/20/2024 at 8:49 a.m., with Registered Nurse 1 (RN 1), observed RN 1 enter Resident 413's room without knocking. When asked if RN 1 had knocked prior to entering Resident 413's room, RN 1 stated that she forgot and that she should have knocked. RN 1 stated that knocking on the resident's room prior to entering is a sign of respect for the resident's personal space and to uphold their dignity. During a review of the facility's policy and procedure titled, Quality of Life-Dignity, last reviewed on 5/22/2024, the policy indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem . staff are expected to knock and request permission before entering residents' rooms .

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) fully closed a resident's privacy curtain while providing care for one of 27 sampled residents (Resident 96). This deficient practice violated the resident's right to privacy. Findings: During a review of Resident 96's admission Record, the document indicated the facility admitted the resident on 3/17/2024 with diagnoses including difficulty in walking, generalized muscle weakness, and glaucoma (a chronic eye disease that can cause vision loss and blindness). During a review of Resident 96's History and Physical (H&P - a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 3/18/2024, the document indicated the resident had the capacity to understand and make decisions. During a review of Resident 96's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/10/2024, the document indicated the resident had intact cognition (thought processes) and required supervision or touching assistance from staff for most activities of daily living (ADLs - activities related to personal care). During an observation on 8/19/2024 at 9:25 a.m., observed Resident 96 fully undressed sitting on the edge of his bed. CNA 1 was assisting Resident 96 with getting dressed. Observed Resident 96's privacy curtain was open at the foot of the bed. During an interview on 8/19/2024 at 9:34 a.m., with CNA 1, CNA 1 verified the observation by stating he should have fully closed Resident 96's privacy curtain when assisting the resident with changing clothes. During an interview on 8/22/2024 at 11:17 a.m., with the Director of Nursing (DON), the DON stated she expected her staff to provide full privacy to all residents when providing ADL care, especially if the resident is fully exposed. The DON stated that residents can possibly feel ashamed or embarrassed if they their privacy curtain is not closed while they are fully exposed. During a review of the facility's policy and procedure titled, Quality of Life - Dignity, last reviewed on 5/22/2024, the policy indicated that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident rooms (Room A) occupied by four residents (Resident 100, Resident 167, Resident 168, and Resident 363) was within the temperature range of 71 degrees Fahrenheit (F, a unit of measure for temperature) to 81 F. This deficient practice had the potential to create an uncomfortable environment and for the residents to become dehydrated (condition occurring when a harmful reduction in the amount of water in the body). Findings: a. During a review of Resident 100's admission Record, the document indicated the facility admitted the resident on 5/21/2024 and re-admitted the resident on 7/15/2024 with diagnoses that included end stage renal disease (chronic irreversible kidney failure) and dependence on dialysis (a medical procedure to remove waste from the body when the kidneys are unable to). During a review of Resident 100's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/19/2024, the document indicated Resident 100 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 100 needed set-up or clean-up assistance (helper sets up or cleans up and resident completes the activity) with eating. b. During a review of Resident 167's admission Record, the document indicated the facility admitted the resident on 7/25/2024 with diagnoses that included anemia (a condition that occurs when the body doesn't produce enough healthy red blood cells to carry oxygen to the body's tissues). During a review of Resident 167's MDS, dated [DATE], the document indicated Resident 167 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 167 needed set-up or clean-up assistance with eating. c. During a review of Resident 168's admission Record, the document indicated the facility admitted the resident on 6/30/2024 and re-admitted the resident on 7/15/2024 with diagnoses that included anemia. During a review of Resident 168's MDS, dated [DATE], the document indicated Resident 168 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 168 needed set-up or clean-up assistance with eating. d. During a review of Resident 363's admission Record, the document indicated the facility admitted the resident on 8/7/2024 with diagnoses that included urinary tract infection (an infection in the urinary system). A review of Resident 363's MDS, dated [DATE], indicated Resident 363 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 363 needed set-up or clean-up assistance with eating. During a concurrent observation and interview on 8/21/2024 at 5:10 p.m., with the Maintenance Supervisor (MS), the MS took the temperature of Room A with an infrared thermometer (or known as a temperature gun, a device that measures an object's temperature from a distance by detecting infrared radiation [a type of energy that is invisible to the human eye but is felt as heat] emitted by the object) which had four residents residing there, Resident 100, Resident 167, Resident 168, and Resident 363. The temperature was taken in four different places inside the room. The temperatures from the window back towards the door were: 87.1 F, 84.9 F, 83.3 F, and 82.7 F. Resident 100, Resident 167, Resident 168, and Resident 363 all complained of the room being warm. The MS stated the normal range of residents' room temperatures was between 71 F and 81 F. During a concurrent observation and interview on 8/21/2024 at 6:10 p.m., with the MS, the MS took the temperature of Room A with an infrared thermometer. The temperatures were: 81.3 F, 79.3 F, and 84.1 F. During an interview on 8/22/2024 at 2:14 p.m., with the Director of Nursing (DON), the DON stated residents' rooms have to be between 71 F and 81 F. The DON stated this was important to keep the rooms within this range so that resident's will not be sweaty and hot. The DON stated keeping residents' rooms within the normal range was important to prevent a resident from suffering from dehydration. During a review of the facility's policy and procedure titled, Homelike Environment (Temperature Log), last reviewed 5/22/2024, the document indicated residents are provided with a safe, clean, comfortable, and homelike environment - specifically to have comfortable temperatures. The policy and procedure indicated staff and management shall take the temperature once a day in five to ten rooms to ensure comfortable temperatures to the extent possible (71 F - 81 F).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by one of three sampled residents (Resident 364). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: During a review of Resident 364's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) and respiratory failure (when not enough oxygen passes from the lungs to the blood) with hypoxia (low levels of oxygen in the body's tissues). During a review of Resident 364's History and Physical (H&P), dated 8/5/2024, the H&P indicated Resident 364 had the capacity to understand and make decisions. During a review of Resident 364's Grievance Report, dated 8/14/2024, the Grievance Report indicated Resident 364 called Family Member 1 (FM 1) and stated that on 8/13/2024 at around 8:00 p.m., Certified Nursing Assistant 4 (CNA ) was rough when assisting Resident 364 to the wheelchair. The Grievance Report dated 8/14/24 indicated that Resident 364 sustained bruises (an injury or mark where the skin has not been broken but is darker in color) on the arm and that CNA 4 threw Resident 364's teddy bear at Resident 364. During an interview on 8/24/2024 at 2:34 p.m. the Administrator (ADM), the ADM stated that Resident 364 informed ADM on 8/14/2024 that CNA 4 was rough when providing care to Resident 364. The ADM stated that being handled rough while providing care should be considered an allegation of abuse. The ADM stated that Resident 364's allegation of being rough handled by CNA 4 was not reported to the SSA. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention Program, reviewed 5/22/2024, the P&P indicated the facility shall report all allegations of abuse to the SSA .

Based on interview and record review, the facility failed to ensure a water pitcher was not left at bedside for one of one sampled resident (Resident 317) who was on strict fluid restrictions. This failure placed Resident 317 at an increased risk for injury and or hospitalization related to hypo-osmolality (a condition where the levels of electrolytes [substances that have a natural positive or negative electrical charge when dissolved in water], proteins, and nutrients in the blood are lower than normal) and hyponatremia (a condition where the level of sodium in your blood is lower than normal). Findings: During a review of Resident 317's admission Record, the document indicated the facility admitted the resident on 7/3/2024 with diagnoses that included hypo-osmolality and hyponatremia, hypokalemia (a condition where the level of potassium [a type of electrolyte] in your blood is lower than normal), kidney failure (when the kidneys [organ that filters waste and extra water from the blood and turns it into urine] are not able to filter any more), and muscle weakness. During a review of Resident 317's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 8/6/2024, the document indicated the resident had the capacity to understand and make decisions. During a review of Resident 317's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/9/2024, the document indicated the resident was able to understand and makes decisions and needed minimal to no assistance from staff on eating, hygiene, toileting, and dressing. The MDS further indicated the resident is completely independent on mobility. During a review of Resident 317's Order Summary Report, the document indicated a physician order for fluid restriction of 1200 milliliters (ml - a measurement of volume) per day on 8/5/2024 and ordered to monitor intake and output (I&O - amount consumed/drank and the amount removed/urinated) every shift on 8/5/2024. During a review of Resident 317's Care Plan (a written document that summarizes a resident's needs, goals, and care/treatment) titled, Potential for Fluid and Electrolyte Imbalance, indicated fluid restriction as ordered, I&O every shift, and no water pitcher at bedside. During an observation on 8/19/2024 at 9:47 a.m., in Resident 317's room, Resident 317 was asleep in bed with a pitcher of water, an empty cup, and large red insulated cup with a lid on Resident 317's bedside table. Observed above Resident 317's bed was a sign that read not to leave water pitchers at bedside. During a concurrent observation and interview on 8/19/2024 at 9:55 a.m., with the Director of Staff Development (DSD), in Resident 317's room, observed the extra cups and water pitcher at Resident 317's bedside. The DSD stated the water pitcher cannot be there because Resident 317 is on water restriction. The DSD further stated the resident could be at risk for fluid overload (too much fluid in the blood/body). During an interview on 8/22/2024 at 1:05 p.m., with the Director of Nursing (DON), the DON stated Resident 317 is on strict fluid restrictions and I&O monitoring. The DON also stated it is important to follow the physician's orders to prevent an imbalance in the electrolytes and hospitalization. During a review of the facility's policy and procedure titled, Fluid Restriction Guidelines, reviewed on 5/22/2024, the policy indicated nursing shall notify dietary once the physician prescribes the order for the resident. Dietary shall request a specific amount of fluid with the remaining volume set aside to the nursing department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was provided a scheduled toileting plan (or bladder [a sac-shaped muscular organ that stores the urine secreted by the kidneys] training, which can involve assisting a resident to the restroom at specific timed intervals) for one of two residents (Resident 4). This deficient practice has the potential for Resident 4 to not to achieve or restore normal bowel (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder function. Findings: During a review of Resident 4's Face Sheet (admission record), the face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a general decline in health in older adults) and extrarenal uremia (increased waste products in the blood that is normally removed by the kidney but caused by conditions outside of the kidneys). During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/14/2024, the MDS indicated that Resident 4 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 4 needed substantial/maximal assistance (helper does more than half the effort) with walking ten feet. The MDS indicated that Resident 4 is continent of bladder and incontinent of bowel. During a review of Resident 4's Care Plan for Bowel and Bladder, the Care Plan initiated 7/17/2024 indicated an intervention to offer Resident 4 a bedpan and/or urinal at regular intervals . and assist to the bathroom at intervals. During a concurrent record review and interview on 8/21/2024 at 10 a.m. with Minimum Data Set Nurse 2 (MDS 2), MDS 2 reviewed Resident 4`s MDS dated [DATE] which indicated that Resident 4 is continent (able to control) of bladder and incontinent (inability to control) of bowel. During a concurrent record review and interview on 8/21/2024 at 10 a.m. with MDS 2, MDS 2 reviewed the facility's policy and procedure titled Bowel and Bladder Pathway last reviewed on 5/22/2024 which indicated the following: 1. When a resident is determined to be incontinent of bowel and/or bladder, the licensed nurse will initiate an elimination (following a set schedule to go to the bathroom for material elimination or voiding[urinating]). 2. Schedule/voiding (urinating) diary of every two hours and as needed on even hours for three days. 3. The certified nursing assistants (CNAs) will document the result of each of their visits with the resident. 4. The elimination/voiding diary will be communicated to all nursing staff and medical records. 5. Medical records staff will start to check the completion of the voiding diary by the CNAs every shift. When MDS 2 was asked regarding the CNA documentation of Resident 4's scheduled bowel elimination as per facility policy, MDS 2 was unable to locate that any scheduled bowel elimination was conducted for Resident 4. During an interview with the Director of Nurses (DON) on 8/21/2024 at 10:28 a.m., the DON stated that licensed nurse should have conducted scheduled bowel elimination after Resident 4 was accessed as being incontinent of bowel. The DON stated it is important to try to maintain a resident's continence or if incontinent to find out the reason and possibly be placed on a bowel training program. During a review of the facility policy and procedure titled Bowel and Bladder Pathway last reviewed on 5/22/2024 which indicated the following: 1. When a resident is determined to be incontinent of bowel and/or bladder, the licensed nurse will initiate an elimination (following a set schedule to go to the bathroom for material elimination or voiding[urinating]). 2. Schedule/voiding (urinating) diary of every two hours and as needed on even hours for three days. 3. The certified nursing assistants (CNAs) will document the result of each of their visits with the resident. 4. The elimination/voiding diary will be communicated to all nursing staff and medical records. 5. Medical records staff will start to check the completion of the voiding diary by the CNAs every shift.

Based on interview and record review, the facility failed to complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 102). This deficient practice placed Resident 102 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions). Findings: During a review of Resident 102's admission Record, the document indicated the facility admitted the resident on 6/23/2024 with diagnoses including end stage renal disease (ESRD - a condition when the kidneys cannot filter blood anymore), dependence on renal dialysis, and muscle weakness. During a review of Resident 102's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 6/24/2024, the document indicated the resident had the capacity to understand and make decisions. During a review of Resident 102's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/29/2024, the document indicated the resident had mildly impaired cognition (mental action or process of acquiring knowledge and understanding), required set up/clean up assistance with eating, substantial assistance with all other activities of daily living (ADLs - activities related to personal care). The MDS indicated Resident 102 was on dialysis. During a review of Resident 102's Care Plan (a written document that summarizes a resident's needs, goals, and care/treatment) titled, ERSD with Dialysis, dated 6/23/2024, the care plan indicated to assess the dialysis access site for bruit (rumbling sound) and thrill (vibration) and for complications such as bleeding. During a review of Resident 102's Dialysis Assessment Form dated 8/20/2024, the document indicated the post dialysis assessment section was not filled out with information including, vital signs (clinical measurements that indicate the state of a patient's essential body functions) and access site description including bruit and thrill. During a review of Resident 102's Electronic Chart, it did not indicate an assessment, notes, or vital signs were completed after Resident 102 returned to the facility from dialysis. During a concurrent interview and record review on 8/21/2024 at 3:40 p.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Resident 162's Dialysis Assessment form dated 8/20/2024. LVN 3 verified by stating the post dialysis assessment section of the form was not completed on 8/20/2024. LVN 3 stated he did not remember to fill out the form after the resident returned from dialysis on 8/20/2024 or write an assessment note in the resident's electronic record. LVN 3 further stated an assessment is important after dialysis to ensure there are not any complications. During an interview on 8/21/2024 at 3:55 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses are responsible to complete the post dialysis assessment upon the resident's return to the facility from dialysis and should include the vital signs and signs or symptoms of bleeding to ensure that the resident is stable and there are no signs of complications. During a review of the facility's policy and procedure titled, End Stage Renal Disease, Care of Resident with, last reviewed 5/22/2024, indicated the licensed nurses look for signs and symptoms of an infection, complications, and training in the care of residents receiving dialysis from an outside facility.

Based on interview and record review, the facility failed to meet professional standards of quality of care by failing to ensure a lidocaine patch (eases pain by numbing the nerves and making them less sensitive to pain) was removed after 12 hours from application as per physician's order for one of five sampled residents (Resident 413). This deficient practice had the potential in excessive dosing and a potential to cause adverse reaction (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 413's admission Record, the document indicated the facility admitted the resident on 8/8/2024 with diagnoses including muscle weakness, history of falling, and chronic kidney disease (your kidneys are damaged and can't filter blood the way they should). During a review of Resident 413's History and Physical (a formal assessment that a physician performs on a resident, which includes a medical history, physical exam, and documentation of findings) dated 8/9/2024, indicated that the resident had the capacity to understand and make decisions. A review of Resident 413's physician orders dated 8/9/2024, indicated an order for lidocaine externa patch 5%, apply to both knees topically one time a day for pain management, one patch 12 hours on, 12 hours off and remove per schedule. During a concurrent medication administration observation and interview on 8/20/2024 at 8:49 a.m., with Registered Nurse 1 (RN 1), observed RN 1 remove two lidocaine patches to administer to Resident 413. RN 1 removed the lidocaine patch from both knees and then applied the new ones to both knees. After the medication administration, RN 1 verified by stating that the patches prior to the one that she just applied should have been removed yesterday for 12 hours per the physician's order. During a review of Resident 413's Medication Administration Record (MAR- used to document medications taken by each resident) dated 8/2024, the MAR indicated that lidocaine patch was applied on 8/19/2024 at 9:00 a.m., which was not removed after 12 hours as evidenced by the lidocaine patch still attached to Resident 413's knees during the medication administration observation on 8/20/2024 at 8:49 a.m. During a concurrent interview and record review on 8/21/2024 at 3:31 p.m., with the Director of Nursing (DON), reviewed the lidocaine patch package insert. The medication insert indicated that excessive dosing by applying longer than the recommended time could result in increased absorption of lidocaine and high blood concentration leading to serious adverse effects. The DON stated that the lidocaine patch should have been removed after 12 hours based on Resident 413's physician's orders. The DON stated that not removing the lidocaine patch could result in the resident receiving excessive dose and it's also uncomfortable to have the lidocaine patch longer than it should be. The DON agreed with the manufacturer's package insert by stating that adverse side effects could potentially result if the patch is nor removed after 12 hours.

b. During a review of Resident 364's admission Record, the record indicated the facility admitted the resident on 8/4/2024 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), respiratory failure (when not enough oxygen passes from the lungs to the blood) with hypoxia (low levels of oxygen in the body's tissues), and generalized muscle weakness. During a review of Resident 364's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 8/5/2024, the H&P indicated Resident 364 had the capacity to understand and make decisions. During a review of Resident 364's care plan titled, Risk for bleeding and easy bruising related to: Anticoagulant therapy heparin (anticoagulant), dated 8/4/2024, the care plan indicated to monitor for bleeding, bruising, blood in the urine, and blood in the stool. During a concurrent interview and record review on 8/21/2024 at 3:36 p.m., with Licensed Vocational Nurse (LVN) 3, reviewed Resident 364's Order Summary Report. The Order Summary Report indicated an order for one (1) milliliter (ml, a unit of measurement) of heparin sodium 5000 units/ml solution to be injected subcutaneously (into the fatty tissue just under the skin) every eight hours for DVT prophylaxis. LVN 3 stated Resident 364 should be monitored for the side effects of heparin such as bleeding and bruising. LVN 3 stated they usually document the side effects of anticoagulants on the Medication Administration Record (MAR, a report detailing the drugs administered to a resident), but this was not done for Resident 364. LVN 3 stated there is no other area of Resident 364's medical record where monitoring for the side effects of heparin is documented. During an interview on 8/22/2024 at 2:06 p.m., with the DON, the DON stated Resident 364 should be monitored for the side effects of heparin as the resident is at increased risk of bleeding, skin impairment, and having blood in the stool. During a review of the facility's policy and procedures titled, Anticoagulation - Clinical Protocol, last reviewed on 5/22/2024, the policy indicated that the staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. Based on interview and record review, the facility failed to ensure licensed nurses monitored for side effects while a resident received an anticoagulant medication (medications that prevent and treat blood clots in the heart and blood vessels) for two of 27 sampled residents (Resident 73 and Resident 364). This deficient practice had the potential to result in the residents experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the anticoagulant. Findings: a. During a review of Resident 73's admission Record, the record indicated the facility originally admitted the resident on 8/17/2021 and readmitted the resident on 3/12/2024 with diagnoses including atherosclerotic heart disease (a vascular disease that occurs when arteries thicken and stiffen, restricting blood flow to the heart and other organs). During a review of Resident 73's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/2/2024, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities related to personal care). During a review of Resident 73's care plan (a document that summarizes a resident's health conditions, treatments, and care needs) for risk for bleeding and easy bruising related to anticoagulant therapy due to the resident being on apixaban (anticoagulant), initiated on 8/20/2024, the care plan indicated to monitor for bleeding or bruising. During a concurrent interview and record review on 8/21/2024 at 3:41 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 73's physician's orders. RN 4 stated Resident 73 had an order for apixaban 2.5 milligrams (mg, a unit of measurement) by mouth twice a day for deep vein thrombosis (DVT - a blood clot that forms in a deep vein in the body, usually in the leg but can also occur in the arms, pelvis, and other areas) prophylaxis (measures designed to preserve health and prevent the spread of disease). RN 4 stated he could not find any documentation indicating that nurses were monitoring for side effects of apixaban. During an interview on 8/22/2024 at 11:10 a.m., with the Director of Nursing (DON), the DON stated nurses should be monitoring for bruising or bleeding when a resident is on an anticoagulant. The DON stated it was important to monitor the side effects of anticoagulants because it increased the resident's risk for bleeding. During a review of the facility's policy and procedures titled, Anticoagulation - Clinical Protocol, last reviewed on 5/22/2024, the policy indicated that the staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems.

Based on observation, interview and record review, the facility failed to ensure a vial of insulin (hormone that lowers the level of glucose [sugar] in the blood) that was past the discard date, was not stored in one of three medication carts (Medication Cart A) for one of one sampled resident (Resident 85). This deficient practice had the potential for an expired insulin to be administered to Resident 85 which could result in uncontrolled blood glucose (the primary sugar in the blood and the body's main source of energy). Findings: During a review of Resident 85's admission Record, the document indicated the facility admitted the resident on 7/19/20204, with diagnosis of diabetes mellitus (DM - a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 85's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/26/2024, the document indicated the resident had the ability to sometimes understand others and the ability to sometimes make self-understood. The MDS indicate that Resident 85 required assistance for self-care. A review of Resident 85's Order Summary Report indicated a physician's order dated 1/31/2022 to administer insulin lispro injection solution (Humalog- a fast-acting insulin) 100 unit per milliliters (U/ml, a unit of measurement) per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges) subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) before meals and at bedtime for DM. During a concurrent medication cart inspection and interview on 8/20/2024 at 9:49 a.m., with Licensed Vocational Nurse 2 (LVN 2), inspected Medication Cart A. Observed a vial of insulin lispro belonging to Resident 85 with an open date of 7/20/2024. LVN 2 stated that the insulin vial should have been discarded after 28 days from opening. LVN 2 stated that insulin that is past 28 days will loss it's efficacy. LVN 2 stated that if the insulin is used, it will not be effective and the resident can experience hyperglycemia (high blood sugar) which could lead to the resident being confused and may fall and sustain an injury. A review of the Solostar insulin manufacturer's literature (provided by the facility), undated, indicated that when stored at room temperature, Humalog U-100 (brand of insulin lispro) can only be used for a total of 28 days, including both not in-use (unopened) and in-use (opened) storage time. Food and Drug Administration guidelines for storing Humalog (insulin lispro) are as follows: Unopened vials- Store in the refrigerator at 36 Fahrenheit (°F, unit of temperature) -46°F (2 Celsius [°C, unit of temperature] -8°C) and keep away from heat and direct light. You can use them until the expiration date on the label, but you should throw them away after 28 days if you store them at room temperature. Do not freeze Humalog, and do not use it if it has been frozen. Opened vials- Store in the refrigerator or at room temperature up to 86°F (30°C) for up to 28 days. Keep them away from heat and direct light, and throw them away after 28 days, even if they still contain insulin.

