Based on observation, record review, and interview the facility failed to maintain dignity and a homelike dining experience in one (West) of two dining/common areas related to staff not removing dinnerware from trays when serving residents. Findings included: On 5/6/24 at 12:38 p.m. the noon meal service was observed on the [NAME] unit. The observation revealed two tables in the dining/common area with two residents sitting at one table and three residents sitting at the second table, one female resident was sitting in front of the television with an overbed table next to her and one male resident was sitting nearby with an overbed table next to him. The observation revealed one out of three residents at one table was served and the female resident sitting in front of the television was served. The observation revealed on 5/6/24 at 12:40 p.m., the second of the three residents sitting at the table was served and at 12:41 p.m., the male resident sitting in front of the television was served. The continued observation, at 12:42 p.m. showed the third resident was served with the dinnerware being left on the food tray. The observation revealed four out of the five residents sitting at the dining tables had their dinnerware remain on the serving trays and four out of five plate covers remained on the table with the residents while dining. On 5/9/24 at 12:25 p.m. an observation showed one male and one female resident sitting at a table on the [NAME] unit with dinnerware still on the serving trays. One resident was sitting in front of the television on the [NAME] unit with the Director of Nursing (DON) standing over her, cutting up food with the dinnerware sitting on the serving tray. On 5/9/23 at 2:13 p.m. an observation was made of a female resident sitting in front of the television, eating a meal with the dinnerware on the serving tray. During the Quality Assurance interview on 5/9/24 at 7:02 p.m. Staff J, Assistant Director of Nursing /Risk Manager (ADON/RM), the observation of staff not removing the residents' dinnerware from their trays when served was disclosed and Staff J did not respond other than nod their head. Review of the policy titled, Quality of Life - Dignity, revised August 2009, revealed: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, individuality. The interpretation and implementation of the policy showed: 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The Dietary Director was asked during an interview on 5/9/24 at 3:13 p.m. about the facility's policy about removing the residents' plates from their meal trays in the dining room. She said she would have to check to see what the facility policy was. During an interview with the Director of Nursing (DON) on 5/9/24 at 4:46 p.m. the concern about the staff not removing the residents' plates from the meal trays was discussed. The DON stated they should remove the plates from the trays. The facility policy was requested at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, including resident assessments, the facility failed to accurately reflect the resident's dental status for one of one resident (#17) reviewed for dental status and services. Findings included: During an observation on 5/6/24 at 1:18 p.m., Resident #17 was observed to have several broken, chipped teeth and dental caries (cavities/tooth decay). On 5/8/24 at 8:40 a.m. Resident #17 was observed during breakfast with multiple chipped teeth, one front tooth was a sliver. She said she fell backwards with a shopping cart and it hit her mouth. She had black gums around several teeth. She was on a regular diet. Review of the Face Sheet revealed Resident #17 was admitted to the facility on [DATE]. Her pertinent diagnoses included hypothyroidism; local infection of the skin and subcutaneous tissue; Vitamin D Deficiency; contracture, left hand; encounter for attention to colostomy; and essential hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 4/26/24 documented the resident's Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact with no indicators of delirium. This assessment coded Resident #17 as requiring set up or clean up assistance with eating and oral hygiene and that she had no pain, no fever, no vomiting, and no dehydration. Resident #17 had no swallowing disorder, her height was 61 (inches), and she weighed 10# (pounds) with no weight loss or gain or unknown. She was coded as being prescribed a therapeutic diet. The Dental status section of the MDS was coded as none of the above. The Quarterly MDS with an ARD of 2/9/24 documented the resident's BIMS score of 3, indicating she had severe cognitive impairment, and no indicators of delirium. This assessment coded Resident #17 as requiring set up or clean up assistance with eating and oral