Based on observation, interview, and record review, the facility staff (Cook 1) failed to check the temperature of all of the food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) during mealtime service on 8/21/2024 at 1:25 p.m. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 110 of 114 medically compromised residents who received food from the kitchen. Findings: During a kitchen tray line observation on 8/21/2024 at approximately 12 p.m., observed [NAME] 1 check the temperatures of the food on the tray line. Observed [NAME] 1 fail to check the temperature of the following food trays : 1. Puree (a very smooth, crushed, or blended food) potato 2. Chopped Turkey 3. Chicken During an interview with [NAME] 1 on 8/21/2024 at 1:25 p.m., [NAME] 1 stated that the temperature of all foods that are to be served during mealtime to residents are to be checked. [NAME] 1 stated that she (Cook 1) missed checking the temperature for the pureed potatoes, chopped turkey, and chicken during the tray line on 8/21/2024 at 12:00 p.m. [NAME] 1 stated that it was important to check the temperature of all the cooked foods served to resident's in order to prevent bacterial contamination (occurs when bacteria multiply on food and cause it to spoil). During a review of the facility's policy and procedure titled, Meal Service, last reviewed 5/22/2024, the policy and procedure indicated the food and nutrition services staff member will take the food temperatures prior to service of the meal with a thermometer .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 29's admission Record, the record indicated the facility originally admitted the resident on 2/6/2017 and readmitted the resident on 5/7/2024 with diagnoses including fracture of the base of neck of the right femur (broken hip), muscle weakness, and vascular dementia (problems with judgment, memory, and other thought processes caused by brain damage from impaired blood flow). During a review of Resident 29's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 5/8/2024, the H&P indicated the resident had history of dementia with behavioral disturbances (common behavioral disturbances are agitation, restlessness, and aggression) and is confused and forgetful. The H&P further indicated Resident 29 is at high risk for falls and should be on fall precautions (steps taken to prevent falls, such as managing risk factors and making changes to the environment). During a review of Resident 29's MDS, dated [DATE], the MDS indicated the resident had severe cognitive impairment. The MDS further indicated the resident was dependent on staff for eating, dressing, and toileting and has had one fall since admission. During a review of Resident 29's Morse Fall Risk Screen (tool used to assess a resident's risk of falling), dated 8/20/2024, the Morse Fall Risk Screen indicated Resident 29 is at high risk for falls. During a review of Resident 29's care plan (a document that summarizes a resident's health conditions, treatments, and care needs) titled, High risk for further falls and injury related to poor safety awareness ., last updated on 8/19/2024, the care plan indicated Resident 29 is to have bilateral floor mats for fall management and to reduce or prevent injury. During a concurrent observation and interview on 8/21/2024 at 2:32 p.m., with Registered Nurse (RN) 4, observed no floor mats placed on the sides of Resident 29's bed. RN 4 stated Resident 29 should have floor mats to the sides of her bed for injury prevention as she is a high fall risk. During an interview with the DON on 8/22/2024 at 11:32 a.m., the DON stated Resident 29 should have floor mats next to her bed because she has fallen before and is at risk for injury. The DON further stated Resident 29 has tried to get out of bed unassisted in the past which put her at risk for falling. During a review of the facility's policy and procedure (P&P) titled, Fall - Prevention, reviewed 5/22/2024, the P&P indicated if a resident is assessed to be a high fall risk, a care plan will be initiated and appropriate measures such as regular assessment and the use of assistive devices will be implemented. Based on observation, interview, and record review, the facility failed to ensure residents were kept safe from injury and accident hazards for three of six sampled residents (Resident 163, Resident 164, and Resident 29) by failing to: 1. Ensure residents' medications, who had no self-administration assessment, were not left unattended at the bedside for Resident 163 and Resident 164. This deficient practice had the potential for other residents to enter the room and take another resident's medication and could experience adverse side effects (undesired harmful effect resulting from a medication or other intervention). 2. Ensure Resident 29 had bedside floor mats (cushioned foam mats which reduce the risk of injury from a fall) placed next to the resident's bed as indicated in the care plan. This deficient practice placed Resident 29 at an increased risk of sustaining an injury from a fall. Findings: 1.a. During a review of Resident 164's admission Record, the document indicated the facility admitted the resident on 8/14/2024 with diagnoses that included left femur (thigh) fracture. During a review of Resident 164's Nurses Weekly Progress Notes, dated 8/19/2024, the document indicated Resident 164 was alert and oriented and was able to make needs known. During a review of Resident 164's physician's orders, the document indicated an order for acetaminophen (medication that reduces pain and fever) 325 milligrams (mg, a unit of measurement), give two tablets by mouth every six hours as needed for pain mild 1-3 out of 10 pain scale (with zero being no pain and ten being the most excruciating pain), dated 8/15/2024. During a review of Resident 164's Self Administration of Medication Assessment, dated 8/21/2024, the document indicated Resident 164 is alert and oriented (a person's level of awareness of their surroundings, including their person, place, time, and situation) and with no cognitive impairment and able to follow direction consistently. The document indicated it is safe for Resident 164 to self-administer medications. During a review of Resident 164's Care Plan (a written document that summarizes a resident's needs, goals, and care/treatment) for Self-Administer Medications, initiated 8/21/2024, the document indicated the resident wishes to self-administer medications. The care plan indicated a goal that Resident 164 will be able to safely administer medications without complication through the next review date. The care plan indicated an intervention to assess Resident 164 for the ability to self-administer his medications. During a concurrent observation and interview on 8/19/2024 at 9:28 a.m., with Resident 164, observed a plastic cup containing one pill on Resident 164's bedside table. Resident 164 stated he takes Tylenol for pain. Resident 164 stated a nurse left it there that morning. Resident 164 stated he took one Tylenol tablet already and will take the other one. During a concurrent observation and interview on 8/19/2024 at 9:50 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed one pill in the medication cup at Resident 164's bedside. LVN 1 stated she gave Resident 164 two Tylenol tablets 325 mg each. LVN 1 stated she thought Resident 164 took the Tylenol. During a concurrent interview and record review on 8/21/2024 at 9:49 a.m., with the Director of Nursing (DON), reviewed Resident 164's medical record. The DON confirmed by stating that a self-administration assessment was not conducted for Resident 164 before leaving the medication at the bedside. The DON stated it is important for a resident to have a self-administration assessment to make sure it is safe for the resident and to make sure the resident has the cognitive ability to understand they have to take their medications. 1.b. During a review of Resident 163's admission Record, the document indicated the facility admitted the resident on 8/5/2024 with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system). During a review of Resident 163's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/9/2024, the document indicated Resident 163 was severely impaired in cognition (thought processes) with skills required for daily decision making. The MDS indicated Resident 163 needed setup or clean-up assistance (helper sets up or cleans up with resident completing the activity) with eating, upper body dressing, and lower body dressing. During a review of Resident 163's physician's orders, indicated the following orders: - Vitamin C (used for the growth and repair of tissues in all parts of the body) tablet 500 mg, give one tablet by mouth one time a day for supplement, dated 8/6/2024. - Cranberry capsule (a medication given as a preventative for a UTI) 450 mg give one tablet by mouth one time a day for supplement, related to UTI, dated 8/6/2024. - Multiple Vitamins- Mineral tablet, give one tablet one time a day for supplement, dated 8/6/2024. - May self-administer medication; licensed nurse to prepare medications for resident and may leave medication at bedside for resident to take, dated 8/19/2024 at 11:32 a.m. During a review of Resident 163's Self Administration of Medication Assessment, dated 8/19/2024 at 11:31 a.m., indicated Resident 163 is alert and oriented and with no cognitive impairment and able to follow direction consistently. The document indicated Resident 163 is safe to self-administer medications. During a review of Resident 163's Nursing Progress Notes, dated 8/19/2024 at 11:32 a.m., the document indicated Resident 163 prefers licensed nurse to prepare Resident 163's medication, and Resident 163 will take it on her own, despite risks and benefits explained. The document indicated Resident 163's physician was notified with order noted for self-administration of medication. During a review of Resident 163's Care Plan for Self-Administration Medication, initiated 8/19/2024, the care plan indicated Resident 163 prefers to self-administer prescribed medications in the absence of a licensed nurse. The care plan indicated an intervention that the licensed nurse prepares medications and resident will take it on her own despite risks and benefits explained. During an observation on 8/19/2024 at 9:45 a.m., observed a plastic cup with three pills on Resident 163's bedside table. During a concurrent observation and interview on 8/19/2024 at 9:50 a.m., with LVN 1, observed the plastic cup with three pills at Resident 163's bedside. LVN 1 stated the pills were: Vitamin C tablet, cranberry capsule, and multi-vitamin tablet. LVN 1 stated Resident 163 was going to take the medication soon, so she left them, and did not come back. LVN 1 stated it was not the usual practice to leave medications at a resident's bedside but was called to another resident's room to give them pain medication. During an interview on 8/21/2024 at 8:04 a.m., with MDS Registered Nurse 2 (MDS 2), MDS 2 stated licensed nurses educate a resident to keep the medications within reach and to take them right away if able to. MDS 2 stated the licensed nurse will check frequently to see if a resident has taken their medications but could not state a time frame for what was meant by frequently. MDS 2 stated when a resident says they want to self-administer their medications, the licensed nurses conduct an assessment to ensure it is safe for a resident to take the medications themselves. During a concurrent interview and record review on 8/21/2024 at 9:49 a.m., with the DON, reviewed Resident 163's Self-Administration Assessment, dated 8/19/24 at 11:31. The DON stated with Resident 163 the process was not followed because the self-administration physician's order and self-administration resident assessment was not done before leaving the medications at Resident 163's bedside. The DON confirmed by stating that Resident 163 did not have a physician's order to self-administer medications prior to the medications left at bedside. The DON stated it is important for a resident to have a self-administration assessment to make sure it is safe for the resident and to make sure the resident has the cognitive ability to understand they have to take their medications. During a review of the facility's policy and procedure titled, Self-Administration of Medications, last reviewed 5/22/2024, the document indicated residents who express a desire to self-administer medications, as part of the evaluation, the staff and practitioner will access each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. The policy and procedure indicated the staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. The policy and procedure indicated self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. During a review of the facility's policy and procedure titled, Accidents, Incidents & Safety - Investigating and Reporting, last reviewed 5/22/2024, indicated the type and frequency of resident supervision is determine on individual resident assessed needs and identified hazards in the environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (PRN) opioid medication (powerful pain-reducing medications) on multiple days for two of 27 sampled residents (Residents 11 and 83). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from opioid pain medication. Findings: a. During a review of Resident 11's admission Record, the record indicated the facility admitted the resident on 4/27/2024 with diagnoses including encephalopathy (a general term for a group of conditions that affect the brain's function or structure, such as diseases, disorders, or damage), migraine headache (a type of headache that cause moderate to severe, throbbing pain on one side of the head or behind the eye), and osteoarthritis (a chronic disease that causes the breakdown of joint tissues, most often in the hands, knees, hips, and back). During a review of Resident 11's History and Physical (a formal assessment of a resident by a healthcare provider that includes a medical history and a physical exam), dated 4/29/2024, the record indicated the resident could make needs known but could not make medical decisions. During a review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/3/2024, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily decision making and was dependent on staff for most activities of daily living (ADLs - activities related to personal care). During a review of Resident 11's care plan (a document that summarizes a resident's health conditions, treatments, and care needs) for risk for pain related to migraine headaches and osteoarthritis, initiated on 5/15/2024, the care plan indicated the following nursing interventions: Assure/Assist to maintain proper body alignment for comfort and positioning; divert attention from pain by conversing with resident during short frequent visit; and provide difference pain relieving method, i.e. positioning for comfort, progressive relaxation, bathing, soft music of choice to divert attention from pain. During a concurrent interview and record review on 8/21/2024 at 4:13 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 11's physician's orders and Medication Administration Record (MAR - a report detailing the drugs administered to a resident by a healthcare professional) dated 6/2024 and 8/2024. RN 4 stated Resident 11 received hydrocodone-acetaminophen (used to relieve moderate to severe pain) 10-325 milligrams (mg - unit of measurement) half tablet by mouth every eight (8) hours as needed for severe pain 7-10/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered on 4/27/2024. RN 4 stated Resident 11 received hydrocodone-acetaminophen 10-325 mg on 6/26/2024, but he could not find any documented evidence that the licensed nurse attempted non-pharmacological interventions prior to administering the medication. RN 4 stated Resident 11 received hydrocodone-acetaminophen 10-325 mg on 8/8/2024 and 8/14/2024, but he could not find any documented evidence that the licensed nurses had attempted non-pharmacological interventions prior to administering the medication. During an interview on 8/22/2024 at 10:12 a.m., with the Director of Nursing (DON), the DON stated that licensed nurses should initially attempt non-pharmacological interventions prior to administering as needed pain medication. The DON stated that non-pharmacological interventions were important because it was possible that the resident may not even need pain medication. The DON stated it was possible the resident just needed to be calmed down or redirected. The DON stated some possible side effects that residents could experience from receiving too much opioid pain medication included nausea, dizziness, and an increased risk for falls. During a review of the facility's policy and procedure titled, Pain Management, last reviewed on 5/22/2024, the policy indicated it is the policy of the facility to follow the plan of care for the management of pain as written in the resident's plan of care. b. During a review of Resident 83's admission Record, the document indicated the facility originally admitted the resident on 10/14/2022 and readmitted the resident on 9/22/2023 with diagnoses including cellulitis (a bacterial infection that affects the deeper layers of the skin and the tissue underneath) of both lower extremities. During a review of Resident 83's History and Physical dated 9/25/2023, the document indicated the resident had the capacity to understand and make decisions. During a review of Resident 83's MDS, dated [DATE], the document indicated the resident had intact cognition and required maximal assistance from staff for most ADLs. During a review of Resident 83's physician's orders, an order dated 9/22/2023 indicated to give hydrocodone-acetaminophen 5-325 mg one tablet by mouth every six (6) hours as needed for moderate to severe pain 4-10/10. During a review of Resident 83's care plan for alteration in comfort due to pain, initiated on 10/30/2022, the care plan indicated to provide non-pharmacological interventions as ordered. During a concurrent interview and record review on 8/21/2024 at 4:27 p.m., with RN 4, reviewed Resident 83's MAR dated 6/2024, 7/2024, and 8/2024. RN 4 stated Resident 83 received hydrocodone-acetaminophen 5-325 mg on 6/2/2024. RN 4 stated he could not find any documented evidence that the nurse attempted non-pharmacological interventions prior to administering the as needed opioid pain medication. RN 4 stated Resident 83 received hydrocodone-acetaminophen 5-325 mg on 7/2/2024. RN 4 stated he could not find any documented evidence that the nurse attempted non-pharmacological interventions prior to administering the as needed opioid pain medication. RN 4 stated Resident 83 received hydrocodone-acetaminophen 5-325 mg on 8/13/2024. RN 4 stated he could not find any documented evidence that the nurse attempted non-pharmacological interventions prior to administering the as needed opioid pain medication. During an interview on 8/22/2024 at 10:12 a.m., with the DON, the DON stated that licensed nurses should initially attempt non-pharmacological interventions prior to administering as needed pain medication. The DON stated that non-pharmacological interventions were important because it was possible that the resident may not even need pain medication. The DON stated it was possible the resident just needed to be calmed down or redirected. The DON stated some possible side effects that residents could experience from receiving too much opioid pain medication included nausea, dizziness, and an increased risk for falls. During a review of the facility's policy and procedure titled, Pain Management, last reviewed on 5/22/2024, the policy indicated it is the policy of the facility to follow the plan of care for the management of pain as written in the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to: 1. Ensure two visitors were for two of four days screened for signs and symptoms of Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection). This deficient practice had the potential to spread COVID-19 to residents in the facility. 2. Ensure Dietary Aide 1 (DA 1) washed their hands after touching a trash can lid. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 110 of 114 residents who received food from the kitchen. 3. Ensure a resident's oxygen nasal cannula tubing (a device that gives additional oxygen through the nose) was labeled for one of one sampled resident (Resident 85). This deficient practice had the potential for contamination of the oxygen tubing, placing the resident at risk for acquiring an infection leading up to respiratory distress (trouble breathing). 4. Ensure a resident's urinal (container used to collect urine) was labeled with a resident identifier for one of 27 sampled residents (Resident 214). This deficient practice had the potential to increase the residents' risk of developing an infection. 5. Ensure a resident's oxygen tubing (medical device that connects an oxygen source to a nasal mask or cannula to deliver oxygen during oxygen therapy) was not touching the floor for one (Resident 56) out of 27 sampled residents. This deficient practice had the potential to increase the residents' risk of developing an infection. Findings: 1. During a concurrent interview and record review on 8/22/2024 at 11:51 a.m., with the Director of Nursing (DON), reviewed the Visitor Screening Tool logs from 8/13/2024 to 8/16/2024. The Visitor Screening Tool logs indicated two visitors were not screened for signs and symptoms of COVID-19 or having close contact with someone with COVID-19 on 8/13/2024 and 8/14/2024. The DON stated they should have been screened as they need to know if a visitor has an illness to protect the residents. During a review of the facility's policy and procedure (P&P) titled, COVID-19: Testing Policy, dated 6/20/2024, the P&P indicated passive visitor screening for COVID-19 will be conducted. The P&P further indicated if a visitor has symptoms consistent with COVID-19 or had close contact with a confirmed positive case, they should reschedule their visit. 3. During a review of Resident 85's admission Record, the document indicated the facility admitted the resident on 7/19/2024, with diagnoses including respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), acute pulmonary edema (a medical emergency that occurs when fluid builds up in the lungs and makes it difficult to breathe), and muscle weakness. During a review of Resident 85's Physician's Progress Note dated 7/30/2024, the document indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/9/2024, the document indicated the resident had severe cognitive (thought processes) impairment and is dependent on facility staff for all activities of daily living (ADLs - activities related to personal care). During a review of Resident 85's Order Summary Report, the document indicated a physician order for oxygen (O2) three (3) liters (L, a metric unit of volume) via nasal cannula continuously, ordered on 7/19/2024. During a concurrent observation and interview on 5/15/2024 at 3:55 p.m., with Registered Nurse 1 (RN 1), inside Resident 46's room, observed Resident 46's nasal cannula not labeled with the date it was last changed. RN 1 stated they place a sticker label with the name, date, room number, and time the tubing was changed for the staff to know when to replace the tubing again. RN 1 stated they change the nasal cannula tubing every week to prevent growth of bacteria in the tubing that can cause respiratory infections. During a review of the facility's policy and procedure titled, Policies and Practices- Infection Control, last reviewed on 1/18/2024, the policy indicated this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. 4. During a review of Resident 214's admission Record, the record indicated the facility admitted the resident on 8/18/2024 with diagnoses including difficulty in walking. During an observation on 8/19/2024 at 9:36 a.m., observed Resident 214 awake in bed. Observed an unlabeled urinal hanging from Resident 214's side rail (a metal or plastic bar that attaches to the side of a bed to help residents stay safe and independent). During a concurrent observation and interview on 8/19/2024 at 9:38 a.m., with the Director of Staff Development (DSD), the DSD verified the observation by stating that Resident 214's urinal was not labeled and stated it should have been labeled with a resident identifier. During an interview on 8/22/2024 at 10:15 a.m., with the DON, the DON stated it was the facility's practice to label urinals with the resident's name for infection control purposes. The DON stated it was important to prevent cross contamination with other residents. During a review of the facility's policy and procedure titled, Urinal Use, last reviewed on 5/22/2024, the policy indicated that urinals must be labeled with a black permanent marker with the resident's name and room number in a visible area. 5. During a review of Resident 56's admission Record, the record indicated the facility originally admitted the resident on 4/21/2021 and readmitted the resident on 4/16/2022 with diagnoses including chronic obstructive pulmonary disease (COPD - a common, progressive lung disease that damages the airways and other parts of the lungs, making it difficult to breathe) and respiratory failure. During a review of Resident 56's History and Physical (H&P - a formal assessment by a healthcare provider that includes a resident's medical history and a physical exam), dated 8/19/2024, the record indicated the resident had the capacity to understand and make decisions. During a review of Resident 56's MDS dated [DATE], the MDS indicated the resident had intact cognition and was dependent on staff for assistance with most ADLs. During an observation on 8/19/2024 at 10:07 a.m., observed Resident 56 awake in bed and wearing a nasal cannula. Observed the nasal cannula tubing touching the floor. During a concurrent observation and interview on 8/19/2024 at 10:10 a.m., with Registered Nurse 4 (RN 4), RN 4 verified the observation by stating that Resident 56's nasal cannula tubing was touching the floor. RN 4 stated it should not have been on the floor and stated he would change it immediately. During an interview on 8/22/2024 at 11:27 a.m., with the DON, the DON stated that oxygen tubing should be kept off the floor for infection control. During a review of the facility's policy and procedure titled, Infections - Clinical Protocol, last reviewed on 5/22/2024, the policy indicated that the physician or provider and staff will identify infection transmission risks and will implement relevant precautions. During a review of the facility's policy and procedure titled, Policies and Practices- Infection Control, last reviewed on 1/18/2024, the policy indicated this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. 2. During a concurrent observation and interview on 8/21/2024 at 11:31 a.m., with DA 1, during the kitchen tray line service, observed DA 1 working in the kitchen, touched a plastic trash can lid, and did not wash their hands after. DA 1 put on gloves without washing their hands first. When asked, DA 1 stated he usually washes his hands first after touching a contaminated surface and before putting on gloves. The Dietary Supervisor (DS) who was present, stated kitchen staff are to wash hands first after touching a contaminated surface and before putting on gloves. During an interview on 8/21/2024 at 12:30 p.m., with the Infection Preventionist (IP), the IP stated DA 1 should have washed their hands before putting on gloves. The IP stated the importance of following this infection control standard is to not introduce bacteria to residents' food. During a review of the facility's policy and procedure titled, Hand Washing Procedure, last reviewed 5/22/2024, the document indicated hand washing is important to prevent the spread of infection. The policy and procedure indicated hands need to be washed after handling soiled dishes and utensils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure Registered Nurse 1 (RN 1) transcribed a physician order accurately and administered the prescribed dose of lisinopril-hydrochlorothiazide (a combination of medication used to treat hypertension) as ordered by the physician for one of three sampled residents (Resident 1) between 3/30/2024 to 3/31/2024 and 4/1/2024 to 4/16/2024. Resident 1 was administered a total of 13 incorrect doses of lisinopril-hydrochlorothiazide. This deficient practice placed Resident 1 at risk for serious health complications as a result of being administered lisinopril-hydrochlorothiazide when the blood pressure (BP - pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) was less than 140/80 mmHg. This can lead to low blood pressure, lightheadedness, dizziness, and weakness. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), acute respiratory failure (occurs when the lungs cannot release enough oxygen into your blood), hypertension (high blood pressure), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1's History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 3/29/2024 indicated Resident 1 can make needs known but cannot make medical decisions. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 4/4/2024, indicated Resident 2 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated Resident 1 required supervision by staff for eating. Resident 1 is dependent on staff for oral hygiene, toileting hygiene and personal hygiene. A review of Resident 1's Telephone Physician Order Communication Note, obtained by RN 1, dated 3/29/2024 timed at 10:56 p.m. indicated to administer lisinopril-hydrochlorothiazide tablet 20-25 milligrams (mg- unit of measure) give 12.5 mg by mouth one time a day for hypertension give only if BP is greater than 140/80 mmHg. Upon further review of Resident 1's Telephone Physician Order Communication Note, obtained by RN 1, dated 3/29/2024 timed at 10:56 p.m. indicated the above order was discontinued on 3/29/2024 at 10:56 p.m. due to an updated dose. A review of Resident 1's updated Telephone Physician Order Communication Note transcribed by RN 1, dated 3/29/2024 timed at 10:56 p.m. indicated a new order to administer lisinopril-hydrochlorothiazide tablet 20-12.5 mg, give one tablet by mouth one time a day for hypertension, hold if vital signs (measurements of the body's most basic functions) shows blood pressure equals (=) systolic blood pressure (SBP- first number, indicates how much pressure your blood is exerting against your artery walls when the heart contracts) is less than (<) 140/80. A review of Resident 1's Medication Administration Record (MAR - a report detailing the medications administered to a resident) from 3/30/2024 to 3/31/2024 and 4/1/2024 to 4/16/2024 indicated to administer lisinopril-hydrochlorothiazide oral tablet 20-12.5 mg one tablet by mouth one time a day for hypertension, hold if vital signs show blood pressure = SBP < 140/80. Further review of Resident 1's MAR indicated Resident 1 was administered lisinopril-hydrochlorothiazide oral Tablet 20-12.5 mg on: 3/30/2024 at 9:00 a.m. BP 130/60 3/31/2024 at 9:00 a.m. BP 129/66 4/1/2024 at 9:00 a.m. BP 130/64 4/2/2024 at 9:00 a.m. BP 134/52 4/3/2024 at 9:00 a.m. BP 128/66 4/4/2024 at 9:00 a.m. BP 106/74 4/6/2024 at 9:00 a.m. BP 112/63 4/7/2024 at 9:00 a.m. BP 123/55 4/8/2024 at 9:00 a.m. BP 123/50 4/13/2024 at 9:00 a.m. BP 138/88 4/14/2024 at 9:00 a.m. BP 116/67 4/15/2024 at 9:00 a.m. BP 120/82 4/16/2024 at 9:00 a.m. BP 128/60 During an interview with RN 1 on 4/18/2024 at 1:15 p.m., RN 1 stated that she did speak with Resident 1's Medical Doctor (MD) on 3/29/2024 to clarify the physician order regarding lisinopril-hydrochlorothiazide 20-25 mg. RN 1 stated Resident 1's MD ordered to administer lisinopril-hydrochlorothiazide oral tablet 20-12.5 mg, give 1 tablet by mouth one time a day for hypertension and hold if vital signs show systolic blood pressure greater than 140/80 mmHg. RN 1 stated that when she transcribed the physician's order, she made a mistake by using < (less than) symbol when she documented Resident 1's MD order. RN 1 stated she should have transcribed and documented > (greater than symbol) 140/80 mmHg instead. During an interview with the Director of Nursing (DON) on 4/18/2024 at 3:00 p.m., the DON stated that the correct process when receiving a telephone order with the medical doctor is to read back the physician's order to the medical doctor or provider to ensure there are no discrepancy or errors in the telephone order. The DON further stated RN 1 should not have used a symbol when receiving a physician order by the telephone. A review of the facility's policy and procedure titled Physician's Orders dated 9/2020 indicated It is the policy of the facility to transcribe physician's order either by phone or verbal for all prescription, non-prescription medications .To have a complete order the following information must be included: 1. The individual's full name 2. The date of the order 3. Name of the medication, and other orders. 4. Dosage and administration information 5. Route of administration 6. Physician's signature The staff is responsible to query and verify with the doctor the order for accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of the Notice of Proposed Transfer or Discharge (NPTD) Form for facility-initiated transfer (the resident expects to return to the facility) or discharge (when return to the facility is not expected) was sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman Program (advocates for residents in nursing homes) before transfer, discharge or in emergency situations as soon as practicable for 14 of 23 sampled residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24). As a result, Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24 were denied protection and advocacy in the event residents were inappropriately or involuntary transferred or discharged from the facility. Findings: 1. A review of Resident 5 ' s admission Record indicated the facility originally admitted the resident on 12/4/2022 and re-admitted Resident 5 on 12/28/2022. A review of Resident 5 ' s Physician ' s Order dated 1/10/2023, indicated Resident 5 had an order to be discharged home on 1/13/2023 with Home Health (HH - health care services provided at home) services. A review of Resident 5 ' s NPTD Form with a notification date of 1/11/2023 indicated the discharge was appropriate because Resident 5's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 5 ' s NPTD Form to the LTC Ombudsman on 4/24/2023. 2. A review of Resident 6 ' s admission Record indicated the facility admitted Resident 6 on 2/3/2023. A review of Resident 6 ' s Physician Order dated 2/6/2023 indicated Resident 6 had an order to be discharged home on 2/6/2023 with HH services. A review of Resident 6 ' s NPTD Form with a notification date of 2/12/2023 indicated the discharge was appropriate because Resident 6's health improved sufficiently and no longer required services provided by the facility. During a review of the facility ' s NPTD Form binder, there were no fax verifications found indicating a copy of Resident 6 ' s NPTD Form was faxed to the LTC Ombudsman. 3. A review of Resident 7 ' s admission Record indicated the facility admitted the Resident 7 on 2/9/2023. A review of Resident 7 ' s Physician Order dated 2/15/2023 indicated Resident 7 had an order to be discharged to a Board and Care Home (BC Home - houses in residential neighborhoods that are equipped and staffed to care for a small number of residents) on 2/18/2023 with HH services. A review of Resident 7 ' s NPTD Form with a notification date of 2/18/2023 indicated the discharge was appropriate because Resident 7's health improved sufficiently and no longer required services provided by the facility. During a review of the facility ' s NPTD Form binder, there were no fax verifications found indicating a copy of Resident 7 ' s NPTD Form was faxed to the LTC Ombudsman. 4. A review of Resident 8 ' s admission Record indicated the facility admitted Resident 8 on 2/28/2023. A review of Resident 8 ' s Physician ' s Order dated 3/6/2023, indicated Resident 8 had an order to be discharged home on 3/6/2023 with HH services. A review of Resident 8 ' s NPTD Form with a notification date of 3/6/2023 indicated the discharge was appropriate because Resident 8's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 8 ' s NPTD Form to the LTC Ombudsman on 5/24/2023. 5. A review of Resident 9 ' s admission Record indicated the facility admitted Resident 9 on 1/5/2023. A review of Resident 9 ' s Physician ' s Order dated 3/6/2023, indicated Resident 9 had an order to be discharged home on 3/9/2023 with HH services. A review of Resident 9 ' s NPTD Form with a notification date of 3/9/2023 indicated the discharge was appropriate because Resident 9's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 8 ' s NPTD Form to the LTC Ombudsman on 5/24/2023. 6. A review of Resident 10 ' s admission Record indicated the facility admitted Resident 10 on 2/6/2023. A review of Resident 10 ' s Physician ' s Order dated 4/11/2023, indicated Resident 10 had an order to be discharged home on 4/11/2023 with HH services. A review of Resident 10 ' s NPTD Form with a notification date of 4/11/2023 indicated the discharge was appropriate because Resident 10's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 10 ' s NPTD Form to the LTC Ombudsman on 7/5/2023. 7. A review of Resident 11 ' s admission Record indicated the facility admitted Resident 11 on 4/9/2023. A review of Resident 11 ' s Physician ' s Order dated 4/17/2023, indicated Resident 11 had an order to be discharged home on 4/20/2023 with HH services. A review of Resident 11 ' s NPTD Form with a notification date of 4/20/2023 indicated the discharge was appropriate because Resident 11's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 11 ' s NPTD Form to the LTC Ombudsman on 7/5/2023. 8. A review of Resident 12 ' s admission Record indicated the facility admitted Resident 12 on 5/8/2023. A review of Resident 12 ' s Physician ' s Order dated 5/9/2023, indicated Resident 12 had an order to be discharged home on 5/14/2023 with HH services. A review of Resident 12 ' s NPTD Form with a notification date of 5/14/2023 indicated the discharge was appropriate because Resident 12's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 12 ' s NPTD Form to the LTC Ombudsman on 10/13/2023. 9. A review of Resident 13 ' s admission Record indicated the facility admitted Resident 13 on 4/20/2023. A review of Resident 13 ' s Physician ' s Order dated 5/16/2023, indicated Resident 13 had an order to be discharged to an Assisted Living Facility (ALF - a residence for older people or people with disabilities who require help with some of the routines of daily living as well as access to medical care when needed) on 5/17/2023 with HH services. A review of Resident 13 ' s NPTD Form with a notification date of 5/17/2023 indicated the discharge was appropriate because Resident 13's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 13 ' s NPTD Form to the LTC Ombudsman on 10/13/2023. 10. A review of Resident 16 ' s admission Record indicated the facility originally admitted Resident 16 on 2/4/2023 and re-admitted Resident 16 on 6/23/2023. A review of Resident 16 ' s Physician ' s Order dated 7/3/2023, indicated Resident 16 had an order to be discharged home on 7/7/2023 with HH services. A review of Resident 16 ' s NPTD Form with a notification date of 7/7/2023 indicated the discharge was appropriate because Resident 16's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 16 ' s NPTD Form to the LTC Ombudsman on 10/19/2023. 11. A review of Resident 17 ' s admission Record indicated the facility admitted Resident 17 on 6/22/2023. A review of Resident 17 ' s Physician ' s Order dated 7/3/2023, indicated Resident 17 had an order to be discharged home on 7/7/2023 with HH services. A review of Resident 17 ' s NPTD Form with a notification date of 7/7/2023 indicated the discharge was appropriate because Resident 17's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 17 ' s NPTD Form to the LTC Ombudsman on 10/19/2023. 12. A review of Resident 18 ' s admission Record indicated the facility admitted Resident 18 on 7/25/2023. A review of Resident 18 ' s Physician ' s Order dated 8/3/2023, indicated Resident 18 had an order to be discharged home on 8/8/2023 with HH services. A review of Resident 18 ' s NPTD Form with a notification date of 8/8/2023 indicated the discharge was appropriate because Resident 18's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 18 ' s NPTD Form to the LTC Ombudsman on 10/20/2023. 13. A review of Resident 22 ' s admission Record indicated the facility admitted Resident 22 on 10/1/2023. A review of Resident 22 ' s Physician ' s Order dated 10/5/2023, indicated Resident 22 had an order to be discharged home on [DATE] with HH services. A review of Resident 22 ' s NPTD Form with a notification date of 10/6/2023 indicated the discharge was appropriate because Resident 22's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 22 ' s NPTD Form to the LTC Ombudsman on 12/19/2023. 14. A review of Resident 24 ' s admission Record indicated the facility admitted Resident 24 on 11/18/2023. A review of Resident 24 ' s Physician ' s Order dated 11/27/2023, indicated Resident 24 had an order to be discharged home on [DATE] with HH services. A review of Resident 24 ' s NPTD Form with a notification date of 11/29/2023 indicated the discharge was appropriate because Resident 24's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 24 ' s NPTD Form to the LTC Ombudsman on 12/19/2023. During an interview on 12/18/2023 at 3:00 p.m., with the Social Services 1 (SS 1), when SS 1 was asked how soon the facility notifies the LTC Ombudsman of a facility-initiated transfer or discharge, SS 1 stated she received instructions from the former Social Services Director (SSD) that the facility needed to fax a copy of the residents ' NPTD on a monthly basis for all transfers or discharges to the LTC Ombudsman. During a concurrent interview and record review on 12/22/2023 at 11:16 a.m. with SS 1, SS 1 reviewed the facility ' s NPTD binder and stated the fax verifications indicated copies of residents ' NPTD for the year of 2023 were faxed to LTC Ombudsman as follows: 1. Residents ' NPTD for January 2023 were faxed on 4/24/2023 2. Residents ' NPTD for February 2023: No fax verifications were found. 3. Residents ' NPTD for March 2023 were faxed on 5/24/2023 4. Residents ' NPTD for April 2023 were faxed on 7/5/2023 5. Residents ' NPTD for May 2023 were faxed on 10/13/2023 6. Residents ' NPTD for June 2023 were faxed on 10/17/2023 7. Residents ' NPTD for July 2023 were faxed on 10/19/2023 8. Residents ' NPTD for August 2023 were faxed 10/20/2023 9. Residents ' NPTD September 2023, October 2023, November 2023, and December 2023 were faxed on 12/19/2023. During an interview with the Director of Nursing (DON) on 12/22/2023 at 1:52 p.m., the DON stated, as soon as a last coverage date was decided, the facility issues the NPTD to the residents or responsible parties notifying them of ending skilled insurance benefits. The DON stated these cases fall under the category of facility-initiated discharges and the facility should have notified the LTC Ombudsman as soon as practicable. A review of the facility ' s P&P titled, Transfer or Discharge Notice, dated June 2020, last reviewed on 5/18/2022, indicated, A resident and/or his or her representative (sponsor) will be given a 30-day notice of an impending transfer or discharge from our facility. Under the following circumstances, the notice will be given as soon as it is practicable of the transfer or discharge The transfer of discharge is appropriate because the resident ' s health has improved sufficiently so the resident no longer needs the services provided by the facility A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) had a physician ' s order to administer supplemental oxygen (O2- a treatment that provides you with extra oxygen to breathe in) prior to providing the resident with oxygen. This deficient practice had the potential to result in complications from lack of sufficient oxygen level in the body and lead to shortness of breath (SOB), rapid breathing, confusion, and loss of consciousness and irregular heartbeats. Findings: A review of Resident 1 's admission Record indicated the facility admitted the resident on 2/13/2020 and readmitted the resident on 6/25/2020 with diagnosis including cerebral infarction (damage to tissues in the brain due to a loss of oxygen) and hypoxia (low levels of oxygen in your body tissues). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/11/2023, indicated the resident is able to understand others and is understood by others. The MDS further indicated that Resident 1 needed moderate assistance for oral and personal hygiene. A review of Resident 1 ' s physician order summary dated 7/1/2023 to 10/1/2023 indicated that there were no orders for Resident 1 to receive supplemental oxygen. A review of Resident 1 ' s Records of O2 sat from 7/1/2023 through 10/1/2023 indicated that Resident 1 received supplemental oxygen via nasal cannula (NC - a medical device that delivers extra oxygen through a tube and into the nose) on the following days: 1. In July/2023: 1, 2, 3, 4, 5, 7, 10, 14, 18, 19, 22, 24, 26, 28, 29, and 31. 2. In August/2023: 2, 4, 8, 9, 14, 16, 20, 21, 25, and 27. 3. In September/2023: 2. 4. In October/2023: 1. During a concurrent interview and record review on 12/18/2023 at 1:45 p.m. with the Director of Nursing (DON), Resident 1 ' s physician orders from 7/1/2023 to 10/1/2023 was reviewed. DON stated that there were no active physician orders for Resident 1 to receive supplemental O2 from 7/1/2023 to 10/1/2023. DON stated that from 7/1/2023 to 10/1/2023, Resident 1 received supplemental oxygen without a physician ' s order. A review of the facility ' s policy and procedures dated 05/2020 and reviewed 5/18/2022, titled Oxygen Administration, indicated, To administer oxygen for the treatment of disease or a condition.

Based on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 4) received prescribed pain management by failing to administer pain medication as ordered by the physician. This deficient practice had the potential to result in confusion on the delivery of care and services rendered and may lead to inadequate management of resident ' s pain. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 9/10/2023 with diagnoses that included intervertebral disc disorder (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, causing pain in the back or neck and frequently in the legs and arms) with myelopathy (compression of the spinal cord and nerve roots) of the lumbar region ( the lower end of the spinal column). A review of Resident 4 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 9/16/2023 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 4 ' s physician orders indicated an order for Oxycodone (medication used to treat moderate to severe pain) 10 milligrams (mg- a unit of measure) give one tablet by mouth every four hours as needed for severe pain (pain rated at seven [7] or higher out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain), ordered on 9/28/2023. A review of Resident 4 ' s physician orders indicated an order for Oxycodone five (5) mg, give one tablet by mouth every four hours as needed for moderate pain (pain rated at four [4] to six (6) out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain), ordered on 9/28/2023. A review of Resident 4 ' s care plan regarding alteration in comfort due to pain date initiated 9/20/2023, indicated under interventions: administer prescribed pain medication; notify physician if interventions are unsuccessful. During an interview and concurrent record review with Licensed Vocational Nurse 1 (LVN 1) on 12/1/2023 at 1:22 p.m., LVN 1 reviewed Resident 4 ' s October 2023 and November 2023 Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident of a facility by a health care professional). LVN 1 stated the following: 1. On 10/31/2023 at 9:30 a.m., Resident 4 was administered Oxycodone 10mg for a pain level of five. 2. On 10/31/2023 at 1:10 p.m., Resident 4 was administered Oxycodone 10mg for a pain level of five. 3. On 11/8/2023 at 8:58 a.m., Resident 4 was administered Oxycodone 10mg for a pain level of four. 4. On 11/8/2023 at 1:48 p.m., Resident 4 was administered Oxycodone 10mg for a pain level of three. LVN 1 stated when giving pain medication, LVN 1 is to assess a resident's pain level and administer the prescribed pain medication based on the resident ' s pain level. LVN 1 stated that based on Resident 4 ' s physician's orders for oxycodone dated 9/28/2023, LVN 1 should have administered Oxycodone five (5) mg to Resident 4 for pain levels of four to six out of 10. When asked why LVN 1 administered Oxycodone 10 mg to Resident 4 when the residents pain level was less than the prescribed parameter of a pain rating of seven or higher out of 10 (severe pain) , LVN 1 stated she administered the Oxycodone 10 mg to Resident 4 even though the resident was not complaining of severe pain because the resident requested to be given the higher dose. LVN 1 continued to state that she should have called Resident 4 ' s physician and informed the physician that Resident 4 ' s prescribed pain medications were not effective so that the physician can reevaluate Resident 4 for better pain management. During an interview with the Director of Nursing (DON) on 12/4/2023 at 2:00 p.m., the DON stated that LVN 1 should have followed the physician ' s order for oxycodone and administered the appropriate pain medication. The DON stated that if Resident 4 ' s pain medications are not effective, LVN 1 should have informed the physician so that the physician can reevaluate the residents pain management regime. A review of the facility ' s policy and procedure titled, Pain Management, last reviewed 5/17/2023, indicated it is the policy of this facility to follow the plan of care for the management of pain as written in the resident ' s plan of care and the approach to be followed are: a. assess pain systematically; b. follow physician ' s orders upon admission or any changes in the pain management orders choose pain control option appropriate for the resident.

Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident of a facility by a health care professional) and Controlled Drug Record (CDR - an accountability log signed by the nurse with the date and time each time a controlled substance [medications with a high potential for abuse] is administered to a resident) coincided and were accurately documented per facility policy for one of two sampled residents. (Resident 4). This deficient practice of failing to accurately account for the use of controlled substances increased the risk that medications may not be available for Residents 4 when needed, and also puts the facility at increased risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use), or accidental exposure to controlled substances. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 9/10/2023 with diagnoses that included intervertebral disc disorder (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, causing pain in the back or neck and frequently in the legs and arms) with myelopathy (compression of the spinal cord and nerve roots) of the lumbar region ( the lower end of the spinal column). A review of Resident 4 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 9/16/2023 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 4 ' s physician orders indicated an order for Oxycodone (medication used to treat pain) 10 milligrams (mg- a unit of measure) give one tablet by mouth every four hours as needed for severe pain (pain rated at seven [7] or higher out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain), ordered on 9/28/2023. During a concurrent interview and record review with the MDS Nurse (MDSN) on 12/1/2023 at 11:20 a.m., MDSN reviewed Resident 4 ' s Controlled Drug Record form for 10/2023 and MAR for 10/2023. MDSN stated the following regarding Resident 4 ' s MAR for 10/2023 and CDR for 10/2023: 1. Three doses of oxycodone 10 mg documented as administered on the MAR for 10/1/2023 was not documented on the CDR form for 10/1/2023. 2. Three doses of oxycodone 10 mg documented as administered on the CDR form for 10/3/2023 was not documented as administered on the MAR for 10/3/2023. 3. Four doses of oxycodone 10 mg documented as administered on the CDR form for 10/4/2023, however only one dose was documented as administered on the MAR for 10/4/2023. 4. Five doses of oxycodone 10 mg were documented as administered on the CDR form for 10/5/2023, however only one dose was documented as administered on the MAR for 10/5/2023. 5. Four doses of oxycodone 10 mg documented as administered on the CDR form for 10/6/2023, however only two doses were documented as administered on the MAR for 10/6/2023. MDSN stated that when administering a narcotic (a drug or other substance that affects mood or behavior ) pain medication to a resident, the licensed nurse should assess the resident for pain, document on the CDR, administer the medication, then document on the MAR that the medication was administered to the resident . The MDSN stated that this process is to ensure that the CDR count is accurate. During a concurrent interview and record review with the Director of Nursing (DON) on 12/1/2023 at 12:36 p.m., the DON reviewed Resident 4 ' s CDR for 10/2023 and MAR for 10/2023. The DON stated that the entries made on the CDR on 10/1/2023, 10/3/2023, 10/4/2023, 10/5/2023, and 10/6/2023 did not match Resident 4 ' s MAR for 10/2023. The DON stated that all medications administered by licensed nurses should be documented on the MAR. A review of the facility ' s policy and procedure titled, Medication Administration Guidelines last reviewed on 5/17/2023, indicated to prepare and administer ordered medications to the resident in an accurate, efficient, and safe manner. Sign out medications after giving. Remember the order: a. Pour/punch/Prepare; b. pass; c. Chart. Sign in the individual Narcotic Count Sheet at the time of the punching/pouring of the ordered medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident ' s responsible party was informed of and explained any changes in Medi-Cal (a public health insurance program that provides free or low-cost medical services) share of cost (the amount you agree to pay for health care before Medi-Cal starts to pay) for one of three sampled residents (Resident 1). This deficient practice had a potential to result in the resident ' s responsible party inability to make an informed decision regarding payments, incurring late fees, and having a delinquent account. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), hemiplegia (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side. A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 10/25/2023, indicated Resident 1 had moderately impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. A review of Resident 1 ' s Eligibility Transaction document (document that shows a resident ' s determined share of cost) dated 10/25/2023, indicated Resident 1 ' s share of cost obligation was $1,412.00. A review of Resident 1 ' s Eligibility Transaction document dated 11/2/2023, indicated Resident 1 ' s share of cost obligation was $1,997.00. During a concurrent interview and record review with the Business Office Manager (BOM) on 11/28/2023 at 10:00 a.m., Resident 1 ' s Eligibility Transaction documents dated 10/25/2023 and 11/2/2023 were reviewed. The BOM stated that for residents that are on custodial care (non-medical care recommended by a medical professional that helps individuals with their daily basic care) and on Medi-Cal, the BOM will check their Medi-Cal eligibility monthly to determine the resident ' s share of cost. The BOM stated that the share of cost is not determined by the facility. The BOM states that the share of cost is determined by an outside entity. The BOM stated that he sends residents and their responsible party a private statement and a copy of their Medi-Cal eligibility monthly. The BOM stated that if there are any changes in coverage or a resident ' s share of cost, the BOM is supposed to inform the resident and or their responsible party of the changes. The BOM stated that Resident 1 ' s responsible party is Family Member 1 (FM 1), and FM 1 is who the BOM is in contact with regarding Resident 1 ' s financial obligations. The BOM reviewed Resident 1 ' s Eligibility Transaction document dated 10/25/2023 and 11/2/2023. BOM stated that Resident 1 ' s share of cost had increased from $1,412.00 on 10/25/2023 to $1,997.00 on 11/2/2023. When asked if the BOM informed FM 1 about the change in Resident 1 ' s Medi-Cal share of cost, the BOM stated that he was supposed to call and inform FM 1 about the increase in Resident 1 ' s share of cost, however, the BOM stated that he was not able to place a call to FM 1. During an interview with the Administrator (ADM) on 11/28/2023 at 12:55 p.m., the ADM stated that the business office will check residents' insurance benefits twice a month. The ADM continued to state that if there are any changes in insurance benefits or share of cost, the business office will inform the residents and or their responsible party of the changes via email or phone call. During an interview with FM 1 on 12/1/2023, at 1:15 p.m., FM 1 stated that she is Resident 1 ' s responsible party and handles the resident ' s finances. FM 1 stated that she did not receive any information or explanation about Resident 1 ' s increase in share of cost for the month of November 2023. During a review of the facility provided policy and procedure titled Resident ' s Rights, last reviewed by the facility on 5/17/2023, indicated the resident has the right to be informed of his or her rights and of the rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. Federal and state regulations guarantee certain basic rights to all residents of this facility; these rights include the resident ' s right to be informed about his or her rights and responsibilities.

Based on observation, interview, and record review, the facility failed to ensure a resident ' s call light (device used by residents that when pressed informs facility staff that assistance is being requested) was placed within reach for one of five sampled residents (Resident 2). On 10/12/2023, observed Resident 2 ' s call light placed on the resident ' s bed and covered with the bed sheet, out of reach from Resident 2 who was sitting by the bed. This deficient practice had the potential to result in a delay with resident care, and residents not receiving assistance with activities of daily living (ADL- fundamental skills required to independently care for oneself, such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and osteoporosis (a condition in which bones become weak and brittle). A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/26/2023, indicated, the resident was rarely able to understand others, and was rarely able to make self-understood. The MDS further indicated that Resident 2 required extensive assistance from staff with bed mobility, dressing, and personal hygiene, and dependent with toilet use. A review of Resident 2 ' s Resident Care Plan for Activities of Daily Living indicated, the resident will have increased ADL participation and will minimize functional decline by 12/2023, and one of the approaches to the plans was for Call light within reach and answer promptly. A review of Resident 2 ' s Resident Care Plan for At Risk for Fall dated 9/23/2023, indicated, one of approaches of the plans was to Keep call light and frequently used items within reach. On 10/12/2023 at 12:51 p.m., during a concurrent observation and interview inside Resident 2 ' s room with Certified Nursing Assistant (CNA) 1 and Certified Nursing Assistant 2 (CNA 2), observed Resident 2 sitting in her wheelchair next to her bed and her call light was out of reach from her sitting position. CNA 1 stated that the resident ' s call light was placed in the middle bed under the bedsheet, and that Resident 2 was not able to use the call light if she needed help. CNA 1 further stated that forgot to place the call light within reach when CNA 1 brought the resident back to the room. Observed CNA 2 use Resident 2 native language to ask the resident if the resident knew where the call light was located. Observe Resident 2 look around the room. CNA 2 then reached for Resident 2 ' s call light which was placed under the resident ' s bedsheet in the middle of the bed and handed the call light to Resident 2. CNA 2 stated that a resident ' s call light should always be within reach so that they can alert staff during times of need. On 10/12/2023 at 5:25 p.m., during an interview with the Director of Nursing (DON), DON stated that the call lights should be placed within reach of a resident and answered promptly to attend the residents ' needs. A review of the facility ' s policy and procedures revised May 2020 and reviewed 5/17/2023 titled Call Light System indicated, To provide a method of communication between nursing and the resident in bed, up in a chair at the bedside, and in some instances in the bathroom. To determine and meet the needs of the residents Signal cord (call light system) will be placed within reach of each resident when in bed, up in chair, or in some instances in the bathroom. All nursing personnel will answer call lights promptly during whether an emergency or a non-emergency need.

Based on interview and record review, the facility failed to provide oral hygiene (cleaning the mouth, teeth, and tongue) to one of five sampled residents (Resident 3), who required extensive assistance from staff with activities of daily living (ADL- describes fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This deficient practice had the potential to place Resident 3 at risk for diseases of the mouth, gums, and teeth. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 7/12/2023 with diagnoses including epilepsy (a long-term disease that causes repeated seizures [a sudden, uncontrolled burst of electrical activity in the brain] due to abnormal electrical signals produced by damaged brain cells). A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/17/2023, indicated, the resident was able to understand others, and was able to make self-understood. The MDS further indicated that Resident 3 required extensive assistance from staff with bed mobility, dressing, personal hygiene, and dependent with transfer by two staff physical assist. A review of Resident 3 ' s Resident Care Plan for Activities of Daily Living dated 7/12/2023, indicated, the resident will have increased ADL participation and will minimize functional decline by 10/2023. Approaches to the plan included to encourage independence with needed assistance and to brush teeth in the morning (AM) and at bedtime (HS). On 10/12/2023 at 1:16 p.m., during an interview with Resident 3, Resident 3 stated that sometimes staff helped to brush the resident ' s teeth, and that sometimes they did not. Resident 3 stated that no one helped to brush the resident ' s teeth today (10/12/23). Resident 3 stated that the staff often forget to brush the resident ' s teeth, especially if the assigned staff is a new employee. Resident 3 stated that they wanted to have their teeth brushed every morning and not randomly. On 10/12/2023 at 1:35 p.m., during an interview with the Director of Nursing (DON) and Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that she was currently the assigned Certified Nurse Assistant (CNA) to Resident 3. CNA 2 stated that they had not yet brushed Resident 3 ' s teeth and that CNA 2 was planning to brush the resident ' s teeth after lunch. When the DON asked CNA 2 how come CNA 2 did not brush Resident 3 ' s teeth in the morning, CNA 2 stated that it was her first day working on the floor and she got busy providing her due morning care to other residents that she missed brushing Resident 3 ' s teeth. The DON informed CNA 2, if she was unable to complete the job assignments, then CNA 2 should have informed the charge nurses and asked for help. DON stated, oral hygiene should be provided at a minimum in the morning, after dinner, and as needed. DON stated that by not routinely performing oral hygiene, the chances were higher to have gum diseases. A review of the facility ' s policy and procedures revised May 2020 and reviewed 5/17/2023 titled Oral Hygiene indicated, To cleanse the mouse for personal hygiene Brushing Teeth: Explain procedure to the resident and let them know that this is an essential part of the morning and evening care.