hygiene and that she had no pain, no fever, no vomiting, and no dehydration. Resident #17 had no swallowing disorder, her height was 61, and she weighed 108# with no weight loss or gain or unknown. She was coded as being prescribed a therapeutic diet. Dental status is not coded on quarterly MDSs. The Annual MDS with an ARD of 5/19/23 documented the Resident #17's dental status as none of the above. None of the MDSs reflected the resident's obvious or likely cavities or broken natural teeth and abnormal mouth tissue. Resident #17 did not have a care plan for dental status. The resident had a small gradual weight loss from 11/01/23 of 114.6 lbs. and a Body Mass Index (BMI) (A person's weight in kilograms divided by the square of height in meters. A high BMI can indicate high body fatness) of 21.65 (normal weight) to 106.5 lbs on 5/1/24 and a BMI of 19.93 (lower range of normal weight). Meal intake for April 2024 averaged 76 to 100%. The Social History assessments, dated 4/26/24 & 11/23/23, did not document any oral/dental issues and indicated No referrals necessary. The Speech Therapy Screens, dated 4/26/24 & 5/16/23, did not document any oral/dental issues. The Nutritional Evaluations, dated 11/21/23 and 4/26/24, marked dental status as none of the above. Review of the current physician orders included multivitamin with minerals, Stress Formula with zinc, offer 8 oz. (ounces) fortified milkshake by mouth twice daily, at 10 AM and 2 PM, document amount of fluid consumed (include bedside water, activities, hydration cart and snacks) every shift, document food at dinner, and Regular diet, fortified foods. Progress Notes revealed the following: 3/25/22 Advanced Practice Registered Nurse note - Lips, teeth, gums - normal dentition. 12/11/23 Physician note - Normal dentition (the development of teeth and their arrangement in the mouth). 4/29/23 Physician note - Normal dentition. There was no documentation in the medical record to indicate the resident had been referred for a dental consult or received any dental services. On 5/9/24 at 4:37 p.m. the Director of Nursing was informed that Resident #17's MDSs were inaccurate for her oral/dental status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide administration of intravenous medication in accordance with professional standards of practice for one (#54) of one resident sampled for intravenous medication administration. Findings included: A review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and infection and inflammatory reaction due to internal left knee prosthesis. A review of Resident #54's physician's orders revealed an order, dated 5/5/2024, for vancomycin 1 gram per 250 milliliters (ml), infuse 250 ml intravenously (IV) over 90 minutes at a rate of 166 ml per hour every other day for a diagnoses of infection and inflammatory reaction d/t internal left knee prosthesis. An observation was conducted on 5/6/2024 at 4:00 PM of Resident #54 in the resident's room. Resident #54 was observed resting in bed, positioned on his right side. An IV pole was observed in Resident #54's room. A 250 ml bag of vancomycin was observed hanging from the IV pole with IV tubing attached to it. The IV tubing was not observed to be labeled with the date it was hung. Approximately 75 ml of fluid was observed inside of the bag of vancomycin. During the observation, Staff H, Registered Nurse (RN) and Unit Manager (UM) entered Resident #54's room and an interview was conducted. Staff H, RN UM stated nursing staff would normally label IV tubing with the date it was hung and was not able to state why so much of the IV medication remained in the IV bag. Photographic evidence was obtained. An interview was conducted on 5/6/2024 at 4:13 PM with Staff I, Licensed Practical Nurse (LPN). Staff I, LPN stated Resident #54 received IV vancomycin every other day for cellulitis. Staff I, LPN was not able to state when the IV vancomycin and IV tubing in Resident #54's room was hung and stated nursing staff would usually label the line and medication with the date it was hung. An interview was conducted on 5/9/2024 at 12:50 PM with Staff G, RN UM. Staff G, RN UM observed the photographic evidence of Resident #54's IV vancomycin medication and tubing captured on 5/6/2024 and stated there's about half a bag left in there when referring to the amount of medication left in the bag. Staff G, RN UM was not able to state why the IV tubing was not labeled with a date or why the IV vancomycin bag contained left over medication. Staff G, RN UM stated if the medication was not administered fully, it would be considered a medication error. An interview was conducted on 5/9/2024 at 7:04 PM with the facility's Director of Nursing (DON). The DON stated IV tubing and medication should