Based on interview and record review, the facility failed to administer tramadol (medication to treat pain) as prescribed by the physician to one of five sampled residents (Resident 1) who had a diagnosis of right shoulder replacement survey. This deficient practice had the potential to result in ineffectively managed pain for the resident and could result in unrelieved pain. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 8/12/2023. A review of Resident 1 ' s History and Physical Examination (H&P) dated 8/14/2023, indicated, the resident ' s right shoulder dislocated ( when your upper arm bone comes out of place from your shoulder socket) after a fall incident on 8/10/2023. A review of Resident 1 ' s General Acute Care Hospital ' s (GACH) Progress Note dated 9/1/2023, indicated, the Resident 1 had surgery a surgery known as right shoulder open reduction (surgeons reposition the pieces of your fractured bone surgically so that your bones are back in their proper alignment) and reverse total shoulder arthroplasty (joint replacement) on 8/31/2023. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/17/2023, indicated, the resident was rarely able to understand others, and was rarely able to make self-understood. The MDS further indicated that Resident 1 required extensive assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1 ' s physician order dated 9/4/2023 at 7 a.m., indicated, an order for tramadol 100 milligram (mg - a unit of measurement of mass) one tablet orally three times a day (TID) for right shoulder pain. On 10/20/2023 at 2:25 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 1 ' s physician ' s tramadol orders dated 9/4/2023 at 7 a.m. and also reviewed Resident 1 ' s Medication Administration Record (MAR- a report detailing the medications administered to a resident) dated 9/2023. LVN 1 stated that on 9/4/2023 at 9 a.m., Resident 1 ' s MAR indicated that the resident ' s 9:00 a.m. due tramadol medication was documented as not given by LVN 1. LVN 1 stated that on the morning of 9/4/2023, LVN 1 checked one of the facility ' s emergency kits (E-Kit - contain a small quantity of medications that can be dispensed when pharmacy services are not available) for tramadol, but the E-kit that LVN 1 checked at the time did not contain tramadol. LVN 1 stated that on 9/4/2023 he at around 11:00 a.m., he remembered that there was another facility E-kit inside the medication storage room. LVN 1 stated that he pulled a dose of 100 mg tramadol from the facility ' s E-kit inside the medication storage room and administered the tramadol to Resident 1 at approximately 12:00 p.m. on 9/4/2023, three (3) hours after the scheduled time. On 10/20/2023 at 3:50 p.m., during an interview with the Director of Nursing (DON), DON stated that prescribed medications should be administered within a one-hour window time frame from the scheduled time (a licensed nurse can administer a medication to a resident either one hour before the scheduled time or one hour after the scheduled time). A review of the facility ' s policy and procedures revised October 2017 and reviewed 5/17/2023 titled Medication Administration – General Guidelines indicated, Medications are administered within 60 minutes of scheduled time (one hour before and one hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were within residents' reach while in bed for two out of three sampled residents (Resident 3 and Resident 5). This deficient practice had the potential to result in resident falls and residents not being able to summon health care workers for assistance when needed. Findings: a. A review of Resident 3's admission Record indicated the facility admitted the resident on 4/7/2023 with diagnoses that included malignant neoplasm (cancer) of head, face and neck, sepsis (life-threatening complication of an infection), and respiratory failure (serious condition that makes it difficult to breathe on your own). A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/7/2023, indicated Resident 3 had moderately impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 3 requires extensive assistance with one-person physical assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 3's Care Plan, with an initiation date of 7/22/2023, indicated Resident 3 requires assistance in the following areas: bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The Care Plan indicated an intervention for call light within reach and answer promptly. During a concurrent observation and interview on 8/15/2023 at 11:24 a.m., with the Infection Preventionist (IP), observed Resident 3 in bed, with his call light not within reach. Observed Resident 3's call light tangled around Resident 3's left siderail with the call light facing towards the floor. Observed the IP untangle Resident 3's call light and placed the call light within Resident 3's reach. The IP stated that call lights should always be within residents' reach for safety. b. A review of Resident 5's admission Record indicated the facility readmitted the resident on 8/8/2023 with diagnoses that included type 2 diabetes mellitus (DM, a condition that affects how the body uses blood sugar), difficulty walking, muscle weakness, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 5's MDS dated [DATE], indicated Resident 5 has moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 5 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 5's Care Plan, with an initiation date of 8/8/2023, indicated Resident 5 requires assistance in the following: bed mobility, transfers, toilet use, and personal hygiene. The Care Plan indicated an intervention for call light within reach and answer promptly. During a concurrent observation and interview on 8/15/2023 at 11:29 a.m., with the IP, observed Resident 5 in bed, with her call light not within reach of the resident. Observed the call light behind Resident 5, at the top of the resident's head, tucked underneath Resident 5's pillow. Observed the IP removing the call light from underneath Resident 5's pillow and placing it next to the resident's left hand, within resident's reach. The IP stated that residents' call lights should be within their reach at all times for safety. A review of the facility-provided policy and procedure titled, Call Light System, revised 5/2020, indicated the purpose is to provide a method of communication between nursing and the resident in bed, up in chair at the bedside, and in some instances in the bathroom and to determine and meet the needs of the residents. Signal cord (call light system) will be placed within reach of each resident when in bed, up in chair, or in some instances in the bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to ensure a staff member (Certified Nursing Assistant 1 [CNA 1]) doffed (took off) their gown and gloves prior to exiting a Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) isolation room for two of two sampled residents (Resident 6 and Resident 7). CNA 1 was observed exiting a COVID-19 isolation room wearing gown and gloves, and then observed walking across the hallway to dispose of the used gown and gloves. This deficient practice had the potential for the spread of infection and cross contamination among residents. Findings: a. A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 5/23/2023 with diagnoses that included cellulitis (a common and potentially serious bacterial skin infection) of right lower limb (leg), malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify), and sepsis (a life-threatening complication of an infection). A review of Resident 6 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/29/2023 indicated Resident 6 had modified independence (some difficulty in new situations) cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 6 requires extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 6 ' s physician ' s orders dated 8/14/2023 at 5:01 p.m., indicated to place Resident 6 on contact droplet isolation (precautionary measures use to prevent spread of infectious disease) related to COVID-19. A review of Resident 6 ' s care plan titled Isolation - Covid dated 8/14/2023, indicated Resident 6 has actual COVID-19. The goal was for Resident 6 to be free of any signs any symptoms of COVID-19 and if present will be resolved. The interventions included to place Resident 6 on contact droplet isolation and for staff to observe isolation precautions and use personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against infectious or hazardous substances or environments) appropriately. b. A review of Resident 7 ' s admission Record indicated the facility admitted the resident on 8/3/2023 with diagnoses that included other specified dermatitis (skin irritation), diabetes mellitus (disease of inadequate control of blood levels of glucose [sugar]) with diabetic polyneuropathy (a type of nerve damage that can occur if you have diabetes), and hemiplegia (severe or complete loss of strength) and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side. A review of Resident 7 ' s MDS dated [DATE] indicated Resident 7 had intact cognitive skills for daily decision making. The MDS indicated Resident 7 requires extensive assistance from staff with two-person physical assistance with bed mobility, dressing, and personal hygiene. A review of Resident 7 ' s physician ' s orders dated 8/14/2023 at 5:20 p.m., indicated to place Resident 7 on contact droplet isolation related to COVID-19. A review of Resident 7 ' s care plan titled Isolation - Covid dated 8/14/2023, indicated Resident 7 has actual COVID-19. The goal was for Resident 7 to be free of any signs any symptoms of COVID-19 and if present will be resolved. The interventions included to place Resident 7 on contact droplet isolation and for staff to observe isolation precautions and use PPE appropriately. During an observation on 8/15/2023 at 11:31 a.m., observed CNA1 exiting Resident 6 and Resident 7 ' s (both residents in the same room) isolation room with her gown, gloves, face shield, and N95 (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne [transported by air] particles) mask on. Observed CNA 1 close the door of the isolation with her gloves on and then proceeded to walk across the hallway. Observed CNA 1 remove her gloves and gown and disposed of it into a trash receptacle (container) in the hallway. During an interview on 8/15/2023 at 11:33 a.m., with CNA 1, CNA 1 stated that the room she exited from was a contact droplet isolation room due to Resident 6 and Resident 7 being COVID-19 positive. CNA 1 stated she did exit the isolation room with her gown and gloves on and threw them away in the trash receptacle located across the hallway. CNA 1 stated that before exiting an isolation room she should have removed her gown and gloves. When asked why she did not do so, CNA 1 did not answer. During an interview on 8/15/2023 at 11:35 a.m., with the Infection Preventionist (IP), the IP stated that all staff exiting an isolation room of any kind should be removing their gown and gloves prior to exiting the room and placing them in the proper receptacle inside the isolation room. The IP stated used gown and gloves should never be brought outside of an isolation room for infection control purposes and to prevent the spread of the infection. A review of the facility-provided policy and procedure titled COVID-19: Isolation/Quarantine, Personal Protective Equipment Requirements, dated 8/4/2023, indicated to prevent the spread of COVID-19 and to protect residents and staff affected by this infectious disease. Under PPE requirements: 1. Staff need to wear eye protection (face shield, goggles), N95 respirator, gown and gloves when caring for symptomatic or confirmed COVID-19 positive residents in isolation. Full PPE will be removed and discarded after each patient encounter. A review of the facility-provided policy and procedure titled Infection Control, dated 5/2020, indicated the facility ' s infection control policies and practices are intended to facilitate and safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the facility's pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) policy by failing to ensure residents were provided education regarding the pneumococcal vaccine for two of five sampled residents (Resident 2 and Resident 4). This deficient practice had the potential for residents to not be aware of the risks and benefits of the pneumococcal vaccine. Findings: a. A review of Resident 2's admission Record indicated the facility admitted the resident on 8/1/2023 with diagnoses that included malignant neoplasm (cancer) of colon (large intestine) and coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/7/2023, indicated Resident 2 had intact cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 2 required limited assistance with bed mobility and requires extensive assistance with transfer, dressing, toilet use, and personal hygiene. A review of Resident 2's pneumococcal immunization record dated 8/4/2023, indicated the pneumococcal vaccine was refused and did not indicate education was provided to resident/family. During a concurrent interview and record review on 8/15/2023 at 12:32 p.m., with the Infection Preventionist (IP), reviewed Resident 2's immunization record for the pneumococcal vaccine dated 8/4/2023 and progress notes dated 8/4/2023-8/15/2023. The IP stated that prior to the administration of any vaccine, education will be provided to the resident and/or responsible party. The IP stated education will be provided verbally and a vaccine information sheet will also be provided to the resident and/or responsible party. The IP continued to state that documentation is completed in the resident's chart indicating education was provided. The IP stated that there was no documented evidence that education was provided to Resident 2 or to Resident 2's responsible party regarding the pneumococcal vaccine. The IP further stated that if there is no documentation of the education provided, then the education was not done because there is no proof. A review of a facility-provided policy and procedure titled Pneumococcal Vaccine, revised 5/2020, indicated before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. A review of a facility-provided policy and procedure titled, Charting and Documentation, revised 5/2020, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional conditions, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. b. A review of Resident 4's admission Record indicated the facility admitted the resident on 7/28/2023 with diagnoses that included syncope (fainting) and collapse and COVID-19. A review of Resident 4's MDS dated [DATE], indicated Resident 4 had intact cognitive skills for daily decision making. The MDS indicated Resident 4 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 4's pneumococcal immunization record dated 8/2/2023, indicated the pneumococcal vaccine was refused and did not indicate education was provided to resident/family. During a concurrent interview and record review on 8/15/2023 at 12:45 p.m., with the IP, the IP reviewed Resident 4's immunization record for the pneumococcal vaccine dated 8/2/2023 and progress notes dated 8/2/2023-8/15/2023. The IP stated that there was no documented evidence that education was provided to Resident 4 or to Resident 4's responsible party regarding the pneumococcal vaccine. The IP further stated that staff should have documented the education provided as proof that staff provided education. A review of a facility-provided policy and procedure titled, Pneumococcal Vaccine, revised 5/2020, indicated before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. A review of a facility-provided policy and procedure titled, Charting and Documentation, revised 5/2020, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional conditions, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observation, interview, and record review, the facility failed to implement its infection control policy and procedures by failing to ensure Licensed Vocational Nurse 3 (LVN 3) did not place a clear bag used to store a resident's suction tubing (clear plastic, hollow cylinder used with a mechanical device to remove pulmonary secretions [build up inside the lungs]) nebulizer tubing (clear plastic, hollow cylinder connected to a small device that turns liquid medication into a mist for inhalation), and nebulizer mask (clear plastic mask placed over a residents mouth and nose used to deliver medication) from the floor onto the resident's nightstand for one of three sampled residents (Resident 1). This deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff other residents. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2019 and readmitted the resident on 12/9/2022 with diagnoses that included dysphagia oropharyngeal phase (swallowing problems that occur in the mouth and/or throat), gastro esophageal reflux disease (GERD- when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and gastritis (inflammation of the stomach lining). A review of Resident 1's History and Physical (H&P) dated 12/12/2022 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - an assessment and screening too) dated 6/3/2023, indicated the resident was unable to understand others and unable to make herself understood. The MDS further indicated that Resident 1 was totally dependent on staff for bed mobility, transfer , dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Physician Orders indicated orders for the following: 1. albuterol sulfate (medication to open up the airways of the lungs) nebulization solution (changing medication from a liquid to a mist so you can inhale it into your lungs) 0.083 percent (%-unit of measure), three (3) milliliters (mL a unit of measurement) inhale orally via nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) every six hours as needed for shortness of breath or wheezing, dated 5/9/2023. 2. suction secretions every two hours for excessive secretions and every one hour as needed for increased secretions, dated 6/8/2023. During an observation on 6/16/2023 at 10:10 a.m., observed LVN 3 inside Resident 1's room. The clear plastic bag containing Resident 1's suction tubing, nebulizer tubing, and nebulizer mask was observed falling onto the floor. LVN 3 was then observed picking up the clear plastic bag containing Resident 1's suction tubing, nebulizer tubing, and nebulizer mask from the floor and placing it on Resident 1's nightstand. During an interview on 6/16/2023 at 10:55 a.m. with LVN 3, LVN 3 stated she placed the clear plastic bag from the floor back onto Resident 1's nightstand. The Surveyor asked LVN 3 if it was her normal practice to place items from the floor onto the resident ' s nightstand. LVN 3 stated, of course it's not okay to put something from the floor onto the nightstand. LVN 3 stated it was not okay because of possible contamination from the dirty floor to the nightstand. During an interview on 6/16/2023 at 12:45 p.m. with the Director of Nursing (DON), the DON stated staff should not place something from a dirty surface such as the floor, to clean surface such as a resident's nightstand because of the risk for contamination. The DON stated that the bag containing Resident 1's suction tubing, nebulizer tubing, and nebulizer mask should have been considered contaminated once it fell to the floor. A review of the facility policy and procedure titled, Infection Control, last reviewed 5/17/2023, indicated the facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objective of the infection control policies and practices are to: prevent, detect, investigate, and control infections in the facility; and maintain a safe, sanitary, and comfortable environment. Based on observation, interview, and record review, the facility failed to implement its infection control policy and procedures by failing to ensure Licensed Vocational Nurse 3 (LVN 3) did not place a clear bag used to store a resident's suction tubing (clear plastic, hollow cylinder used with a mechanical device to remove pulmonary secretions [build up inside the lungs]) nebulizer tubing (clear plastic, hollow cylinder connected to a small device that turns liquid medication into a mist for inhalation), and nebulizer mask (clear plastic mask placed over a residents mouth and nose used to deliver medication) from the floor onto the resident's nightstand for one of three sampled residents (Resident 1). This deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff other residents. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2019 and readmitted the resident on 12/9/2022 with diagnoses that included dysphagia oropharyngeal phase (swallowing problems that occur in the mouth and/or throat), gastro esophageal reflux disease (GERD- when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and gastritis (inflammation of the stomach lining). A review of Resident 1's History and Physical (H&P) dated 12/12/2022 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS – an assessment and screening too) dated 6/3/2023, indicated the resident was unable to understand others and unable to make herself understood. The MDS further indicated that Resident 1 was totally dependent on staff for bed mobility, transfer , dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Physician Orders indicated orders for the following: 1. albuterol sulfate (medication to open up the airways of the lungs) nebulization solution (changing medication from a liquid to a mist so you can inhale it into your lungs) 0.083 percent (%-unit of measure), three (3) milliliters (mL a unit of measurement) inhale orally via nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) every six hours as needed for shortness of breath or wheezing, dated 5/9/2023. 2. suction secretions every two hours for excessive secretions and every one hour as needed for increased secretions, dated 6/8/2023. During an observation on 6/16/2023 at 10:10 a.m., observed LVN 3 inside Resident 1's room. The clear plastic bag containing Resident 1's suction tubing, nebulizer tubing, and nebulizer mask was observed falling onto the floor. LVN 3 was then observed picking up the clear plastic bag containing Resident 1's suction tubing, nebulizer tubing, and nebulizer mask from the floor and placing it on Resident 1's nightstand. During an interview on 6/16/2023 at 10:55 a.m. with LVN 3, LVN 3 stated she placed the clear plastic bag from the floor back onto Resident 1's nightstand. The Surveyor asked LVN 3 if it was her normal practice to place items from the floor onto the resident's nightstand. LVN 3 stated, of course it's not okay to put something from the floor onto the nightstand . LVN 3 stated it was not okay because of possible contamination from the dirty floor to the nightstand. During an interview on 6/16/2023 at 12:45 p.m. with the Director of Nursing (DON), the DON stated staff should not place something from a dirty surface such as the floor, to clean surface such as a resident's nightstand because of the risk for contamination. The DON stated that the bag containing Resident 1's suction tubing, nebulizer tubing, and nebulizer mask should have been considered contaminated once it fell to the floor. A review of the facility policy and procedure titled, Infection Control, last reviewed 5/17/2023, indicated the facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objective of the infection control policies and practices are to: prevent, detect, investigate, and control infections in the facility; and maintain a safe, sanitary, and comfortable environment.

Based on observation, interview, and record review, the facility failed to ensure: A. Licensed nurses (Licensed Vocational Nurse 1 [ LVN 1] and Licensed Vocational Nurse 3 [LVN 3]) did not use a syringe (a small hallow tube without a needle, fitted with a sliding plunger) to push (the act of depressing the plunger in a syringe to apply force in order to advance medications through the gastrostomy tube [GT or g-tube, a tube that is inserted into the stomach) medications through the GT of one of three sampled residents (Resident 1). B. Facility staff (LVN 3) did not leave one of three sampled residents' (Resident 1) medication unattended at the resident's bedside table. These deficient practices placed Resident 1 at increased risk for abdominal distention (when air or fluid accumulate in the stomach causing expansion), nausea (an urge to vomit), and vomiting; had the potential to result in theft and loss of medication, and place residents at increased risk for drug overdose and or medication errors. Findings: A. A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2019 and readmitted the resident on 12/9/2022 with diagnoses that included dysphagia oropharyngeal phase (swallowing problems that occur in the mouth and/or throat), gastro esophageal reflux disease (GERD- when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and gastritis (inflammation of the stomach lining). A review of Resident 1's History and Physical (H&P) dated 12/12/2022 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - an assessment and screening too) dated 6/3/2023, indicated the resident was unable to understand others and unable to make herself understood. The MDS further indicated that Resident 1 was totally dependent on staff for bed mobility, transfer , dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Physician Orders indicated orders for the following: 1. Clopidogrel bisulfate (a medication used to prevent blood clot [clumps that occur when blood hardens from a liquid to a solid] formation) tablet, 75 milligrams (mg- a unit of measurement), give one tablet by mouth one time a day for cerebrovascular accident (CVA- a loss of blood flow to part of the brain which damages brain tissue) prophylaxis (prevention), dated 5/11/2023. 2. Pantoprazole Sodium (Protonix- a medication that decreases the amount of acid in the stomach) oral packet 40 mg, give one (1) packet via GT one time a day for GERD, dated 6/13/2023. 3. Docusate Sodium (Colace-a stool softener medication) oral tablet 100 mg, give 200 mg via GT two times a day for bowel management, dated 12/9/2022. 4. Hydrocodone-acetaminophen (Norco-medication used to treat moderate to severe pain]) oral tablet five (5) mg of Hydrocodone and 325 mg of acetaminophen (5/325 mg),give one (1) tablet via GT two times a day, dated 5/11/2023. 5. Oxcarbazepine (a medication used to treat seizures [abnormal electrical activity in the brain]) tablet 150 mg, give one (1) tablet via GT three times a day for gastritis, dated 12/13/2022. 6. Mesalamine (medication used to treat gastritis) oral capsule extended release (the medication is released within the body over a period of time) 500 mg, give one (1) capsule via GT three times a day for gastritis, dated 12/14/2022. During a medication pass observation on 6/12/2023 at 11:20 a.m. observed LVN 1 preparing Resident 1's pantoprazole in a medication cup at Station 2, Medication Cart 2. Observed LVN 1 then enter Resident 1's room, assessed the GT, suctioned (draw the medication into the syringe tube) the pantoprazole into a syringe, placed the syringe tip onto the GT and applied pressure to the plunger to advance the medication by push method. LVN 1 was then observed suctioning 30 mL of water into the syringe and then pushing the 30 mL of water into the GT. During an interview on 6/12/2023 at 11:50 a.m. with LVN 1, LVN 1 stated that when she was administering Resident 1's pantoprazole medication, she used the plunger to push the medication through the resident's GT. LVN 1 stated that she was not aware that medication administered through a GT should be given by gravity (the act of removing the plunger, pouring medication into the syringe, and allowing the medication to flow without applying force). During an interview on 6/14/2023 at 11:54 p.m. with the Director of Nursing (DON), the DON stated gravity should be attempted prior to applying gentle boosts with the plunger when administering medications into a GT. The DON stated LVN 1 did not follow the facility policy for GT medication administration because LVN 1 did not first try to administer the medication by gravity. The DON stated it is not the facility's practice to administer GT medication by push. During a medication pass observation on 6/16/2023 at 10:10 a.m. observed LVN 3 prepare Resident 1's medication at Station 2 Medication Cart 2. Observed LVN 3 prepare Norco, Protonix, Colace, clopidogrel, oxcarbazepine, and mesalamine to administer to Resident 1 via GT. Observed LVN 3 place the prepared medications on a tray, walk into Resident 1's room, place the medications and tray on the resident's bedside table, and assessed Resident 1's GT. LVN 3 retrieved the previously prepared medications from the bedside table and administered the medications to Resident 1 by placing each medication separately into the syringe, attaching the syringe to the GT tubing, and applying pressure to the plunger to advance the medication by push method. During an interview on 6/16/2023 at 10:55 a.m. with LVN 3, LVN 3 stated she pushed all of Resident 1's medications via the resident's GT. LVN 3 stated sometimes she administered medications by gravity. LVN 3 stated she administered Resident 1's medications by pushing because it was a habit, but she should have administered the medications to Resident 1 by gravity. During a concurrent interview and record review on 6/16/2023 at 12:45 p.m. with the DON, the facility's policy and procedure titled Medication Administration through an Enteral Tube (a tube connected to the stomach that allows for the administration of food and or medications) was reviewed. The DON stated that she had been informed by LVN 3 that LVN 3 had had used a syringe to push all of Resident 1's medications rather than using gravity. The DON stated that when administering medications via a GT, staff is not to use the syringe to push the medications through the GT. DON stated that by pushing the medications through the GT, it can lead to complications such as stomach upset and or damage the GT. A review of the facility policy and procedure titled, Medication Administration through an Enteral Tube last reviewed 5/17/2023, indicated for staff to allow medications to flow down the medication syringe via gravity. Do not push medications through a tube. Use gentle boosts with plunger, if necessary. B. During a medication pass observation on 6/16/2023 at 10:10 a.m. observed LVN 3 prepare Resident 1's medication at Station 2 Medication Cart 2. Observed LVN 3 prepare Norco, Protonix, Colace, clopidogrel, oxcarbazepine, and mesalamine to administer to Resident 1 via GT. Observed LVN 3 place the prepared medications on a tray, walk into Resident 1's room, place the medications and tray on the resident's bedside table, and assessed Resident 1's GT. LVN 3 then exited Resident 1's room and left Resident 1's medications at bedside out of sight and unattended. LVN 3 walked down the hallway toward Nursing Station 2 and spoke with the Director of Staff Development (DSD). LVN 3 returned to Resident 1's bedside, retrieved the medications from the bedside table and administered the medication to Resident 1. During an interview on 6/16/2023 at 10:55 a.m. with LVN 3 stated that she had left Resident 1's medications at bedside unattended because she walked down the hall to greet a coworker. When asked if leaving medications at bedside out of site and unattended was LVN 3's normal practice, LVN 3 stated of course not. LVN 3 stated leaving Resident 1's medication at bedside unattended was not her normal practice. LVN 3 stated that she should not have left Resident 1's medications out of sight and unattended. During an interview and record review on 6/16/2023 at 12:45 p.m. with the Director of Nursing (DON), the DON stated medications should always be within sight of the medication nurse and if they need to step away, then they should call someone to watch the medication until they return. The DON stated the reason medications are not left out of sight was residents, staff, or visitors could take the medication. The DON stated if another resident took medication not intended for them, then they could have an adverse reaction like low blood pressure, headaches, dizziness, falls, or nausea and vomiting. A review of the facility policy and procedure titled, Specific Medication Administration Procedures, last reviewed 5/17/2023, indicated the facility policy was to administer medications in a safe and effective manner. A review of the facility policy and procedure titled, Medication Administered Through an Enteral Tube, last reviewed 5/17/2023, indicated medications are administered as prescribed in accordance with standard nursing principles and practices only by staff qualified authorized to do so. Medications are administered at the time they are prepared.

Based on observation, interview, and record review, the facility failed to ensure license nurses provided the prescribed medications of metoprolol tartrate (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and benazepril hydrochlorothiazide (benazepril HCL- medication to treat high blood pressure) as ordered by the physician for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at increased risk for hypotension which could then lead to damage of the heart, brain, and other organs. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2019 and readmitted the resident on 12/9/2022 with diagnoses that included hypertension (HTN-high blood pressure). A review of Resident 1's History and Physical (H&P) dated 12/12/2022 indicated the resident did not have the capacity to understand and make decisions. The H&P further indicated to keep the residents systolic blood pressure ( SBP- measures the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) between 130 to 150 millimeters of mercury (mmHg-a unit of measure) per neurology (a branch of medicine that deals with disorders of the brain). A review of Resident 1's Minimum Data Set (MDS - an assessment and screening too) dated 6/3/2023, indicated the resident was unable to understand others and unable to make herself understood. The MDS further indicated that Resident 1 was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Physician Orders indicated orders for the following: 1. Benazepril HCL tablet 20 milligrams (mg- a unit of measurement), give one tablet via gastrostomy tube [GT or g-tube, a tube that is inserted into the stomach) one time a day for HTN, hold if SBP less than 130 mmHg, dated 12/12/2022. 2. Metoprolol Tartrate tablet 50 mg, give one tablet via GT two times a day for HTN, hold if SBP less than 130 mmHg or pulse rate (PR, heart rate [HR]) is less than 60 beats per minute (bmp), dated 12/12/2022. A review of Resident 1's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily) dated June of 2023 noted the following: 1. On 6/13/2023 at 9 a.m., Resident 1's SBP was noted at 127mmHg, the MAR indicated metoprolol and benazepril HCL were both administered to Resident. During a concurrent interview and record review on 6/13/2023 at 12:25 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 reviewed Resident 1's physician orders and MAR for 6/13/2023 at 9 a.m. LVN 2 stated that a MAR is used to document when licensed nurses administer medications to a resident. LVN 2 stated that on 6/13/2023 at 9 a.m. Resident 1's vital signs were as followed: 1. SBP was 127 mmHg 2. HR was 76 beats per minute LVN 2 stated that she administered metoprolol and benazepril to Resident 1. LVN 2 stated the physician's order for benazepril indicated to hold (not give) the medications if Resident 1's SBP was less than 130mmHg. LNV 2 stated technically the benazepril should not have been given because the SBP was less than 130 on 6/13/2023 at 9 a.m. LVN 2 stated the physician's order for metoprolol indicated to hold the medication if Resident 1's SBP was less than 130 or Resident 1's HR was less than 60. LVN 2 stated she gave Resident 1 the medication on 6/13/2023 at 9 a.m. LVN 2 stated it was okay to give Resident 1's ordered metoprolol on 6/13/2023 at 9 a.m. because the HR was over 60. LVN 2 stated the physician order indicated or which meant both the HR and the SBP had to meet the parameters in order to hold the medication. LVN 2 stated it was okay that she gave metoprolol to Resident 1 on 6/13/2023 at 9 a.m. despite the fact that the resident's SBP was less than 130 mmHg. During a concurrent interview and record review on 6/13/2023 12:56 p.m. with Registered Nurse 1 (RN 1), RN 1 reviewed Resident 1's physician orders, progress notes, and MAR dated April, May, and June of 2023. RN 1 stated that Resident 1's physician orders for Metoprolol 50mg dated 12/12/2022 indicated to hold metoprolol if SBP is less than 130 mmHg or HR is less than 60 BMP. RN 1 stated that Resident 1's physician order for benazepril HCL 20mg dated 12/12/2022 indicated to hold the medication for SBP less than 130 mmHg. RN 1 stated the word or in the physician order for metoprolol 50mg dated 12/12/2022 meant to hold the medication if either the SBP was less than 130mmHg or the HR was less than 60 BPM. RN 1 stated that only one of the hold parameters needed to be met for the licensed nurses to not give Resident 1 the medication. RN 1 stated both BP medications should have been held for Resident 1 on 6/13/2023 at 9 a.m. since the resident's SBP was less than 130 mmHg. RN 1 reviewed Resident 1's MAR dated April, May and June of 2023 and progress notes dated April, May and June of 2023 and noted the following: 1. On 4/6/23 at 6 p.m., Resident 1's SBP was noted at 125 mmHg, the MAR indicated metoprolol was administered to Resident 1. 2. On 4/28/23 at 6 p.m., Resident 1's SBP was noted at 126 mmHg, the MAR indicated metoprolol was administered to Resident 1. 3. On 5/4/23 at 9 a.m., Resident 1's SBP was noted at 129 mmHg, the MAR indicated metoprolol and benazepril HCL were administered to Resident 1. 4. On 5/9/2023 at 6 p.m., Resident 1's SBP was noted at 126 mmHg, the MAR indicated metoprolol was administered to Resident 1. 5. On 5/11/2023 at 9 a.m., Resident 1's SBP was noted at 109 mmHg, the MAR indicated metoprolol and benazepril HCL were administered to Resident 1. 6. On 5/25/2023 at 9 a.m. Resident 1's SBP was noted at 129 mmHg, the MAR indicated both metoprolol and benazepril HCL were administered to Resident. 7. On 5/25/2023 at 6 p.m., Resident 1's SBP was noted at 127 mmHg, the MAR indicated metoprolol was administered to Resident 1. 8. On 5/30/2023 at 6 p.m., Resident 1's SBP was noted at 127mmHg, the MAR indicated metoprolol was administered to Resident 1. 9. On 6/13/2023 at 9 a.m., Resident 1's SBP was noted at 127mmHg, the MAR indicated metoprolol and benazepril HCL were both administered to Resident. RN 1 stated licensed nurses should not have administered Resident 1's blood pressure medications of metoprolol or benazepril HCL on the days where the resident's SBP was less than 130 mmHg. During an observation on 6/13/2023 at 1:20 p.m., observed RN 1 speaking with LVN 2 at Station Two, Medication Cart 2. LVN 2 stated Resident 1's metoprolol and benazepril HCL were administered on 6/13/2023 at 9 a.m. despite Resident 1's SBP of 127 mmHg. LVN 2 stated that it was okay that she administered Resident 1's metoprolol, but her administering Resident 1's benazepril HCL was indeed a medication error. RN 1 stated to LVN 2 that LVN 2 should have held both Resident 1's metoprolol and benazepril HCL being that Resident 1's SBP was 127 mmHg. RN 1 stated to LVN 2 that she would inform Resident 1's physician of the medication errors. During an interview on 6/13/2023 at 1:40 p.m. with Registered Nurse 2 (RN 2), RN 2 stated Resident 1's medication of metoprolol and benazepril HCL were ordered with parameters by the physician to hold the medication if Resident 1's SBP was less than 130 mmHg because the resident had a history of stroke. RN 2 stated that Resident 1's physician wanted to sustain Resident 1's SBP greater than 130mmHg to ensure adequate blood flow to the brain. During a concurrent interview and record review on 6/16/2023 at 12:13 p.m. with Licensed Vocational Nurse 5 (LVN 5), LVN 5 reviewed Resident 1's MAR dated May 2023. LVN 5 stated that he had cared for Resident 1 and the MAR indicated that he administered metoprolol on the following dates: 1. 5/9/2023 at 6 p.m. 2. 5/25/2023 at 6 p.m. 3. 5/30/2023 at 6 p.m. LVN 5 stated that on 5/9/2023 at 6 p.m., 5/25/2023 at 6 p.m., and 5/30/2023 at 6 p.m. Resident 1's SBP was less than 130 mmHg. LVN 5 stated that since Resident 1's SBP was less than 130 mmHg, he should not have administered metoprolol to Resident 1. LVN 5 stated sometimes it gets very busy at the facility. LVN 5 stated the importance of holding BP medication per the parameters was to prevent hypotension (low blood pressure). During a concurrent interview and record review on 6/16/2023 at 12:40 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 reviewed Resident 1's MAR dated April 2023. LVN 4 stated on 4/6/2023 at 6 p.m., she documented Resident 1's SBP as 125 mmHg and yet still administered metoprolol to Resident 1. LVN 4 stated that she should hot have administered Resident 1's metoprolol on 4/6/2023 at 6 p.m. as the resident's SBP was noted at 125 mmHg. During an interview and record review on 6/16/2023 at 12:45 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedure regarding medication administration and stated medication should be held per the hold parameters. The DON stated Resident 1's metoprolol and benazepril HCL medications should have been held for the resident whenever the resident had an SBP of less than 130 mmHg. The DON stated if high blood pressure medications are given outside of ordered parameters, it can result in hypotension (low blood pressure). The DON stated the risk of hypotension for Resident 1, who had a history of CVA, was the potential for decreased blood circulation to the brain. A review of the facility policy and procedure titled, Medication Administration General Guidelines, last reviewed 5/17/2023, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by staff qualified and authorized to do so. Medications are administered in accordance with written orders of the attending physician. Based on observation, interview, and record review, the facility failed to ensure license nurses provided the prescribed medications of metoprolol tartrate (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and benazepril hydrochlorothiazide (benazepril HCL- medication to treat high blood pressure) as ordered by the physician for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at increased risk for hypotension which could then lead to damage of the heart, brain, and other organs. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2019 and readmitted the resident on 12/9/2022 with diagnoses that included hypertension (HTN-high blood pressure). A review of Resident 1's History and Physical (H&P) dated 12/12/2022 indicated the resident did not have the capacity to understand and make decisions. The H&P further indicated to keep the residents systolic blood pressure ( SBP- measures the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) between 130 to 150 millimeters of mercury (mmHg-a unit of measure) per neurology (a branch of medicine that deals with disorders of the brain). A review of Resident 1's Minimum Data Set (MDS – an assessment and screening too) dated 6/3/2023, indicated the resident was unable to understand others and unable to make herself understood. The MDS further indicated that Resident 1 was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Physician Orders indicated orders for the following: 1. Benazepril HCL tablet 20 milligrams (mg- a unit of measurement), give one tablet via gastrostomy tube [GT or g-tube, a tube that is inserted into the stomach) one time a day for HTN, hold if SBP less than 130 mmHg, dated 12/12/2022. 2. Metoprolol Tartrate tablet 50 mg, give one tablet via GT two times a day for HTN, hold if SBP less than 130 mmHg or pulse rate (PR, heart rate [HR]) is less than 60 beats per minute (bmp), dated 12/12/2022. A review of Resident 1's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily) dated June of 2023 noted the following: 1. On 6/13/2023 at 9 a.m., Resident 1's SBP was noted at 127mmHg, the MAR indicated metoprolol and benazepril HCL were both administered to Resident. During a concurrent interview and record review on 6/13/2023 at 12:25 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 reviewed Resident 1's physician orders and MAR for 6/13/2023 at 9 a.m. LVN 2 stated that a MAR is used to document when licensed nurses administer medications to a resident. LVN 2 stated that on 6/13/2023 at 9 a.m. Resident 1's vital signs were as followed: 1. SBP was 127 mmHg 2. HR was 76 beats per minute LVN 2 stated that she administered metoprolol and benazepril to Resident 1. LVN 2 stated the physician's order for benazepril indicated to hold (not give) the medications if Resident 1's SBP was less than 130mmHg. LNV 2 stated technically the benazepril should not have been given because the SBP was less than 130 on 6/13/2023 at 9 a.m. LVN 2 stated the physician's order for metoprolol indicated to hold the medication if Resident 1's SBP was less than 130 or Resident 1's HR was less than 60. LVN 2 stated she gave Resident 1 the medication on 6/13/2023 at 9 a.m. LVN 2 stated it was okay to give Resident 1's ordered metoprolol on 6/13/2023 at 9 a.m. because the HR was over 60. LVN 2 stated the physician order indicated or which meant both the HR and the SBP had to meet the parameters in order to hold the medication. LVN 2 stated it was okay that she gave metoprolol to Resident 1 on 6/13/2023 at 9 a.m. despite the fact that the resident's SBP was less than 130 mmHg. During a concurrent interview and record review on 6/13/2023 12:56 p.m. with Registered Nurse 1 (RN 1), RN 1 reviewed Resident 1's physician orders, progress notes, and MAR dated April, May, and June of 2023. RN 1 stated that Resident 1's physician orders for Metoprolol 50mg dated 12/12/2022 indicated to hold metoprolol if SBP is less than 130 mmHg or HR is less than 60 BMP. RN 1 stated that Resident 1's physician order for benazepril HCL 20mg dated 12/12/2022 indicated to hold the medication for SBP less than 130 mmHg. RN 1 stated the word or in the physician order for metoprolol 50mg dated 12/12/2022 meant to hold the medication if either the SBP was less than 130mmHg or the HR was less than 60 BPM. RN 1 stated that only one of the hold parameters needed to be met for the licensed nurses to not give Resident 1 the medication. RN 1 stated both BP medications should have been held for Resident 1 on 6/13/2023 at 9 a.m. since the resident's SBP was less than 130 mmHg. RN 1 reviewed Resident 1's MAR dated April, May and June of 2023 and progress notes dated April, May and June of 2023 and noted the following: 1. On 4/6/23 at 6 p.m., Resident 1's SBP was noted at 125 mmHg, the MAR indicated metoprolol was administered to Resident 1. 2. On 4/28/23 at 6 p.m., Resident 1's SBP was noted at 126 mmHg, the MAR indicated metoprolol was administered to Resident 1. 3. On 5/4/23 at 9 a.m., Resident 1's SBP was noted at 129 mmHg, the MAR indicated metoprolol and benazepril HCL were administered to Resident 1. 4. On 5/9/2023 at 6 p.m., Resident 1's SBP was noted at 126 mmHg, the MAR indicated metoprolol was administered to Resident 1. 5. On 5/11/2023 at 9 a.m., Resident 1's SBP was noted at 109 mmHg, the MAR indicated metoprolol and benazepril HCL were administered to Resident 1. 6. On 5/25/2023 at 9 a.m. Resident 1's SBP was noted at 129 mmHg, the MAR indicated both metoprolol and benazepril HCL were administered to Resident. 7. On 5/25/2023 at 6 p.m., Resident 1's SBP was noted at 127 mmHg, the MAR indicated metoprolol was administered to Resident 1. 8. On 5/30/2023 at 6 p.m., Resident 1's SBP was noted at 127mmHg, the MAR indicated metoprolol was administered to Resident 1. 9. On 6/13/2023 at 9 a.m., Resident 1's SBP was noted at 127mmHg, the MAR indicated metoprolol and benazepril HCL were both administered to Resident. RN 1 stated licensed nurses should not have administered Resident 1's blood pressure medications of metoprolol or benazepril HCL on the days where the resident's SBP was less than 130 mmHg. During an observation on 6/13/2023 at 1:20 p.m., observed RN 1 speaking with LVN 2 at Station Two, Medication Cart 2. LVN 2 stated Resident 1's metoprolol and benazepril HCL were administered on 6/13/2023 at 9 a.m. despite Resident 1's SBP of 127 mmHg. LVN 2 stated that it was okay that she administered Resident 1's metoprolol, but her administering Resident 1's benazepril HCL was indeed a medication error. RN 1 stated to LVN 2 that LVN 2 should have held both Resident 1's metoprolol and benazepril HCL being that Resident 1's SBP was 127 mmHg. RN 1 stated to LVN 2 that she would inform Resident 1's physician of the medication errors. During an interview on 6/13/2023 at 1:40 p.m. with Registered Nurse 2 (RN 2), RN 2 stated Resident 1's medication of metoprolol and benazepril HCL were ordered with parameters by the physician to hold the medication if Resident 1's SBP was less than 130 mmHg because the resident had a history of stroke. RN 2 stated that Resident 1's physician wanted to sustain Resident 1's SBP greater than 130mmHg to ensure adequate blood flow to the brain. During a concurrent interview and record review on 6/16/2023 at 12:13 p.m. with Licensed Vocational Nurse 5 (LVN 5), LVN 5 reviewed Resident 1's MAR dated May 2023. LVN 5 stated that he had cared for Resident 1 and the MAR indicated that he administered metoprolol on the following dates: 1. 5/9/2023 at 6 p.m. 2. 5/25/2023 at 6 p.m. 3. 5/30/2023 at 6 p.m. LVN 5 stated that on 5/9/2023 at 6 p.m., 5/25/2023 at 6 p.m., and 5/30/2023 at 6 p.m. Resident 1's SBP was less than 130 mmHg. LVN 5 stated that since Resident 1's SBP was less than 130 mmHg, he should not have administered metoprolol to Resident 1. LVN 5 stated sometimes it gets very busy at the facility. LVN 5 stated the importance of holding BP medication per the parameters was to prevent hypotension (low blood pressure). During a concurrent interview and record review on 6/16/2023 at 12:40 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 reviewed Resident 1's MAR dated April 2023. LVN 4 stated on 4/6/2023 at 6 p.m., she documented Resident 1's SBP as 125 mmHg and yet still administered metoprolol to Resident 1. LVN 4 stated that she should hot have administered Resident 1's metoprolol on 4/6/2023 at 6 p.m. as the resident's SBP was noted at 125 mmHg. During an interview and record review on 6/16/2023 at 12:45 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedure regarding medication administration and stated medication should be held per the hold parameters. The DON stated Resident 1's metoprolol and benazepril HCL medications should have been held for the resident whenever the resident had an SBP of less than 130 mmHg. The DON stated if high blood pressure medications are given outside of ordered parameters, it can result in hypotension (low blood pressure). The DON stated the risk of hypotension for Resident 1, who had a history of CVA, was the potential for decreased blood circulation to the brain. A review of the facility policy and procedure titled, Medication Administration General Guidelines, last reviewed 5/17/2023, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by staff qualified and authorized to do so. Medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to ensure the hospice services ( a type of medical care for residents who are in the last stages of life) were coordinated and delivered to one of three sampled residents (Resident 1). Resident 1's head of bed (HOB) was not kept elevated at 90 degrees (°- a unit of measure) at all times as ordered by the hospice physician. This deficient practice placed Resident 1 at increased risk for aspiration (when food, liquid, or other material enters a resident ' s airway and eventually the lungs by accident)) and lung infection which could then lead to a decrease in quality of life for a terminally ill (having a disease that cannot be cured and will cause death) resident. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2019 and readmitted the resident on 12/9/2022 with diagnoses that included dysphagia oropharyngeal phase (swallowing problems that occur in the mouth and/or throat), gastro esophageal reflux disease (GERD- when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and gastritis (inflammation of the stomach lining). A review of Resident 1's History and Physical (H&P) dated 12/12/2022 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - an assessment and screening too) dated 6/3/2023, indicated the resident was unable to understand others and unable to make herself understood. The MDS further indicated that Resident 1 was totally dependent on staff for bed mobility, transfer , dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Hospice Physician Order form, dated 5/19/2023 at 2:36 p.m., indicated Resident 1 was found lying flat on her back .Resident 1 is a high risk for aspiration. Physician Orders for the following: 1. Maintain HOB elevated 90 degrees at all times, dated 5/19/2023. 2. Keep resident side lying at all times. Switch position from left to right side every two hours as tolerated, dated 5/19/2023. During an interview on 6/7/2023 at 11:30 a.m. with Hospice Provider 1 (HP 1), HP 1 stated that Resident 1's hospice orders were not being followed by the facility staff. HP 1 stated that the facility's failure to follow the hospice physician orders which included maintaining the resident's HOB at 90 degrees at all times and keeping Resident 1 side lying at all times was affecting the care of Resident 1. HP 1 stated the hospice has a contract with the facility and sends staff to provide care in coordination with the facility, the hospice physician, and the family of Resident 1. HP 1 stated Resident 1's family finds the resident lying flat on her back. HP 1 stated Resident 1 should not be flat on her back because the resident builds up secretions (liquid substances produced by the body, like saliva). During an observation on 6/12/2023 at 1:45 p.m., with Licensed Vocational Nurse 2 (LVN 2) inside Resident 1's room, observed Resident 1 with the HOB elevated to approximately 45 degrees. During a concurrent interview and record review on 6/12/2023 at 2:07 p.m. with Registered Nurse 1 (RN 1), Resident 1's hospice physician order to maintain the HOB elevated to 90 degrees dated 5/19/2023 was reviewed. RN 1 stated she was not aware of the order to keep Resident 1's HOB elevated to 90 degrees at all times. During a concurrent interview and record review on 6/12/2023 at 3:20 p.m. with Registered Nurse 2 (RN 2), Resident 1's hospice physician order to maintain the HOB elevated to 90 degrees dated 5/19/2023, and Resident 1's hospice physician order to keep the resident side lying at all times dated 5/19/2023 was reviewed. RN 2 stated Resident 1 usually has the HOB elevated 30 to 45 degrees and is repositioned every two hours including being placed on her back. RN 2 stated that he was not aware of the hospice physician orders for Resident 1. RN 2 stated there was no documented evidence that the hospice orders to maintain the HOB at 90 degrees at all times and side lying position only were carried out. RN 2 stated the importance of keeping the HOB at the correct elevation was to facilitate breathing and avoid secretion buildup and possible aspiration. RN 2 stated if a resident aspirated, they could get a lung infection and pneumonia. During a concurrent observation and interview on 6/13/2023 at 12:05 p.m. with Certified Nursing Assistant 1 (CNA 1), Resident 1 was observed while inside the resident's room, CNA 1 stated that Resident 1's HOB elevated to approximately 45 degrees. CNA 1 stated that Resident 1 is turned every two hours and is placed on her right side, left side, and on the resident's back. CNA 1 stated she was never told to not place Resident 1 on her back. During an interview on 6/13/2023 at 3:30 p.m., with the Director of Staff Development (DSD), the DSD stated she observes Resident 1 mostly with the HOB elevated at 45 degrees and encourages the CNAs to put Resident 1 in semi-Fowlers at 30 to 45 degrees. The DSD stated she was not aware of an order for Resident 1 to keep the HOB elevated at 90 degrees. During an interview on 6/16/2023 12:45 p.m. the DON stated that the facility staff informed her that there the hospice orders to maintain the HOB of Resident 1 at 90 degrees at all times, and the hospice orders to maintain Resident 1 side lying at all times were not followed. The DON stated that the hospice plan of care was not followed because the hospice orders for Resident 1's positioning were not followed. During an interview on 6/16/2023 at 3:30 p.m. with Hospice Licensed Vocational Nurse 1 (HLVN 1), HLVN 1 stated there were hospice orders for Resident 1 to have the HOB elevated to 90 degrees and keep the resident side lying. HLVN 1 stated she offered to do an in-service for hospice care for the facility, but the facility refused. HLVN 1 stated Resident 1 should not be placed on her back with the HOB lowered than 90 degrees because the resident builds up secretions, vomits, and has crackling (abnormal lung sounds) in the lower lungs. HLVN 1 stated the orders were for safety to prevent aspiration and resulting complications like pneumonia (lung infection). During an interview on 6/23/2023 at 11:15 a.m., with the DON, the DON stated the importance of following the hospice plan of care is to make sure the resident and family are comfortable at the end of the resident's life, and the goal is to maintain the resident's quality of life all the way up to their death to ensure resident passes (dies) in a comfortable manner. A review of the facility policy and procedure titled, Hospice Program, last reviewed 5/17/2023, indicated hospices services are available to residents at the end of life. The policy further indicated that it is the responsibility of the facility to meet the resident ' s personal care and nursing needs in coordination with the hospice representative and ensure the level of care provided is appropriate based on the individual resident needs. These include administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated (described) in the hospice plan of care. Based on observation, interview, and record review, the facility failed to ensure the hospice services ( a type of medical care for residents who are in the last stages of life) were coordinated and delivered to one of three sampled residents (Resident 1). Resident 1's head of bed (HOB) was not kept elevated at 90 degrees (°- a unit of measure) at all times as ordered by the hospice physician. This deficient practice placed Resident 1 at increased risk for aspiration (when food, liquid, or other material enters a resident's airway and eventually the lungs by accident)) and lung infection which could then lead to a decrease in quality of life for a terminally ill (having a disease that cannot be cured and will cause death) resident. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2019 and readmitted the resident on 12/9/2022 with diagnoses that included dysphagia oropharyngeal phase (swallowing problems that occur in the mouth and/or throat), gastro esophageal reflux disease (GERD- when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and gastritis (inflammation of the stomach lining). A review of Resident 1's History and Physical (H&P) dated 12/12/2022 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS – an assessment and screening too) dated 6/3/2023, indicated the resident was unable to understand others and unable to make herself understood. The MDS further indicated that Resident 1 was totally dependent on staff for bed mobility, transfer , dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Hospice Physician Order form, dated 5/19/2023 at 2:36 p.m., indicated Resident 1 was found lying flat on her back .Resident 1 is a high risk for aspiration. Physician Orders for the following: 1. Maintain HOB elevated 90 degrees at all times, dated 5/19/2023. 2. Keep resident side lying at all times. Switch position from left to right side every two hours as tolerated, dated 5/19/2023. During an interview on 6/7/2023 at 11:30 a.m. with Hospice Provider 1 (HP 1), HP 1 stated that Resident 1's hospice orders were not being followed by the facility staff. HP 1 stated that the facility's failure to follow the hospice physician orders which included maintaining the resident's HOB at 90 degrees at all times and keeping Resident 1 side lying at all times was affecting the care of Resident 1. HP 1 stated the hospice has a contract with the facility and sends staff to provide care in coordination with the facility, the hospice physician, and the family of Resident 1. HP 1 stated Resident 1's family finds the resident lying flat on her back. HP 1 stated Resident 1 should not be flat on her back because the resident builds up secretions (liquid substances produced by the body, like saliva). During an observation on 6/12/2023 at 1:45 p.m., with Licensed Vocational Nurse 2 (LVN 2) inside Resident 1's room, observed Resident 1 with the HOB elevated to approximately 45 degrees. During a concurrent interview and record review on 6/12/2023 at 2:07 p.m. with Registered Nurse 1 (RN 1), Resident 1's hospice physician order to maintain the HOB elevated to 90 degrees dated 5/19/2023 was reviewed. RN 1 stated she was not aware of the order to keep Resident 1's HOB elevated to 90 degrees at all times. During a concurrent interview and record review on 6/12/2023 at 3:20 p.m. with Registered Nurse 2 (RN 2), Resident 1's hospice physician order to maintain the HOB elevated to 90 degrees dated 5/19/2023, and Resident 1's hospice physician order to keep the resident side lying at all times dated 5/19/2023 was reviewed. RN 2 stated Resident 1 usually has the HOB elevated 30 to 45 degrees and is repositioned every two hours including being placed on her back. RN 2 stated that he was not aware of the hospice physician orders for Resident 1. RN 2 stated there was no documented evidence that the hospice orders to maintain the HOB at 90 degrees at all times and side lying position only were carried out. RN 2 stated the importance of keeping the HOB at the correct elevation was to facilitate breathing and avoid secretion buildup and possible aspiration. RN 2 stated if a resident aspirated, they could get a lung infection and pneumonia. During a concurrent observation and interview on 6/13/2023 at 12:05 p.m. with Certified Nursing Assistant 1 (CNA 1), Resident 1 was observed while inside the resident's room, CNA 1 stated that Resident 1's HOB elevated to approximately 45 degrees. CNA 1 stated that Resident 1 is turned every two hours and is placed on her right side, left side, and on the resident's back. CNA 1 stated she was never told to not place Resident 1 on her back. During an interview on 6/13/2023 at 3:30 p.m., with the Director of Staff Development (DSD), the DSD stated she observes Resident 1 mostly with the HOB elevated at 45 degrees and encourages the CNAs to put Resident 1 in semi-Fowlers at 30 to 45 degrees. The DSD stated she was not aware of an order for Resident 1 to keep the HOB elevated at 90 degrees. During an interview on 6/16/2023 12:45 p.m. the DON stated that the facility staff informed her that there the hospice orders to maintain the HOB of Resident 1 at 90 degrees at all times, and the hospice orders to maintain Resident 1 side lying at all times were not followed. The DON stated that the hospice plan of care was not followed because the hospice orders for Resident 1's positioning were not followed. During an interview on 6/16/2023 at 3:30 p.m. with Hospice Licensed Vocational Nurse 1 (HLVN 1), HLVN 1 stated there were hospice orders for Resident 1 to have the HOB elevated to 90 degrees and keep the resident side lying. HLVN 1 stated she offered to do an in-service for hospice care for the facility, but the facility refused. HLVN 1 stated Resident 1 should not be placed on her back with the HOB lowered than 90 degrees because the resident builds up secretions, vomits, and has crackling (abnormal lung sounds) in the lower lungs. HLVN 1 stated the orders were for safety to prevent aspiration and resulting complications like pneumonia (lung infection). During an interview on 6/23/2023 at 11:15 a.m., with the DON, the DON stated the importance of following the hospice plan of care is to make sure the resident and family are comfortable at the end of the resident's life, and the goal is to maintain the resident's quality of life all the way up to their death to ensure resident passes (dies) in a comfortable manner. A review of the facility policy and procedure titled, Hospice Program, last reviewed 5/17/2023, indicated hospices services are available to residents at the end of life. The policy further indicated that it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure the level of care provided is appropriate based on the individual resident needs. These include administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated (described) in the hospice plan of care.

Based on interview and record review, the facility failed to document the administration of an initial dose of Keflex (a prescription medicine that is used to treat infections) 500 milligrams (mg- a unit of measurement) in the Medication Administration Record (MAR-serves as a legal record of the drugs administered to a resident in a facility by a health care professional) for one of four sampled residents (Resident 1). This deficient practice had the potential to result in confusion with the care and services for Resident 1 with regards to medications administered, which could place the resident at risk for not receiving the appropriate number of total antibiotic (a drug used to treat infections) doses and can also cause the resident to develop antibiotic resistance (the ability of a microbe [germ] to resist the effects of a drug due to overuse of an antibiotic). Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/14/2022 with diagnoses that included pneumonia (an infection that affects the lungs), sepsis (the body ' s overwhelming and life-threatening response to infection), and type 2 diabetes mellitus (a condition that affects how the body uses blood sugar). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 6/20/2022, indicated that the resident had the ability to make self- understood and the ability to understand others. The MDS indicated that the resident required extensive assistancefrom staff with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1`s Change in Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated 8/12/2022, indicated that Resident 1 was noted with middle of the back cellulitis (a potentially serious skin infection). A review of Resident 1`s Physician`s Order dated 8/12/2022, indicated an order to give 500 mg tablet of Keflex orally (by mouth) two times a day for seven days (7). A review of the facility`s Pharmacy Log, indicated that on 8/12/2022, Licensed Vocational Nurse 2 (LVN 2) obtained one tablet of Keflex 500 mg from the facility ' s emergency ( a kit that contains a small quantity of medications that can be dispensed when pharmacy services are not available). A review of Resident 1 ' s MAR dated 8/12/22, indicated there was no documentation in the MAR that Keflex was administered on 8/12/22. A review of Resident 1`s progress notes dated 8/12/2022 timed at 10:24 p.m. indicated that the first dose of Keflex was taken from the facility emergency kit. During an interview on 5/9/2023 at 10:45 a.m., with Registered Nurse 2 (RN 2), RN 2 stated medication administrations are documented in the electronic MAR or if the computers were under maintenance, they would document the administration in a paper MAR. RN 2 stated that documenting administered medications will help the nurses track the administration of a medication especially if the medication has a parameter (specific instructions that you can measure). RN 2 stated that the nurse that obtains the medication from the medication cart or the emergency kit, has to be the same nurse that will document the administration. During an interview on 5/9/2023 at 11:31 a.m., with Registered Nurse 3 (RN 3), RN 3 stated that administration of medications including initial doses of antibiotics are to be documented in the MAR of a resident. RN 3 stated that if a medication is not documented as administered, RN 3 would assume that the medication was not given. During an interview on 5/22/2023 at 1:33 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that she was the licensed nurse who took out the Keflex from the emergency kit on 8/12/2022 at 10:30 p.m. for Resident 1. LVN 2 stated that she did not document in Resident 1 ' s MAR that she administered a dose of Keflex 500mg on 8/12/2022 at 10: 30 p.m. LVN 2 stated that she should have documented the administration of Keflex to Resident 1 on 8/12/2023 at 10:30 p.m. in the resident ' s MAR. During a concurrent interview and record review on 5/22/2023 at 1:43 p.m. with the Infection Preventionist Nurse (IPN), Resident 1 ' s MAR for 8/12/2022, Progress Notes for 8/12/2022 were reviewed. IPN stated that there was no documented evidence that indicated a time and date that Resident 1 was first administered a dose of Keflex 500mg as ordered by the physician. IPN stated that it is the facility ' s practice that nursing staff is to document the administration of a medication immediately upon administering the medication to a resident. A review of the facility`s policy and procedure titled Procedures for All Medications, dated 5/18/2022, indicated To administer medications in a safe and effective manner . after administration, return to cart and document administration on the MAR, TAR (details administration history by resident/medication for a selected month), or Nursing Progress Notes.

Based on interview and record review, the facility staff failed to follow its policy and procedure to ensure that the medical records for one of four sampled residents (Resident 1) were centrally located within the facility ' s electronic medical record charting system (EMRCS) to ensure that the clinical records provide effective communication among the interdisciplinary team (IDT-a group of experts from various disciplines working together to treat a resident ' s ailment, injury, or chronic health condition). This deficient practice had the potential to result in confusion among the Interdisciplinary Team regarding Resident 1 ' s condition and what care and services were provided to Resident 1 Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/14/2022 with diagnoses that included pneumonia (an infection that affects one or both lungs), sepsis (the body ' s overwhelming and life-threatening response to infection), and type 2 diabetes mellitus (a condition that affects how the body uses blood sugar). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 6/20/2022, indicated that the resident had the ability to make self- understood and the ability to understand others. The MDS indicated that the resident required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1 ' s Change of Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated 8/12/2022, indicated that Resident 1 was noted with middle of the back cellulitis (a common and potentially serious bacterial [are caused by small, single-cell organisms called bacteria that invade the body] skin infection). A review of Resident 1 ' s Progress Notes indicated the following entries handwritten and not in the resident ' s EMRCS, documented by Registered Nurse 1 (RN 1): a) 8/12/2022 notes timed at: 4:00 p.m., 5:30 p.m., 7:40 p.m., 8:00 p.m., 8:10 p.m., 10:06 p.m., 10:24 p.m., 10:25 p.m. b) 8/13/2022 notes timed at: 11:30 a.m., 3:00 p.m., 3:40 p.m., 4:08 p.m., 4:26 p.m. c) 8/14/2022 notes timed at: 10:00 a.m., 11:15 a.m., 11:53 a.m., 12:00 noon; 12:03 p.m., 12:10 p.m., 1:15 p.m., 1:20 p.m., and 1:25 p.m. During an interview on 5/9/2023 at 11:31 a.m., with Registered Nurse 3 (RN 3), RN 3 stated that all residents progress notes are to be documented in the facility ' s EMRCS. RN 3 stated that the only time facility staff is to utilize paper charting is if the EMRCS is down or inoperable. During a concurrent interview and record review on 5/9/2023 at 3:11 p.m., with the Director of Nursing (DON), DON reviewed Resident 1 ' s handwritten progress notes from 8/12/2022 to 8/14/2022 by RN 1. DON stated that nurses can handwrite progress notes outside of the facility ' s EMRCS because it is faster than typing. DON stated that it takes a lot of time typing in the EMRCS. DON stated that RN 1 handwrote the progress notes for Resident 1 from 8/12/2022 to 8/14/2022 because RN 1 is not a typist and RN 1 is slow at typing. During an interview with the Administrator (ADM) on 5/22/2023 at 2:30 p.m., the ADM was asked what the facility considers a centralized charting system. ADM stated that a centralize charting system means any health record can be found anywhere inside the facility. During an interview with Infection Preventionist (IP) on 5/22/2023 at 2:41 p.m., IP stated that on the dates of the handwritten progress notes for Resident 1 documented by Registered Nurse 1 (RN 1) on 8/12/2022, 8/13/2022, and 8/14/2022, the facility ' s EMRCS was fully operational. During an interview with the Director of Staff Development (DSD) on 5/22/2023 at 3:20 p.m., DSD stated the facility ' s EMRCS is the centralize and standardized location for resident medical records. DSD stated that facility staff is encouraged to document in the facility ' s EMRCS, but it is also the practice of the facility to allow medical records to be documented via paper documentation even if the ability to document within the EMRCS is available. DSD stated that the facility does allows the nursing staff to freely use their own discretion as to when or when not to use the facility ' s EMRCS. DSD stated that because the facility allows the nurses to document resident care records in multiple different sources such as paper documentation and or within the EMRCS, a resident ' s medical records can be placed in multiple different areas. When the DSD was asked if storing medical records in multiple different locations increases the likelihood for resident medical records to be overlooked, and or inadvertently missed by other members of the IDT, DSD stated yes, the risk for a medical record to be overlooked or missed by the IDT is increased. DSD stated that it is important for staff to utilize the EMRCS because it can cause less confusion and help increase efficiency. DSD stated that by exclusively using the EMRCS, it would increase efficiency because it allows the user to search and find documentations faster as it is located in one system. When the DSD was asked if the facility allowing the staff to pick and choose when they want to utilize the EMRCS helps centralize the charting system, the DSD stated no it does not. During an interview on 5/22/2023 at 4:37 p.m. with Registered Nurse 2 (RN 2), RN 2 stated that the facility ' s centralized system for medical records is the EMRCS. RN 2 stated that the facility allows the staff to use their own discretion to freely choose when and when not to use the EMRCS. When RN 2 was asked if they document medical records outside of the EMRCS despite being able to make the documentation electronically, RN 2 stated yes. RN 2 stated that there are multiple records that he documents outside of the EMRCS that are available to be documented within the facility ' s EMRCS. RN 2 states that he chooses to document certain resident medical records on paper rather than utilizing the facility EMRCS because he finds it more convenient When RN 2 was asked how he would be able to improve and become more efficient with using the facility ' s EMRCS if he chooses to document via paper for convenience, RN 2 stated that he would make more of an effort to utilize the facility ' s EMRCS. A review of the facility ' s policy and procedure titled Chapter III Legal Health Records dated 9/18/18 indicated that all clinical information regarding a resident ' s stay will be centralized in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nurses followed physicians ' orders to apply a bed alarm (device that contains sensors that trigger an alarm or warning light when it detects a change in pressure) or tab alarm (features a pull-string that attaches magnetically to the alarm with a garment clip to the resident) while residents, who were high risk for falls, were in bed for two (Residents 5 and 6) out of seven sampled residents. This deficient practice had the potential to result in major injuries from a fall to Resident 5 and 6. Findings: a. A review of Resident 6 ' s admission Record indicated the facility originally admitted the resident on 4/9/2021 and readmitted the resident on 10/23/2022 with diagnoses including dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and generalized muscle weakness. A review of Resident 6 ' s Minimum Data Set (MDS – a standardized assessment cand care screening tool), dated 1/25/2023, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 4/13/2023 at 3:54 p.m., during a concurrent observation, interview, and record review, reviewed Resident 6 ' s physician ' s orders with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated the resident had an order for a bed alarm, dated 4/6/2023. Observed resident awake in bed. LVN 2 verified that the resident did not have a bed alarm. On 4/14/2023 at 12:50 p.m., during a concurrent interview and record review, reviewed Resident 6 ' s Post-Fall Risk Assessment (dated 4/6/2023), fall care plan (initiated on 4/6/2023) (contains relevant information about a resident ' s diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), and Change in Condition Evaluation (dated 4/6/2023) (COC – provides a framework for communication between members of the health care team about a resident ' s condition) with Minimum Data Set Nurse 1 (MDSN 1). MDSN 1 stated that the resident fell in the facility on 4/6/2023. MDSN 1 stated that, according to the resident ' s Post-Fall Risk Assessment, dated 4/6/2023, the resident was considered high risk for falls. MDSN 1 stated that a bed alarm was added to the resident ' s fall care plan, which was initiated on 4/6/2023. On 4/14/2023 at 4:06 p.m., during an interview, the Director of Nursing (DON) stated that Resident 6 had recently fallen in the facility. The DON stated the potential outcome for not following the physician ' s order for a bed alarm was an increased risk for fall. The DON stated the resident may have periods of confusion and may not be able to call for assistance. The DON stated that sometimes residents may think they are strong enough to do things on their own. A review of the facility ' s policy and procedure titled, Fall – Prevention, indicated that if a resident is the policy [sic] of this facility, that upon admission of a resident, the admitting nurse will initiate the Fall Risk Assessment as part of the admission screening. If the resident has a total score of 45 and above, said resident will be considered high risk for fall. The nurse supervisor will then initiate a care plan and will list or endorse the resident and the CNA assigned. The interdisciplinary team (IDT - an approach to healthcare that integrates multiple disciplines through collaboration) will then be informed and will be discussing appropriate measures to impose the prevention of falls such as regular assessment of the need to use any type of device needed. b. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 1/31/2022 with diagnoses including dementia and generalized muscle weakness. A review of Resident 5 ' s MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making and required extensive assistance from staff for bed mobility, dressing, eating, toilet use, and personal hygiene. On 4/13/2023 at 3:24 p.m., during a concurrent observation, interview, and record review, reviewed Resident 5 ' s physician ' s orders with the Director of Staff Development (DSD) and Infection Preventionist (IP). The DSD stated the resident had an order for a tab alarm while in bed to alert staff when resident attempts to get out of bed unassisted, ordered on 5/10/2022. Observed the resident awake in bed. The DSD and IP verified that the resident did not have a tab alarm on his bed. On 4/14/2023 at 12:50 p.m., during a concurrent interview and record review, reviewed Resident 5 ' s Quarterly Fall Risk Assessment (dated 3/29/2023), fall risk care plan, and Quarterly Device Evaluation Tool (dated 3/29/2023) with MDSN 1. MDSN 1 stated that, according to the resident ' s Quarterly Fall Risk Assessment, dated 3/29/2023, the resident was high risk for falls. MDSN 1 stated that, according to the Quarterly Device Evaluation Tool, dated 3/23/2023, the IDT agreed to continue using the tab alarm while the resident is in bed to alert staff when the resident attempts to get out of bed due to the resident ' s impairment in cognition and communication. The IDT also indicated that the resident aphasic (a disorder that affects how you communicate), unable to verbalize needs, and his safety awareness and judgment were poor. MDSN 1 stated that the resident ' s fall risk care plan indicated for the resident to have a tab alarm while in bed. On 4/14/2023 at 4:06 p.m., during an interview, the DON stated she was later informed by the nurses that Resident 5 ' s tab alarm was inside the drawer of his nightstand. The DON stated it should have been attached to the resident since he is a high risk for falls. The DON stated the potential outcome for not following the physician ' s order for a bed alarm was an increased risk for fall. The DON stated the resident may have periods of confusion and may not be able to call for assistance. The DON stated that sometimes residents may think they are strong enough to do things on their own. A review of the facility ' s policy and procedure titled, Fall – Prevention, indicated that if a resident is the policy [sic] of this facility, that upon admission of a resident, the admitting nurse will initiate the Fall Risk Assessment as part of the admission screening. If the resident has a total score of 45 and above, said resident will be considered high risk for fall. The nurse supervisor will then initiate a care plan and will list or endorse the resident and the CNA assigned. The interdisciplinary team will then be informed and will be discussing appropriate measures to impose the prevention of falls such as regular assessment of the need to use any type of device needed.

Based on observation, interview, and record review, the facility failed to maintain the kitchen pest free (free of cockroaches) and prevent pest harborage areas. This deficient practice had the potential to place all 114 residents residing in the facility and receiving food or utensils from the kitchen at risk of vector-borne diseases (Illness that results from infections transmitted to humans by insects, such as cockroaches) if cockroaches spread in the facility. Findings: On 4/3/2023, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint about physical environment. The Public Health permit to operate the kitchen was suspended due to live cockroach and live nymph found ware wash unit. During a concurrent observation and interview with the Maintenance Supervisor (MS) on 4/3/2023, at 3:59 p.m., the evaluator observed crevices behind the drain board (between the wall and the drain board) at the dish washing area. The MS confirmed observation and stated, the crevices will be sealed. During a concurrent observation and interview with the MS on 4/3/2023, at 4:03 p.m., the evaluator observed deteriorated wall covering creating crevices on the wall below the left side of dish washing drain board at the dish washing area. The MS confirmed observation and stated that the wall covering will be fixed and the crevices will be sealed. During a concurrent observation and interview with the MS on 4/3/2023, at 4:08 p.m., the evaluator observed one live nymph (immature cockroach) on the wall below the right side of the drain board at the dish washing area. The MS confirmed observation and reached out to kill the cockroach with a napkin. During a concurrent observation and interview with the MS on 4/3/2023, at 4:08 p.m., the evaluator observed crevices on the bottom wall (where the wall and tiles meet) inside the dry storage room. The MS confirmed observation. During a concurrent observation and interview with the MS, on 4/3/3023, at 4:30 p.m., the evaluator observed crevices and open pipes on the wall under and around the three-compartment sink area. The MS confirmed observation and stated, openings will be sealed. During a concurrent observation and interview with the MS, on 4/3/2023, at 4:47 p.m., the evaluator observed another nymph cockroach on the wall going in and out of the holes around an electrical box below the right side of the dish washing drain board. The MS confirmed observation. During an interview with the MS, on 4/3/2023, at 4:25 p.m., the MS stated that cockroaches are very hard to control and that when one cockroach gets in the facility and survives, they reproduce, they make a lot . On 4/4/2023 at 9:45 a.m., during an interview with the Director of Nursing (DON), the DON stated that there were 111 residents who received oral feeding from the kitchen and three residents on enteral feeding (intake of food through a tubing directly into the gastrointestinal tract); the water for these three residents was placed in water pitchers sanitized in the kitchen. The DON stated the pest control program included a regular twice a month service and as needed. Per DON, the result of the inspection by the EHS was reported to her by the Dietary Supervisor (DS) wherein live cockroaches were observed in the kitchen area. According to the DON, presence of cockroaches can contaminate the food and can result to foodborne illnesses (types of foodborne illnesses spread by cockroaches; salmonella, Escherichia coli, and listeria monocytogenes) among the residents in the facility. A review of the facility's Pest Control policy and procedure, reviewed and approved on 5/18/2022, the document indicated that the facility shall maintain an effective pest control program and that the facility maintains an on-going pest control program to ensure that the building is kept as free as possible of insects and rodents . A review of the facility's Safe Environment policy and procedure, reviewed and approved on 5/18/2022, the document indicated that It is the policy of the facility to provide a safe environment in accordance with State and Federal regulations . The procedure include: 1. The facility will be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel, and the public. 2. The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 3. The facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 4. The facility will maintain an effective pest control program. A review of the facility's Sanitation policy and procedure, dated 2018, the document indicated that On a monthly basis, a pest control company will inspect and service the Food & Nutrition Services Department. If any time additional servicing is needed, the pest control company will be notified. A review of the facility`s Food Borne Illness Outbreak policy and procedure (PP), dated 2018, indicated an important factor which led to many foodborne illness outbreaks includes insects and rodents. The PP indicated scenarios and examples such as failure to eliminate pest breeding or entry areas, failure to eliminate grime, spilled food, breeding and nesting attractions for pest and failure to report and take control action when pests or evidence of pest are noted.

Based on observation, interview and record review, the facility failed to ensure one of three staff, Certified Nursing Assistant 1 (CNA 1) failed to remove the protective gown before leaving Resident 1 ' s room who was on isolation precautions (intended to minimize spread of infection) for Coronavirus Disease 2019 (COVID-19, highly contagious respiratory illness in humans capable of producing severe symptoms). This deficient practice has the potential to result in the spread of the COVID-19 to all residents and staff. Findings: A review of Resident 1 ' s admission Record (Face Sheet), indicated the facility admitted the resident on 12/3/2022 with diagnoses including alcohol abuse, Coronavirus Disease 2019 (COVID-19, highly contagious respiratory illness in humans capable of producing severe symptoms) and difficulty in walking. A review of Resident 1 ' s History and Physical Examination dated 12/4/22, indicated, resident had the capacity to understand and make decisions. A review of Resident 1 ' s Order Summary Report (physician order) dated 12/3/2022, indicated an order for contact droplet isolation (are used to prevent touching an infected person and their belongings which might be exposed with mucus and other secretions from the nose and sinuses, throat, airways, and lungs when a person talks, sneezes or coughs, droplets containing germs that can travel about three feet) due to COVID-19. A review of Resident 1 ' s care plan on isolation for COVID-19 dated 12/3/2022, indicated an intervention to place resident on isolation and observe isolation precautions and use PPE (personal protective equipment) utilize appropriately. During an observation on 12/12/2022 at 10:14 a.m., in the red zone unit (area designated for COVID-19 positive residents), CNA 1 donned (put on) a protective gown before entering Resident 1 ' s room and left the room wearing the protective gown and went to the staff breakroom. During a concurrent observation and interview on 12/12/2022 at 10:15 a.m., with Registered Nurse 1 (RN 1) in the red zone unit. RN 1 observed CNA 1 inside the staff break room with protective gown on. RN 1 stated CNA 1 should remove his gown before leaving Resident 1 ' s room and place the soiled protective gown in the designated trash bin inside the room to prevent the spread of COVID-19. During an interview on 12/12/2022 at 10:17 a.m., CNA 1 stated he went inside Resident 1 ' s room but the resident requested water, so he went out and forgot to remove the protective gown before leaving the room. During an interview on 12/12/2022 at 10:30 p.m., the Infection Preventionist (IP) stated protective gown should be remove before leaving the isolation room for infection control. During an interview on 12/12/2022 at 10:40 a.m., with the Director of Nursing (DON), the DON stated NA 1 should remove his protective gown before leaving Resident 1 ' s room for infection control. A review of facility ' s policy and procedure titled, Universal Source Control: Personal Protective Equipment, dated 1/6/2022, indicated, All staff members, regardless of vaccination status, must don and doff gowns each resident encounter with symptomatic residents and /or asymptomatic yet recently exposed to positive COVID-19 infection, or in accordance with the current federal, state, or local health department guidance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there was a dignity bag (a cover for a catheter bag, used to protect one's dignity) to cover a resident's indwelling catheter (a tube inserted into the bladder allowing urine to drain from the bladder) drainage bag (bag used to collect urine) for one (Resident 84) out of one resident sampled for dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 84's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis that included retention of urine (a condition in which one's bladder does not empty completely). A review of Resident 84's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 05/04/2021, indicated the resident had severe impairment in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. The MDS also indicated the resident had an indwelling catheter (a tube inserted into the bladder allowing urine to drain from the bladder). A review of Resident 84's Order Summary Report (a summary of physicians' orders) indicated there was a physician's order, dated 03/13/2021, for a Foley catheter (the most common type of indwelling urinary catheter) 16 French gauge (Fr - diameter of thickness of the tube)/10 milliliter (ml - unit of measurement) balloon (inflated after the catheter is properly placed in the bladder to help keep the catheter seated in the bladder) connected to drainage bag secondary to urinary retention. On 06/01/2021 at 10:25 a.m., during an observation, observed Resident 84 asleep in bed. Resident's indwelling catheter (a tube inserted into the bladder allowing urine to drain from the bladder) drainage bag (bag used to collect urine) was hanging off the side of his bed facing his roommate. The drainage bag did not have a dignity bag (a cover for a catheter bag, used to protect one's dignity) to cover it. Dark yellow urine inside the drainage bag was clearly visible to the resident's roommate. On 06/01/2021 at 10:40 a.m., during a concurrent observation and interview, Certified Nursing Assistant 3 (CNA 3) verified the resident did not have a dignity bag to cover his urinary drainage bag. CNA stated it was the facility's practice to put a dignity bag over residents' catheter drainage bags. CNA stated the importance of using a dignity bag to cover the drainage bag was so no one could see the resident's urine inside the bag, which would maintain the resident's sense of dignity. On 06/07/2021 at 10:37 a.m., during an interview, the Director of Nursing (DON) stated nurses were supposed to put a dignity bag over residents' urinary catheter drainage bag so the resident could have some privacy. A review of the facility's policy and procedures titled, Quality of Life - Dignity, revised on 02/2020, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem . Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect Resident 21's back brace (device used to support the lower back) from loss or theft, for one of one sampled residents. This deficient practice had the potential to result in limited functional movement and restricted participation in activities for Resident 21. Findings: A review of the admission Record indicated Resident 21 was originally admitted to the facility on [DATE], with diagnoses that included difficulty in walking, muscle weakness, and fracture of the backbone. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 9/28/2020, indicated Resident 21 had intact cognition (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated Resident 21 required supervision to extensive assistance with activities of daily living (ADLs - routine activities people do every day). A review of Resident 21's Inventory of Personal Effects, dated 9/22/2020, indicated items acquired included one black back support belt. During a concurrent observation and interview, on 6/1/2021 at 10:26 a.m., Resident 21 stated he had lost his back brace upon return from general acute care hospital (GACH) and could not do the physical therapy. Resident 21 reported to the facility staff they facility staff were unable to obtain it. There was no back braces observed in his room. During a concurrent interview and record review, on 6/3/2021 at 3:20 p.m., Minimum Data Set Nurse 1 (MDS 1) confirmed the inventory list on 9/22/2020 included one black back brace. MDS 1 stated the resident was last re-admitted to the facility from the hospital was on 11/18/2020. During an interview, on 6/3/2021 at 3:28 p.m., Occupational Therapist (OT) stated Resident 21 ambulated in the room using the back brace in 12/2020. During an interview, on 6/3/2021 at 4:04 p.m., the Certified Nurse Assistant 4 (CNA 4) stated Resident 21 had a black back brace upon admission on [DATE]. CNA 4 stated Resident 1 requested for her to look for his back brace sometime in 1/2021 and could not find it. CNA 4 stated she reported this to the Registered Nurse 1 (RN1) and Social Service Director (SSD). During an interview, on 6/3/2021 at 4:25 p.m., the RN1 stated CNA 4 reported Resident 21's missing back brace. RN 1 stated she looked for the brace and could not found it. RN 1 stated that she reported the missing brace to the SSD. RN 1 stated she did not follow up with the SSD. RN 1 stated she should have followed up and make it available for him. RN 1 stated that it was important for the resident to support his back. During a concurrent interview and record review, on 6/3/2021 at 4:32 p.m., the SSD stated she did not remember that anyone reported to her regarding Resident 21's lost back brace. The SSD stated she usually filed missing items in Theft and Lost log book. The SSD stated there was no documented evidence in theft and lost log book regarding Resident 21's back brace. The SSD stated she should have done an investigation and contacted the rehabilitation director to replace the item. The SSD stated because Resident 21's back brace was part of his inventory list, the facility was responsible of the replacement. During an interview, on 6/7/2021 at 3:10 p.m., the Director of Nursing (DON) stated CNA 4 and RN 1 should have reported the missing item to herself or the Director of staff Development (DSD). The RN 1 should have followed up to ensure whether the back brace was found or replaced. The DON stated the facility should have been responsible of replacing the back brace. A review of the facility's undated policy titled, Personal Property, indicated residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. A review of the facility's policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised in 12/2006, indicated when as incident of theft and or misappropriation of resident property is reported, the Administrator will appoint a staff member to investigate the incident. The Administrator or his designee will notify the resident and/or the resident's representative (sponsor) of the result of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Registered Nurse 2 (RN 2) verified gastrostomy tube (g-tube - a tube inserted through the belly that brings nutrition directly to the stomach) placement before administering medications, as indicated in the policy, for one (Resident 507) out of six sampled residents observed for medication administration. This deficient practice had the potential to result in the resident not receiving his medications. Findings: A review of Resident 507's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status (resident has a gastrostomy tube [g-tube - a tube inserted through the belly that brings nutrition directly to the stomach]). A review of Resident 507's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/25/2021, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS also indicated the resident was totally dependent on staff for eating and required extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. The MDS also indicated the resident had a feeding tube (a device inserted into one's stomach through the abdomen). A review of Resident 507's care plan, initiated on 06/01/2021, indicated the resident was at risk for aspiration (when a person accidentally inhales an object or fluid into their windpipe and lungs), dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake), tube feeding intolerance (the inability to digest enteral feedings), social isolation, and significant weight changes as the resident required a feeding tube related to dysphagia, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety, psychosis (a mental disorder characterized by a disconnection from reality), and encephalopathy (any brain disease that alters brain function or structure). The care plan also indicated the resident had episodes of pulling out his g-tube despite risks and benefits explained. Among the interventions was to check tubing for placement before administering feeding or medications. On 06/03/2021 at 04:23 p.m., during medication administration observation, observed Registered Nurse 2 (RN 2) administer the following medications to Resident 507: 1. Bethanechol (used to relieve difficulties in urinating) 50 milligrams (mg - unit of measurement) 2. Apixaban (anticoagulant - used to treat and prevent blood clots) 5 mg 3. Simethicone (used to reduce bloating, discomfort, or pain caused by excessive gas) 80 mg 4. Vancomycin Hydrochloride (antibiotic used to treat inflammation of the intestine caused by certain bacteria) 50 mg/milliliter (ml - unit of measurement), 2.5 ml 5. Metoprolol (treats high blood pressure) 25 mg RN 2 did not check for g-tube placement prior to administering the medications. RN 2 did not have a stethoscope (medical instrument used in listening to sounds produced within the body) with her. On 06/07/2021 at 10:45 a.m., during an interview, the Director of Nursing (DON) stated the nurse should have checked g-tube placement before administering the medications. A review of the facility's policy and procedures titled, Medication Administration - General Guidelines, dated 04/2008, indicated that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. A review of the undated article titled, Clinical Practice Guideline: Gastric Tube Placement Verification, indicated that gastric tube misplacement can result in serious and even lethal complications such as respiratory distress or death. The standard of care requires placement verification of the gastric tube prior to its use in order to minimize complications resulting from misplacement. A review of the facility's policy and procedures titled, Specific Medication Administration Procedures - Enteral Tube Medication Administration, dated 04/2008, indicated to verify tube placement by inserting a small amount of air into the tube with the syringe and listening to the stomach with a stethoscope for gurgling sounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including hypertension (increased blood pressure), anemia (lack enough healthy red blood cells to carry adequate oxygen to body's tissues) and protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 10/6/2020, indicated Resident 39 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated Resident 39 required extensive assistance with activities of daily living (ADLs - routine activities people do every day). A review of Resident 39's Order Summary Report, dated 5/8/2021, indicated to provide low air loss mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure ulcers) for wound prevention every shift. A review of Resident 39's Care Plan (written guide that organizes information about the resident's care), dated 5/1/2020, indicated Resident 39 was at risk for skin impairment. The care plan interventions included to provide pressure reducing mattress. A review of the Weights and Vitals Summary indicated Resident 39's weight on 5/1/2021 was 138 pounds (lbs. -unit of weight measurement). During an observation, on 6/1/2021 at 9:15 a.m., Resident 39 was observed on LAL mattress with weight settings above 400 lbs. During a concurrent observation and interview, on 6/1/2021 at 11:02 a.m., the Director of Staff Development (DSD) confirmed the weight setting on LALM was greater than 400 lbs. The DSD stated the weight setting on the LALM mattress should depend on resident 39's weight. The DSD stated the weight settings on the LAL mattress was not helpful for resident's skin management. During a telephone interview, on 6/4/2021 at 2 p.m., the (Company name) LAL mattress representative (MR), stated the LAL mattress pressure set up should be equal to resident's weight. During an interview, on 6/4/2021 at 2:16 p.m., the Licensed Vocational Nurse 3 (LVN 3), stated Resident 39's weight was 138 lbs. LVN 3 stated the weight settings on the LALM mattress should have between 80 and 160 lbs. LVN 3 stated she should have checked the LAL mattress set up to make sure it was in the therapeutic level. She also stated it was important to protect the resident's skin and prevent development of pressure ulcer. During an interview, on 6/7/2021 at 3:25 p.m., the Director of Nursing (DON) stated Resident 39's LALM should have been equal to resident's body weight. She also stated it was important to prevent the development of pressure ulcers for the resident. A review of the facility-provided, undated User's Manual titled Medline Supra APL - Alternating Pressure Therapy Pump Overlay/ Replacement Mattress, indicated this system is a high quality, affordable mattress system, suitable for the treatment and prevention of pressure ulcers. The pressure adjustment knob controls the air pressure in the mattress. Higher pressures will support heavier patients. A review of the facility's policy titled, Pressure Sores-Quality of Care, revised in 4/2013, indicated this facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility without pressure sores, does not develop pressure sores, unless pressure sores may be expected and unavoidable, due to the predictable cyclical patterns of the resident's clinical condition, or the resident or his/her representative's refusal care and treatment to prevent sores. Based on the comprehensive assessment of a resident, the resident's risk for pressure sores shall be identified, using the resident assessment protocols. Aggressive preventative care shall be provided and included within the care plan. Some of the examples are as follows: Application of pressure reduction relief devices. Based on observation, interview, and record review, the facility: 1. Failed to provide a resident with heel protectors (a medical device usually constructed of foam, air-cushioning, gel, or fiber-filling, and is designed to minimize or remove weight on the heel) and failed to offload (minimize or remove weight placed on the foot to help prevent and heal ulcers) the resident's heels, as ordered by the physician, for one (Resident 43) out of four sampled residents investigated for pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice had the potential to increase the resident's risk of developing a pressure ulcer. 2. Failed to ensure the resident's low air loss mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure ulcers was set according to the resident's weight per manufacturer's guidelines, for one (Resident 39) out of four sampled residents investigated for pressure ulcer/injury. This deficient practice placed the resident at risk for discomfort and development of pressure ulcers. Findings: a. A review of Resident 43's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included generalized muscle weakness (muscle weakness throughout the body) and unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of Resident 43's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/05/2021, indicated the resident was severely impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS also indicated the resident was totally dependent on staff for transfers, locomotion on and off the unit, toilet use, and personal hygiene, and required extensive assistance for bed mobility. The MDS also indicated the resident was at risk of developing pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin). A review of Resident 43's Order Summary Report (a summary of a resident's physicians' orders), dated 05/28/2021, indicated a physician's order, dated 07/29/2020, for heel protectors (a medical device usually constructed of foam, air-cushioning, gel, or fiber-filling, and is designed to minimize or remove weight on the heel) on both heels when in bed every shift. The Order Summary Report also indicated a physician's order, dated 07/29/2020, to offload minimize or remove weight placed on the foot to help prevent and heal ulcers) both heels with a pillow under the legs in bed every shift. A review of Resident 43's care plan (contains all of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders [including what observations are needed and what actions must be performed], and a plan for evaluation), initiated on 08/20/2020, for high risk for skin breakdown related to fragile skin indicated a goal that the resident will maintain skin integrity through the next review date. Among the interventions listed was to offload both heels with a pillow under the legs every shift. On 06/02/2021 at 1:12 p.m., during an observation, observed Resident 43 awake in bed. The resident had no heel protectors on, and the resident's heels were not offloaded with a pillow. Both the resident's heels were on the bed. On 06/03/2021 at 10:14 a.m., during a concurrent observation and interview, observed Resident 43 awake in bed. The resident had a pillow under her knees, but both heels were on the bed. Certified Nursing Assistant 5 (CNA 5) verified the resident did not have heel protectors on. On 06/03/2021 at 3:03 p.m., during a concurrent interview and record review, Minimum Data Set Nurse (MDS 3) stated the resident was at moderate risk for developing a pressure ulcer. MDS 3 stated, according to the resident's care plan for high risk for skin breakdown, the resident's heels should be offloaded with a pillow every shift. MDS 3 also stated the resident had a physician's order to have heel protectors on while in bed every shift. On 06/03/2021 at 3:09 p.m., during a concurrent observation and interview, MDS 3 verified the resident did not have any heel protectors on while in bed, and there were none to be found at her bedside. On 06/07/2021 at 10:41 a.m., during an interview, the Director of Nursing (DON) stated the resident's heels should have been offloaded as a preventative measure for pressure injuries. A review of the facility's policy and procedures titled, Pressure Sores - Quality of Care, revised on 04/2013, indicated the facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility without pressure sores, does not develop pressure sores, unless pressure sores may be expected and unavoidable, due to the predictable cyclical patterns of the resident's clinical condition, or the resident or his/her representative's refusal of care and treatment to prevent sores. Based on the comprehensive assessment of a resident, the resident's risk for pressure sores shall be identified, using the Resident Assessment Protocols. Aggressive preventative care shall be provided and included within the care plan. Some of these examples are as follows: a) Turning and proper positioning, b) Application of pressure reduction relief devices, c) Providing good skin care, d) Providing clean and dry bed linens, e) Maintaining adequate nutrition, as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor nutritional parameters for Resident 1's insidious weight loss (gradual, unplanned progressive weight loss over time) for one of one sampled resident (Resident 1). This failure had the potential to result in continued undesirable weight loss. Findings: During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a disease that causes obstructed airflow from the lungs), generalized muscle weakness, essential hypertension (high blood pressure), and asthma (a condition where a person's airways become inflamed that causes difficulty in breathing). During a review of the Minimum Data Set (MDS- a standardized assessment and care-planning tool, dated 5/14/2021, indicated Resident 1 had severe cognitive impact function. The MDS indicated Resident 1 required one person physical assistance for bed mobility, limited assistance with one person physical assist for transfer, and limited assistance with one person physical assist for walk in room. A review of the Order Summary Report, dated 7/22/2019, indicated Resident 1 was on No Added Salt (NAS) diet Dysphagia (difficulty swallowing) Mechanical texture, thin liquid consistency. A review the Progress Notes, dated 10/22/2020, indicated Resident 1 was on monitoring for poor oral intake and needed a Registered Dietician consult. A review of the Progress Notes, dated 1/13/2021, indicated Resident weighed 144 lb (pounds) with 4 lb loss for 30 days . The record indicated weight loss was related to variable meal intake with noted with decline with episodes less than 50%. Resident 1 required more assistance with meals at times. Resident 1 was at risk for weight changes. Recommendation: Weekly weight for 4 weeks. Diet and supplementation at estimated nutrition needs. The record indicated will review weight, labs, and meal tolerance. According to the Weights and Vitals Summary, the following was Resident 1's weights: On 1/4/2021, Resident 1 weighed 144 pounds (weight loss four pounds). On 1/28/2021, Resident 1 weighed 144 pounds. On 2/1/21, Resident 1 weighed 140 pounds (weight loss of four pounds). On 2/4/21, Resident 1 weighed 140 pounds. There was no follow up dietary note and no new nutrition interventions when Resident 1 lost four pounds from 1/28/21 to 2/4/21. During a concurrent dining observation and interview, on 6/1/2021 at 12:55 p.m., Resident 1 was observed screaming out loud that she did not like her lunch. Resident 1 stated she wanted a pizza pie and chicken nuggets, not the pureed food that they gave her. The Certified Nursing Assistant (CNA 1) stated Resident 1 had no dentures and the speech therapist placed her on this diet. CNA 1 stated that Resident 1 did not like the food because of the puree texture. During an interview, on 6/1/21 at 1:10 p.m., the Licensed Vocational Nurse (LVN1) stated Resident 1 cried because she did not want her food and wanted something else not pureed. LVN 1 stated that at times, Resident 1 refused her meal tray and had failed speech therapy. During a concurrent interview and record review, on 6/2/21 at 10:45 a.m., the Dietary Supervisor (DS) reviewed Resident 1's Dietary Profile dated 5/12/21 and stated Resident 1 had 12 pounds weight loss in the last 180 days. DS then agreed that there was gradual weight loss. During an interview with DS, on 6/3/21 at 8:15 a.m., DS stated it will be the charge nurse and herself to follow up on residents that are placed on weekly weights for four weeks. DS stated if it was crucial weight change then the resident will be placed in weight variance. During an interview, on 6/2/21 at 2:47 p.m., the Registered Dietician (RD) stated DS should have followed up on the weekly weights back in 2/2021. A review of facility's policy titled Nutritional Screening/Assessments/Resident Care Planning, dated 2018, indicated Change in eating habits, difference in eating pattern, eating problems, weight and other problems will be recorded in the dietary progress notes and resident care plan. The Consultant Dietitian is to complete the 'Registered Dietitian Nutrition Assessment.' All recommendations will be noted on the consultant report (under section 2). Follow-up documentation will be done on Dietary Progress Notes, Dietary Quarterly Notes, or Annual Notes. A review of facility's policy titled Weight Change Protocol, dated 2018, indicated early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner. Residents who experience significant changes in weight or insidious weight loss will be assessed by the RD. The policy indicated, The following criteria define significant or insidious weight changes: Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights. 3# (pound) weight loss or gain in 1 week or as facility policy stated. 5# weight loss or gain in 1 month .The RD will assess, nutritionally diagnosis, suggest interventions, monitor and evaluate the success of the interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 252's admission Records, indicated the facility admitted the resident on 05/29/2021, with diagnoses including chronic kidney disease stage 5 (the stage of kidney disease where the kidneys are getting very close to failure or have completely failed), acute kidney failure (when kidneys suddenly become unable to filter waste products from you blood), and heart failure (chronic, progressive condition which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 252's History and Physical (H & P) Examination, dated 05/30/21, indicated the resident had the capacity to understand and make decisions. A review of Resident 252's Physician's Order dated 06/02/2021indicated hemodialysis (a method for removing waste products from the blood when the kidneys fail) every Mondays, Wednesdays, and Fridays, at 3 p.m. A review of Resident 252's care plan, dated 06/02/2021, indicated the care plan goal for the resident to be free from signs and symptoms of renal (kidney) complications through the next review date. The care plan interventions included to arrange hemodialysis as scheduled and as ordered. A review of Resident 252's care plan, dated 06/02/2021, indicated the resident missed dialysis on 06/02/2021. One of the care plan interventions indicated dialysis center contact information and transportation to be arranged by insurance medical group case manager. During an interview, on 06/03/2021 at 9:31 a.m., Resident 252 stated he needed to take care of his kidneys before he worries about anything else. A review of Resident 252's Situation-Background-Assessment-Recommendation (SBAR - framework for communication between members of the health care team and is used as a tool to foster patient safety) communication form, dated and timed on 06/03/2021 at 11 p.m., indicated Resident 252 appeared to have shortness of breath with saturation (a measurement of your blood oxygen) of 88 percent (% - unit of measurement) on room air. Resident 252 was immediately put to high-Fowlers (head of the bed is elevated as high as possible) position and oxygen inhalation started at 3-4 liter per minute (LPM - unit of measurement) via nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils). The resident's oxygen saturation gradually increased and maintained 95-96 %. A review of Resident 252's Physician's Order, dated 06/04/2021, signed by Nurse Practitioner (NP), indicated to transfer for Resident 252 to the general acute care hospital (GACH) emergency room (ER) for hemodialysis. During an interview with Licensed Vocational Nurse 2 (LVN 2), on 06/07/2021 at 10:36 a.m., LVN 2 stated Resident 252 was scheduled for dialysis last 06/02/2021with transportation pick-up scheduled for 2 pm to receive dialysis scheduled for 4 pm, but transportation did not make it in time and resident did not receive dialysis as scheduled. LVN 2 further stated Resident 252 also missed dialysis last 06/04/2021 due to transportation company did not pick up the resident as scheduled. When asked if Resident 252 was notified of missed dialysis treatment due to transportation issues, LVN 2 stated Resident 252 was ready to go to dialysis and was asking LVN 2 whether he would be receiving dialysis that day. LVN 2 stated the risk for Resident 252 missing dialysis could be life threatening. During an interview with Registered Nurse (RN 1), on 06/07/2021 at 11:32 a.m., RN 1 stated Resident 252 missed dialysis on 06/02/2021 because transportation came too late. RN 1 stated Resident 252 missed dialysis on 6/4/2021, because transport vehicle broke down. RN 1 stated she spoke to Resident 252's insurance case manager regarding missed transportation to dialysis center for Resident 252 for both days. RN 1 stated the risk of Resident 252 missing dialysis treatment could be life threatening. During an interview with the Social Services Director (SSD), on 06/07/2021 at 11:41 a.m., the SSD stated transportation to dialysis center for Resident 252 was arranged by insurance medical group. and SSD did not do anything with transportation. SSD stated the risk to Resident 252 for missing dialysis treatments is that resident could pass away. During a phone interview with Dialysis Center Registered Nurse (DRN), on 06/07/2021 at 3:09 p.m., DRN stated Resident 252 missed dialysis treatment on 06/02/2021 and 06/04/2021. DRN stated she notified the facility on 06/02/2021, that Resident 252 should go to the hospital to receive dialysis because resident missed dialysis treatment. DRN further stated she called the facility on 06/04/2021 and spoke to Registered Nurse 3 (RN 3) to notify the resident's physician that Resident 252 missed two dialysis treatments, and the urgency for Resident 252 to go to emergency room to receive dialysis. During a phone interview with the Nurse Practitioner (NP), on 06/07/2021 at 4 p.m., the NP stated she does not choose the residents' transportation to dialysis and does not coordinate transportation transfers. NP further stated her focus is medical management. During an interview with the Director of Nursing (DON), on 06/07/2021 at 5:10 p.m., the DON stated the insurance company had contracts with transportation company and the facility did not have a say. When asked if there was a contingency plan if transportation could not take Resident 252 to dialysis center, the DON stated they did not want to have duplication of transportation services for the resident. During an interview with Administrator (Adm), on 06/07/2021 at 5:13 p.m., Adm stated the insurance company had total control of Resident 252's transportation because the insurance company paid for it. The Adm stated the facility did not set up transportation. During a review of Resident 252's Emergency Department (ED) notes from GACH, dated 06/04/2021, the notes indicated Resident 252's primary medical history of End Stage Renal Disease (ESRD) with last hemodialysis one week ago, and presented with constant, gradually worsening, moderate shortness of breath (SOB) associated with increased fluid overload, worsened by missed hemodialysis appointment. During a review of Resident 252's History and Physical (H&P) notes from GACH, dated 06/05/2021, the notes indicated Resident 252 was not taken to his dialysis appointment from the skilled nursing facility (SNF) for a week and presented with shortness of breath (SOB), and in need of hemodialysis. A review of the facility's agreement with Resident 252's insurance company, titled Long Term Care Outpatient Dialysis Services Coordination Agreement, dated 05/29/2021, indicated the long term care facility shall be responsible for arranging for suitable and timely transportation of the ESRD Residents to and from the ESRD Dialysis Unit, including the selection of the mode of transportation, qualified personnel to accompany the ESRD Residents, transportation equipment usually associated with this type of transfer or referral in accordance with applicable federal and state laws and regulations and all costs or transportation expenses associated with such transfer. Based on observation, interview, and record review, the facility: 1. Failed to provide a resident with a sack lunch while at the dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) center for one (Resident 40) out of two sampled residents investigated for dialysis. This deficient practice had the potential to cause discomfort to the resident and increase the resident's risk of not getting enough nutrients. 2. Failed to ensure a reliable transportation to the dialysis center was available for one (Resident 252) out of two sampled residents reviewed under the care area of dialysis. This deficient practice resulted in Resident 252's missing two scheduled dialysis treatment with the dialysis center and may have contributed to resident's transfer to the general acute care hospital. Findings: a. A review of Resident 40's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included end stage renal disease (when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state), dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right buttock unstageable, pressure ulcer of left buttock unstageable, and pressure ulcer of left heel Stage I (superficial reddening of the skin). A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/31/2021, indicated the resident was moderately impaired in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS also indicated the resident received dialysis treatments. A review of Resident 40's Order Summary Report (summary of physicians' orders), dated 05/28/2021, indicated a physician's order, dated 03/29/2021, for dialysis three times a week every Tuesday, Thursday, and Saturday at 12:45 p.m. at an off-site dialysis center with pick up time of 11:45 a.m. A review of Resident 40's care plan (contains all of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders [including what observations are needed and what actions must be performed], and a plan for evaluation), initiated on 06/30/2020, for impaired renal function related to chronic kidney disease (CKD - gradual loss of kidney function), end stage renal disease, indicated the resident was receiving hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean your blood) three times a week through her permacath (a special intravenous [IV - within a vein] line into the blood vessel in the neck or upper chest, used for short-term dialysis treatment) on the right upper chest. Among some of the interventions listed was to pack the resident a lunch on dialysis days. On 06/02/2021 at 1:04 p.m., during an interview, Resident 40 stated the facility sometimes did not send lunch with her when she went out for her dialysis. The resident stated she did not eat lunch yesterday when she went to the dialysis center. On 06/03/2021 at 11:22 a.m., during a concurrent observation and interview, observed Resident 40 being picked up by transportation. Registered Nurse 2 (RN 2) stated the resident was going out for dialysis. When asked if the facility provided the resident with lunch while in the dialysis center, RN 2 stated the facility did not provide the resident with lunch. RN 2 stated the dialysis center provided the resident with lunch. On 06/03/2021 at 11:37 a.m., during an interview, Dietitian at dialysis center (DD) stated the dialysis center was not equipped to feed residents lunch, so the dialysis center was responsible for providing residents with food. DD stated she had sometimes seen Resident 40 at the dialysis center without food. On 06/03/2021 at 4:42 p.m., during an observation, observed Resident 40 returning to the facility from the dialysis center. On 06/03/2021 at 3:23 p.m., during a concurrent interview and record review, Minimum Data Set Nurse 3 (MDS 3) stated the charge nurse was responsible for ensuring the resident was sent to the dialysis center with lunch. On 06/07/2021 at 8:58 a.m., during a concurrent interview and record review, MDS 3 stated he could not find any nurses' notes indicating the resident was sent out with lunch on any of her dialysis days. On 06/07/2021 at 10:36 a.m., during an interview, the Director of Nursing (DON) stated residents were supposed to be sent out with a sack lunch on their dialysis days. A review of the facility's undated policy and procedure titled, Hemodialysis, Care of Resident, indicated it is the policy of the facility to provide guidelines for obtaining adequate nutrition and hydration to dialysis residents. The policy and procedures also indicated about dialysis resident's care plan and documentation, to have pertinent data available for all care givers of dialysis residents to decrease errors and provide quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent (5 %) or greater, as evidenced by the identification of five medication administration errors out of 29 opportunities (observations during medication pass) for error, to yield a cumulative error rate of 17.24 % for one (Resident 507) out of six sampled residents observed during medication administration. Registered Nurse 2 (RN 2) crushed all five medications and administered them all together at once when giving medications via gastrostomy tube (g-tube -a tube inserted through the belly that brings nutrition directly to the stomach) for Resident 507. This deficient practice had the potential to result in medication interactions, rendering them less effective for the resident. Findings: A review of Resident 507's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status (resident has a gastrostomy tube [g-tube - a tube inserted through the belly that brings nutrition directly to the stomach]). A review of Resident 507's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/25/2021, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS also indicated the resident was totally dependent on staff for eating and required extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. The MDS also indicated the resident had a feeding tube (a device inserted into one's stomach through the abdomen). On 06/03/2021 at 4:23 p.m., during the medication administration observation, observed Registered Nurse 2 (RN 2) crush and mix the following medications together: 1. Bethanechol (used to relieve difficulties in urinating) 50 milligrams (mg - unit of measurement) 2. Apixaban (anticoagulant - used to treat and prevent blood clots) 5 mg 3. Simethicone (used to reduce bloating, discomfort, or pain caused by excessive gas) 80 mg 4. Vancomycin Hydrochloride (antibiotic used to treat inflammation of the intestine caused by certain bacteria) 50 mg/milliliter (ml - unit of measurement), 2.5 ml 5. Metoprolol (treats high blood pressure) 25 mg On 06/03/2021 at 4:50 p.m., during the medication administration observation, observed RN 2 dilute and pour all five medications together at once through the resident's g-tube. RN 2 did not flush the resident's g-tube before administering the medications. On 06/07/2021 at 10:45 a.m., during an interview, the Director of Nursing (DON) stated nurses should crush each medication separately when administering g-tube medications in order to avoid any medication interactions. Nurses should also flush with water between each medication. A review of the facility's policy and procedure titled, Medication Administration - General Guidelines, effective 04/2008, indicated that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's vancomycin (antibiotic medication used to kill bacteria in the intestines) was stored inside a refrigerator, as indicated on the label, for one (Resident 507) out of ten residents on antibiotics (medicines that fight infections caused by bacteria in humans and animals by either killing the bacteria or making it difficult for the bacteria to grow and multiply). This deficient practice had the potential to render the resident's antibiotic less effective. Findings: A review of Resident 507's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection) and urinary tract infection (an infection in any part of your urinary system - your kidneys, ureters, bladder and urethra). A review of Resident 507's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/25/2021, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS also indicated the resident was totally dependent on staff for eating and required extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. A review of Resident 507's Order Summary Report (summary of physicians' orders), dated 06/07/2021, indicated the following physician's orders: 1. Vancomycin (antibiotic medication used to kill bacteria in the intestines) Hydrochloride (HCl) solution 50 milligrams/milliliter (mg/ml - units of measurement). Give 2.5 ml via gastrostomy tube (g-tube - a tube inserted through the belly that brings nutrition directly to the stomach) one time a day for prophylaxis (action taken to prevent disease) for clostridium difficile (c. diff - a germ that causes severe diarrhea and colitis [an inflammation of the colon]) until 06/26/2021, ordered on 05/27/2021. 2. Vancomycin HCl suspension 50 mg/ml. Give 2.5 ml via g-tube three times a day for prophylaxis for c. diff until 06/10/2021, ordered on 05/27/2021. 3. Vancomycin HCl suspension 50 mg/ml. Give 2.5 ml via g-tube two times a day for prophylaxis for c. diff until 06/17/2021, ordered on 05/27/2021. On 06/03/2021 at 2:28 p.m., during an observation of Station One Yellow Zone (area for the following residents: those who have been in close contact with known cases of COVID-19 [a highly contagious viral infection that can trigger respiratory tract illness]; newly admitted or re-admitted residents; unvaccinated residents who frequently leave the facility; those who have symptoms of possible COVID -19 pending test results; and for residents with indeterminate tests) Medication Cart One, observed a bottle of Firvanq (vancomycin hydrochloride) 50 mg/ml oral solution inside the cart. The medication label indicated to keep refrigerated. Registered Nurse 2 (RN 2) stated they did not have a refrigerator for medications in the yellow zone. On 06/07/2021 at 10:45 a.m., during an interview, the Director of Nursing (DON) stated the vancomycin should have been kept in a refrigerator. A review of the facility's policy and procedures titled, Medication Storage in the Facility, effective 04/2008, indicated that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 2° C (36° F) and 8° C (46° F) are kept in a refrigerator with a thermometer to allow temperature monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review Face Sheet indicated Resident 250 was admitted on [DATE] with diagnoses including dementia and Covid 19. During a concurrent interview and record review on 6/2/21 at 11:22 am, Licensed Vocational Nurse (LVN 2) stated when no POLST (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency), or Advanced Directive Acknowledgment Form was in Resident 250's chart, that they just endorsed code status but no notes or advanced directive in the chart or on electronic chart. During interview, on 6/3/21 at 8:01 a.m., with Director of Nursing (DON), the DON stated the advanced directive should be done as soon as possible. The DON stated she would check front desk if done and that every resident was full code until the form was done. A review of the facility's undated policy titled, Advance Directives, indicated that Advance Directives will be respected in accordance with state law and facility policy. The resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. The plan of care for each resident will be consistent with his or her documented treatment preferences (POLST) and/or advance directive. c. A review of the Face Sheet indicated Resident 252 was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes, Covid 19, and heart failure. A review of the Initial History and Physical (H & P), dated 5/30/2021, indicated Resident 252 had the capacity to understand and make decisions. During a concurrent interview and record review on 6/2/21 at 02:21 pm, LVN 2 stated there was no POLST or advanced directive in chart. LVN 2 then indicated in Initial Notes of Medicare Q Shift Charting log dated 5/29/21 at 2:19 a.m., that Resident 252 is full code. LVN 2 states advanced directive should be done on admission and there should be a form in the chart and per policy, new admissions are full code until they talk to family. During interview on 6/3/21 at 8:01 a.m., with Director of Nursing (DON), no POLST or Advanced Directive Acknowledgment Form were found in Resident 252's chart. The DON stated the advanced directive should be done as soon as possible, would check front desk if done, and that every resident is full code until the form is done. During interview on 6/3/21 at 2:22 p.m., with Social Services Director (SSD), the SSD stated she is able to call the family, the nurse will give the form, and the POLST is in admission packets. The SDD states acknowledgment forms are done during care plan meetings by phone for acknowledgement forms. The SSD also stated completing acknowledgment forms took longer because residents were in covid unit and she does not go in there. A review of the facility's undated policy and procedure titled, Advance Directives, indicated that Advance Directives will be respected in accordance with state law and facility policy. The resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. The plan of care for each resident will be consistent with his or her documented treatment preferences (POLST) and/or advance directive. Based on interview and record review, the facility failed to provide residents written material with information regarding formulating an Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), for three out of 14 sampled residents (Residents 504, 250 and 252) investigated for Advance Directives. These deficient practices violated the resident's right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict due to a lack of communication regarding the resident's wishes about his medical treatment and delay care in an emergency. Findings: a. A review of Resident 504's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included alcohol dependence with intoxication (a disturbance in behavior or mental functioning during or after alcohol consumption). A review of Resident 504's Initial History and Physical (the starting point of a patient's story as to why they sought medical attention or are now receiving medical attention), dated 05/28/2021, indicated the resident had the capacity to understand and make decisions. A review of the Social Service Evaluation (a psychosocial assessment of residents and sometimes their family members to determine their needs and to identify any mental or emotional distress that could exacerbate their condition), dated 05/25/2021, indicated the resident did not have an Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). On 06/03/2021 at 10:43 a.m., during a concurrent interview and record review, Resident 504 had an Advance Directive Acknowledgement Form (form indicating whether a resident has an Advance Directive or not, and indicates whether written information regarding Advance Directives was provided to the resident), dated 05/25/2021, in his medical record, signed by the resident's responsible party (his mother) via telephone. The Social Services Director (SSD) stated she did not document in her progress notes that she discussed the formulation of Advance Directives with either the resident or his responsible party. On 06/03/2021 at 11:18 a.m., during an interview, Family Member 1 (FM 1) stated she did not know what an Advance Directive was. Resident 504 stated SSD never asked him if he wanted assistance with formulating an Advance Directive, and he did not know what an Advance Directive was. On 06/07/2021 at 10:22 a.m., during a concurrent interview and record review, Minimum Data Set Nurse 3 (MDS 3) verified he could not find any documentation indicating that Advance Directives were discussed with the resident. On 06/07/2021 at 10:33 a.m., during an interview, the Director of Nursing (DON) stated it was important for residents to have an Advance Directive because the facility needed to know the resident's wishes regarding life-sustaining support, code status, or what to do if there were any changes in condition. The DON stated that the Social Services and Admissions department were responsible for discussing Advance Directives with the resident. The DON stated the topic of Advance Directives were usually discussed upon admission. A review of the facility's undated policy and procedures titled, Advance Directives, indicated that Advance Directives will be respected in accordance with state law and facility policy. The resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information.

Based on observation, interview, and record review, the facility failed to follow menu as written for residents on pureed diet (food that residents cannot normally chew) as evidenced by: 1. The residents on pureed diet received less food than residents on regular diet. 2. The residents on pureed diet received five ounces of the lasagna instead of eight ounces per menu. This deficient practice had the potential to result in weight loss due to inadequate caloric intake and delay recovery from illness or injury for 11 residents who were on puree diet. Findings: During a concurrent observation and interview, on 6/1/2021 at 11:36 a.m., [NAME] 2 was observed using a white handle scoop for puree lasagna. [NAME] 2 stated the white scoop was scoop size number six. During an interview with Dietary Supervisor (DS) on 6/1/21 at 11:57 a.m., the DS stated scoop size number six was five ounces. During an concurrent interview and record review, on 6/1/21 at 12:25 p.m., [NAME] 2 looked at the diet spreadsheet (meal serving size guide) for the puree entree and stated pureed diet should receive eight ounces (one cup) of the lasagna. [NAME] 2 looked up the scoop size and confirmed scoop size number six was five ounces. [NAME] 2 stated she used the wrong scoop size. [NAME] 2 further stated the residents on pureed diet received less lasagna than the residents on the regular diet. During an interview, on 6/1/21 at 12:36 p.m., the DS stated because [NAME] 2 used scoop size number six, residents on a puree diet did not receive enough calories. A review of undated recipe titled Zesty Lasagna, serving instructions indicated under special diets Pureeds: puree, 1 cup. A review of facility document titled Spring Cycle Menus, for lunch 6/1/2021, indicated under the heading pureed the serving size should be eight ounces or one cup. A review of facility's policy, dated 2018, titled Menu Planning, indicated the menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Standardize recipes adjusted to appropriate yield shall be maintained and used in food preparation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Frozen foods and nutrition supplements thawing in the walk-in refrigerator with no thaw (frozen to liquid state) date or use by date. 2. Expired milk cartons in the walk-in refrigerator and expired boxes of food items in dry storage area was not properly disposed. 3. Unknown food items with no labels and date in the walk-in freezer and unknown items with no label and date in the residents' refrigerator. 4. One fruit cocktail can with side dented in the dry storage room was not properly disposed. 5. The can opener blade had dried black residue with the potential to harbor harmful bacteria that were not easily cleanable. 6. The ice machine parts were not maintained in a sanitary manner and proper sanitation practice not followed to prevent rust color residue surrounding the ice dispensing area. 7. Dietary Aide (DA 1) not following hand hygiene procedures when removing clean and sanitized dishes from the dish machine. These deficiencies had the potential to cross contaminate dishes and result in food-borne illness in a medically vulnerable resident population of 94 who received the food prepared by the facility and 9 residents who are on nutrition supplements at the facility. Findings: 1. During a concurrent kitchen tour observation and interview, on 6/1/2021 at 8:10 a.m., there were three bags of pork cube stew meat, two bag of beef cubes meat, one bag of chicken meat in a zip lock, two bags of ham and turkey meat, and two boxes of tilapia stored in the walk-in refrigerator to thaw. The meats were observed not to have thaw dates or use by date labeling. The Dietary Supervisor (DS) stated the bags has been thawing for three days and confirmed no thaw date written on bag. The DS stated that usually the chef checked the menu a few days before and placed the frozen meat in the refrigerator to thaw. During a concurrent interview, [NAME] 1 stated the meats begin thawing on Saturday. [NAME] 1 stated usually the cooks keep track of the thawing date and they kept it in the freezer, looked at the menu, and then pulled it out into walk-in refrigerator for thawing. During a concurrent observation and interview in the kitchen, on 6/1/2021 at 8:20 a.m., one carton of strawberry nutrition supplement shake and two cartons of vanilla nutrition supplement shakes had no thaw date or use by date in the facility's walk-in refrigerator. The DS stated the expiration date was on the carton which was 12/21/2021. She then read the manufacturer label instruction which indicated to thaw from frozen under 40 degrees Fahrenheit below, after thaw to be used within 14 days. DS confirmed she did not know the date the nutrition supplements begin thawing. A review of facility's policy titled Procedure for Refrigerated Storage, dated 3/2013, indicated Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. Follow the manufacturer's recommendations (specifications) for shelf life. 2. During a concurrent observation and interview in the kitchen, on 6/1/2021 at 8:15 a.m., there were eight cartons of milk with best by date 5/30/2021 located in a large grey container mixed with juice cartons with best by date 6/2021. [NAME] 1 stated the milk cartons were expired. The DS stated the milk cartons needed to be discarded. During a concurrent observation and interview in the kitchen, on 6/1/2021 at 9:10 a.m., six unopened boxes and one opened box of cream of rice with manufacturer expiration dated 4/10/21 was expired. [NAME] 1 confirmed cream of rice boxes were expired. A review of facility's undated policy titled Storage of Food and Supplies, indicated no food will be kept longer than the expiration date on the product. A review of facility's policy titled Procedure for Refrigerated Storage, dated 3/2013, indicated food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice. Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. Milk, cottage cheese, cream and soft cheese are to be used by the pull date on the carton unless a written policy is provided by the milk supplier stating otherwise. 3. During a concurrent observation and interview in the kitchen, on 6/1/2021 at 8:25 a.m., one bag of frozen food item with no name labeled and one bag of frozen food item with no name labeled and an illegible date in the walk-in freezer. [NAME] 1 stated he had to open the bag to look to identify the food item. [NAME] 1 confirmed he cannot read the date. A review of facility's undated policy titled Procedure for Freezer Storage, indicated all frozen food should be labeled and dated. During a concurrent observation and interview, in the residents' refrigerator on 6/2/2021 at 9:51 a.m., one round food container in a clear plastic bag had no received date or use by date labeled and one orange container with liquid inside had no name and no received date or use by date labeled. Licensed Vocational Nurse (LVN 1) stated there was no label of use by date on the round container and there was no label of name and use by date on the orange container with liquid. LVN 1 stated it was a certified nursing assistant or licensed vocational nurse responsible for putting the resident's name and date. A review of facility's policy titled Food for Residents From Outside Sources, dated 2018, indicated prepared food brought in for the resident must be consumed within one (1) hour of receiving it in an effort to prevent food borne illness. Unused food will be disposed of immediately thereafter. Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station's refrigerator, or in the residents' personal refrigerator otherwise if unopened, refrigerated or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened and disposed of in 2 days after opening. 4. During a concurrent observation and interview, in the dry storage area on 6/1/2021 at 9:15 a.m., one fruit cocktail can was dented on the side. The DS and [NAME] 1 confirmed dented cans should be taken out and placed in the back and the delivery will pick up the dented cans on Wednesdays. A review of the facility's undated policy titled Food Storage-Dented Cans, undated, indicated cans with side seam dents, rim dents or swells shall not be retained or used by the facility. All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to [NAME] for refund. 5. During a concurrent observation and interview in the kitchen food preparation area on 6/1/2021 at 9:20 a.m., the can opener was observed to have dried black residue near the blade. The DS stated the can opener blade should be washed after each use. She confirmed the can opener blade needed further washing. 6. During a concurrent observation and interview, of the facility's ice machine located in the employees' lounge on 6/1/2021 at 9:20 a.m., the swept ice machine dispenser with white towel was observed to have small amount of rust color residue. During an interview with the Maintenance Supervisor (MS) on 6/1/2021 at 9:24 a.m., he stated he cleaned the inside bin of the machine last month in May and should be cleaned monthly. In addition he stated the machine was relatively new and they did not have outside company to come clean the parts and internal tubing. He confirmed the ice dispenser had a little residue. A review of facility's policy titled Cleaning Ice Machine, dated 1/2014, indicated maintenance of the sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins. Use a clean cloth and the solution and wipe out the inside of the machine. A review of the 2017 U.S. Food and Drug Administration Food Code indicated Equipment contacting food that was is not time/temperature control for safety food shall be cleaned: in equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers at a frequency specified by the manufacturer or absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. 7. During a concurrent observation and interview, on 6/1/21 at 8:50 a.m., DA 1 was observed touching dirty trays from the cart. DA 1 went over to touch the clean trays from the dishwashing machine without taking off soiled gloves and washing his hands. At 9 a.m., DA 1 was observed unloading dirty dishes and touching clean trays without washing his hands and changing gloves. DA 1 stated that he was the only one washing and cleaning right now and was waiting for another dietary aide to arrive. DA 1 stated he did not change gloves and that he could use hand sanitizer when going from dirty to clean dishes. DA 1 stated once he loads the dirty dishes, he rinses his hands with the gloves using the water hose that was used to rinse the soiled dishes. After rinsing his gloves, he removed the clean and sanitized trays from dish machine. He further stated hand washing was important because he was touching dirty dishes. A concurrent interview, the Dietary Supervisor (DS) stated the DA 1 can sanitize hands in between tasks. When asked about sanitizing hands between handling of solid wastes and clean dishes, the DS confirmed that DA 1 needed to wash hands and change gloves in between tasks. A review of facility's policy, dated 2018, titled Hand Washing Procedure, indicated when hands need to be washed: After handling soiled dishes and utensils. Use warm running water and soap, preferably from a dispenser. 2. Wet hands and forearms first. Add soap and rub hands together forming a lather. Rub the palms, back of the hands, the fingers, between the fingers, the finger nail area, and above the wrist area for 20 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. During interview, on 6/1/2021 at 11:21 a.m., CNA 2 stated she was the only designated staff working in the red zone (COVID unit) for the 7 a.m. to 3 p.m. shift. CNA 2 stated an LVN would come to bring medications, an RN would bring intravenous (IV) medications, and either would come when she text messaged them for residents' requests. CNA 2 stated she was told by RN 2 that the LVN in yellow zone would take care of the red zone; only CNAs are dedicated. During an interview, 6/1/2021 at 1:45 p.m., RN 1 stated vital sign checks were done every 4 hours, and she comes as needed after green zone and yellow zone. RN 1 stated LVNs should be the ones always in the unit, for the day a LVN was assigned from yellow zone and should check on residents every 2 hours. During concurrent interview and record review, on 6/1/21 2:07 p.m. the Director of Nursing (DON) stated there was a designated CNA for all 3 shifts. The DON stated licensed nurses go to unit as much as possible from yellow zone for medication pass, they start in yellow zone first and then go to red zone. The DON also stated that in the policy, the use of licensed nurses in the red zone was based on staffing-licensed nurses do rounds, medication pass, blood sugar checks, and the CNAs will alert them when needed. The DON stated for the day RN 1 was assigned for rest of shift and usually LVN 2 was assigned for yellow and red zones. During an interview, on 6/2/21 at 09:59 a.m., LVN 2 stated she was not usually the station nurse for red zone and would do vital sign checks instead of the CNA before giving certain medications. A review of facility's Mitigation Plan, revised 2/2021, indicated the facility will assign staff to work Red space only to the extent possible. A review of the Department's Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 4/11/2021, indicated staff assigned to the Red Cohort should not care for patients in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between cohorts. The Guidelines also indicated that Red Cohort (zone) staff can work in the Yellow Cohort or [NAME] Cohort as long as staff is following all infection prevention and control practices including wearing appropriate PPE with correct donning and doffing, then they can start working in a different cohort/zone on a different day in a different shift. The staff should wear clean clothes for the different cohort. A review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 3/29/2021, the recommendations indicated the facility should identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. If possible, HCP should avoid working on both the COVID-19 care unit and other units during the same shift. f. A review of the admission Record indicated Resident 250 was admitted to the facility on [DATE] with diagnoses that included COVID-19 [a highly contagious infection affects the respiratory system and can cause death]) and diabetes mellitus (DM-disease causes abnormally high levels of the sugar in the blood). A review of the History and Physical, dated 6/4/2021, indicated Resident 250 did not have the capacity to understand and make decisions. A review of Resident 250's Order Summary Report, dated 5/28/2021, indicated to provide contact and droplet isolation (precautions used for diseases that can be transmitted during contact or by large respiratory droplets) related to COVID-19 infection. A review of Resident 250's Patient Visit Report from general acute care hospital (GACH), dated 5/28/2021, indicated SARS-COV-2 test (test to detect COVID-19), result was detected on 5/22/2021. During an interview on 6/7/2021, at 11:33 a.m., the Infection Control Preventionist (IP) stated Resident 250 was admitted to red zone (designated area for COVID -19 positive residents) in the facility from GACH on 5/28/2021 and the resident was tested positive for COVID-19 on 5/22/2021. The IP nurse stated the resident was transferred to green zone (designated area for residents with no COVID-19) on 6/6/2021. The resident was asymptomatic. The IP nurse stated the resident was transferred to the green zone after 14 days from the COVID -19 test positive date. During a concurrent interview and record review, on 6/7/2021 at 12:05 p.m., the IP nurse stated the resident should have been in the red zone for 20 days. The IP nurse stated she made the decision jointly with the Director of Nursing (DON) to transfer the resident to green zone after 14 days. The IP nurse also stated it was important to follow the guidelines to prevent the spread COVID -19 infection. During an interview on 6/7/2021, at 2:55 p.m., the DON stated Resident 250 should have remained in the red zone for 20 days from the date of positive COVID test to make sure the resident was not contagious (capable to spread the infection) to spread COVID 19 infection. g. A review of the admission Record indicated Resident 251 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included COVID-19 and sepsis (sepsis is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues). A review of the History and Physical, dated 6/4/2021, indicated Resident 251 had the capacity to understand and make decisions. A review of Resident 251's Order Summary Report, dated 5/28/2021, indicated to provide contact and droplet isolation related to COVID-19 infection. A review of Resident 251's Patient Visit Report from general acute care hospital (GACH), dated 5/28/2021, indicated SARS-COV-2 test (test to detect COVID-19), result was detected on 5/23/2021. During an interview on 6/7/2021, at 11:33 a.m., the Infection Control Preventionist (IP) stated, Resident 251 was admitted to red zone (designated area for COVID -19 positive residents) in the facility from GACH on 5/28/2021 and the resident was tested positive for COVID-19 on 5/23/2021. The IP nurse stated, the resident was transferred to green zone (designated area for residents with no COVID-19) on 6/6/2021. The resident was asymptomatic. The IP nurse stated, the resident was transferred to the green zone after 14 days from the COVID -19 test positive date. During a concurrent interview and record review, on 6/7/2021 at 12:05 p.m., the IP nurse verified the resident should have been in the red zone for 20 days. The IP nurse stated, she made the decision jointly with the Director of Nursing (DON) to transfer the resident to green zone after 14 days. The IP nurse also stated it was important to follow the guidelines to prevent the spread COVID -19 infection. During an interview on 6/7/2021, at 2:55 p.m., the DON stated Resident 251 should have remained in the red zone for 20 days from the date of positive COVID test to make sure the resident was not contagious (capable to spread the infection) to spread COVID 19 infection. A review of the facility's policy titled Infection Prevention and Control: Novel Coronavirus (COVID-19)- Inter facility Transfers and Home Discharge Guidelines, dated 2/2021, indicated resident with confirmed COVID-19 infection transferring from hospital and returning to facility of origin: Continue standard, contact and droplet transmission-based precautions at the facility. Transmission based precautions(TBP) should be continued for 20 days after hospital admission. Resident will be placed in a location designated to care for COVID 19 residents (Red Zone). Resident may be placed in a shared room, with other confirmed COVID residents. Residents with confirmed COVID 19 infection and not a returning resident of the facility may be transferred if they meet anyone of the two criteria below: 10 days have passed since symptoms first appeared (or since date of first positive viral test) And no fever for 24 hours without the use of fever reducing medications and symptoms have improved. Continue standard, contact, and droplet transmission- based precautions at the facility. TBP should be continued for 20 days after hospital admission. Resident will be placed in a location designated to care for COVID 19 residents (Red Zone). Resident may be placed in a shared room, with other confirmed COVID residents. 20 days have passed since symptoms first appeared (or since date of first positive viral test) AND no fever 24 hours without the use of fever reducing medications and symptoms have improved. c. A review of Resident 505's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (occurs when your heart muscle doesn't pump blood as well as it should), acute respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (low oxygen in your blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 505's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 05/24/2021, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and required extensive assistance from staff for dressing and toilet use, and limited assistance for bed mobility, transfers, walking in the room, and personal hygiene. The MDS also indicated the resident received oxygen therapy. A review of Resident 505's Order Summary Report (a summary of physicians' orders), dated 05/28/2021, indicated a physician's order, dated 05/17/2021, for oxygen at three liters per minute (l/min - units of measurement) via nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils) continuously every shift. On 06/01/2021 at 10:46 a.m., during an observation, Resident 505 was awake sitting in his wheelchair at his bedside. The resident's oxygen was turned on via nasal cannula at 3 L/min. Observed resident's oxygen tubing on the floor. On 06/07/2021 at 10:38 a.m., during an interview, the Director of Nursing (DON) stated the resident's oxygen tubing should have been kept off the floor for the purpose of infection control. A review of the facility's policy and procedures titled, Standards for Infection Control, indicated the Centers for Disease Control and Prevention (CDC) has developed new precautions to provide a standard for infection control. A two-tier system has been developed. The first tier is standard precautions, designed for the care of all residents, regardless of their diagnosis or presumed infection status. Implementation of standard precautions is the primary strategy for successful control of nosocomial infections (infections acquired during the process of receiving health care that was not present during the time of admission). Handle patient care equipment so as to prevent personal contamination and transfer to other patients. d. A review of Resident 34's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis that included contact dermatitis (a condition that makes skin red or inflamed after contact with an allergen or an irritant). A review of Resident 34's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/25/2021, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and required extensive assistance from staff for bed mobility, transfers, walking in the room and in the corridor, and locomotion on and off the unit. The MDS also indicated the resident was at risk of developing pressure ulcers/injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and received applications of ointments/medications other than to the feet. On 06/01/2021 at 11:27 a.m., during an observation, observed resident's room to be in the yellow zone (area for the following residents: those who have been in close contact with known cases of COVID-19 [a highly contagious viral infection that can trigger respiratory tract illness]; newly admitted or re-admitted residents; unvaccinated residents who frequently leave the facility; those who have symptoms of possible COVID -19 pending test results; and for residents with indeterminate tests) and had a personal protective equipment (PPE - protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) bin outside of his room. In the top drawer, observed two 8 ounces (oz - unit of measurement) plastic cups, uncovered and unlabeled, filled with A & D ointment (a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations). On 06/01/2021 at 11:33 a.m., during a concurrent observation and interview, Certified Nursing Assistant 5 (CNA 5) and Licensed Vocational Nurse 2 (LVN 2) both stated that the A & D ointment should not have been left open inside the PPE bin. LVN 5 stated it should have been thrown out. CNA 5 confirmed that it belonged to Resident 34. On 06/07/2021 at 10:39 a.m., during an interview, the Director of Nursing (DON) stated the A & D ointment should have been disposed of for the purpose of infection control. A review of the facility's policy and procedures titled, Standards for Infection Control, indicated the Centers for Disease Control and Prevention (CDC) has developed new precautions to provide a standard for infection control. A two-tier system has been developed. The first tier is standard precautions, designed for the care of all residents, regardless of their diagnosis or presumed infection status. Implementation of Standard Precautions is the primary strategy for successful control of nosocomial infections (infections acquired during the process of receiving health care that was not present during the time of admission). Handle patient care equipment so as to prevent personal contamination and transfer to other patients. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by: 1. Failing to clean and disinfect the glucometer (a small, portable machine that's used to measure how much glucose [a type of sugar] is in the blood) before and after using with one (Resident 18) of two sampled residents observed during medication administration. 2. Failing to clean and disinfect the blood pressure monitor (a device used to measure blood pressure, composed of an inflatable cuff to collapse and then release the artery under the cuff in a controlled manner) before and after use for one (Resident 14) of two sampled residents observed during medication administration. 3. Failing to ensure a resident's oxygen tubing was not on the floor for one (Resident 505) out of four sampled residents investigated for infection control. 4. Failing to ensure there were no two 8 ounce (oz) plastic cups, undated and unlabeled, filled with A & D ointment (a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations), left inside the personal protective equipment (PPE - protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) bin for one (Resident 34) out of four sampled residents investigated for infection control. 5. Failing to assign designated licensed nurses to work only in the red zone (designated space for COVID-19 [a highly contagious infection affects the respiratory system and can cause death] positive residents). 6. Failing to ensure the confirmed COVID -19 positive residents admitted from general acute care hospital (GACH) remained in the red zone for 20 days for two out of three residents (Resident 250 and 251) investigated addressing COVID-19 infection control. These deficient practices had the potential to result in spread of infections, staff members spreading COVID-19 infection, and possibly cause an outbreak at the facility. Findings: a. A review of Resident 18's admission Record indicated the resident was admitted on [DATE], with diagnoses including muscle weakness and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/13/2021, indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident required limited assistance with dressing and personal hygiene; and required extensive assistance with toilet use and bathing from staff. A review of Resident 18's Physician's Orders dated 5/27/2021 included the following orders: 1. Admelog Solostar Solution Pen-injector 100 units/milliliters (unit/ml - units of measurement) Insulin Lispro (fast-acting human insulin used to improve blood sugar control in adults with type 2 diabetes) inject 2 unit subcutaneously (tissue layer between the skin and the muscle) before meals for type 2 diabetes mellitus. 2. Admelog Solostar Solution Pen-injector 100 units/ml - Insulin Lispro inject as per sliding scale (progressive increase in the insulin dose based on pre-defined blood glucose ranges) subcutaneously before meals for type 2 diabetes mellitus. During a medication pass observation and interview, on 6/2/2021 at 4:40 p.m., observed Licensed Vocational Nurse 4 (LVN 4) outside Resident 18`s room verifying and reviewing the resident`s medication orders in the computer. LVN 4 stated that Resident 18 have insulin orders that required blood sugar check prior to administration of the insulin. LVN 4 then sanitized her hands proceeded to the resident`s room, and obtained the resident`s blood sugar using a glucometer (a small, portable machine that's used to measure how much glucose [a type of sugar] is in the blood). After LVN 4 finished the procedure, she then returned the glucometer to the upper left-most drawer of the medication cart. LVN 4 then took out the Admelog Solostar Solution Pen injector from the medication cart and and proceeded to administer the ordered insulin. After pointing out that LVN 4 did not clean and disinfected the glucometer before and after it was used, LVN 4 then stated she forgot to clean and disinfect the glucometer. LVN 4 stated that the glucometer should have been cleaned before and after using it to prevent the spread of infection. A review of the facility`s Mitigation Plan - Infection Control dated 02/2021, indicated that all non-dedicated, non-disposable medical equipment used for resident`s care should be cleaned and disinfected in between resident`s use by following the manufacturer`s instructions and may use alcohol based wipes or sprays containing at least 70 percent (% - unit of measurement) alcohol. b. A review of Resident 14's admission Record indicated the resident was admitted on [DATE], with diagnoses including muscle weakness and hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time). A review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/12/2021, indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident required extensive assistance with bed mobility, dressing, eating, toilet use; and total dependence on staff for personal hygiene and bathing. A review of Resident 14's Physician's Orders dated 5/27/2021 included an order to administer carvedilol (can treat high blood pressure and heart failure) tablet 6.25 milligram (mg - unit of measurement) by mouth two times a day for hypertension [elevated blood pressure], hold for systolic blood pressure (SBP - measures the force your heart exerts on the walls of your arteries each time it beats) below 110 millimeters of mercury (mmHg - unit of measurement) or heart rate below 60 beats per minute. During a medication pass observation and interview on 6/2/2021, which started at 4:40 p.m., and after attending to Resident 18, observed Licensed Vocational Nurse 4 (LVN 4) verify and prepare for the medications due for administration for Resident 14. As noted by LVN 4, the medication due for administration included carvedilol which required taking the blood pressure prior to administration. LVN 4 then took the blood pressure monitor from the top of the medication cart and proceeded to take Resident 14`s blood pressure. After LVN 4 finished the procedure, she then placed back the blood pressure monitor on top of the medication part. LVN 4 then proceeded to gather all the medications due for administration and administered the medications. After pointing out that LVN 4 did not clean and disinfect the cuff and the blood pressure monitor before and after it was used, LVN 4 stated she forgot to clean and disinfect the blood pressure cuff. LVN 4 stated that the blood pressure cuff and monitor should have been cleaned before and after using it to prevent the spread of infection. A review of the facility`s Mitigation Plan - Infection Control dated 02/2021, indicated that all non-dedicated, non-disposable medical equipment used for resident`s care should be cleaned and disinfected in between resident`s use by following the manufacturer`s instructions and may use alcohol based wipes or sprays containing at least 70 percent (% - unit of measurement) alcohol.