be labeled with the date it was hung and could remain hung for 24 hours. The DON also stated IV medications should run via IV pump or a manual flow regulator until the medication is fully administered. The DON stated if a medication was not fully administered to a resident, it would be considered a medication error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care was provided in accordance with professional standards related to 1.) failed to ensure proper storage of respiratory equipment for one (#54) of two residents sampled for oxygen therapy, 2.) failed to ensure physician's orders for oxygen therapy were obtained for one (#54) of two residents sampled for oxygen therapy, 3.) failed to ensure oxygen tubing was changed in accordance with physician's orders for one (#126) of two residents sampled for oxygen therapy, and 4.) failed to ensure signage indicating oxygen was in use outside of resident rooms for one (#126) of two residents sampled for oxygen therapy. Findings included: A review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE]. Resident #54's diagnoses included Parkinson's Disease and need for assistance with personal care. An interview was conducted on 5/6/2024 at 4:00 PM with Resident #54 in the resident's room. Resident #54 was observed resting in bed at the time of the interview. An oxygen concentrator was observed next to Resident #54's bed with an oxygen nasal cannula and tubing set bundled on top of the concentrator. The oxygen tubing was not observed to be dated and was not stored in a storage bag. Resident #54 stated he used oxygen on an as needed basis. During the interview, Staff H, Registered Nurse (RN) and Unit Manager (UM) entered Resident #54's room. Staff H, RN UM stated nursing staff were to label oxygen nasal cannula and tubing with the date the set was changed. An observation was conducted on 5/8/2024 at 12:10 PM of Resident #54 in the resident's room. Resident #54 was observed resting in bed with oxygen being administered via nasal cannula at 2 liters per minute. A review of Resident #54's physician's orders revealed an order, dated 5/9/2024 for oxygen via nasal cannula at 2 liters per minute as needed for shortness of breath. Review of Resident #54's discontinued physician's orders did not reveal an oxygen order previous to 5/9/2024. An interview was conducted on 5/9/2024 at 12:50 PM with Staff G, Registered Nurse (RN) and Unit Manager (UM). Staff G, RN UM stated respiratory equipment should be stored in the plastic bag provided in the resident's room when not in use and should be thrown away and replaced if not stored properly. Staff G, RN UM also stated Resident #54 should have had an order for oxygen as needed prior to 5/9/2024. An interview was conducted on 5/9/2024 at 7:11 PM with the facility's Director of Nursing (DON). The DON stated a physician's order is required to administer oxygen to a resident. The DON also stated when respiratory equipment is not in use, it should be stored in a plastic bag and labeled with the date the equipment was changed out, which is done every week in accordance with the resident's order. If respiratory equipment is not stored correctly, it should be discarded and replaced. Review of the facility policy titled Oxygen Administration, last revised in December 2017 revealed, under the section titled Preparation staff are to verify that there is a physician's order for oxygen administration prior to administration of oxygen. The policy also revealed under the section titled Equipment and Supplies the following equipment and supplies will be necessary when performing oxygen administration: - Portable oxygen cylinder or concentrator. - Nasal cannula, nasal catheter, or mask (as ordered). - No Smoking/Oxygen in Use signs. - Regulator. Review of the facility policy titled Storage of oxygen and respiratory equipment, last revised in November 2020, revealed under the section titled Infection Control Considerations Related to Oxygen Administration staff are to change the oxygen cannula and tubing every seven (7) days, or as needed and staff are to keep the oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use. On 5/06/24 at 4:26 PM, Resident #126's oxygen tubing that was attached the standard oxygen concentrator (a machine that uses room air to make oxygen for people who need supplemental oxygen) in her room, had a date of 4/21/24 on a bright pink label. Photographic evidence obtained. There were no cautionary and safety signs indicating the use of oxygen posted outside the resident's room. On 5/07/24 at 10:37 AM, Resident #126's oxygen tubing had a date of 4/21/24 on it. There were no cautionary and safety signs indicating the use of oxygen posted outside the resident's room. On 5/08/24 at 07:19 AM, There were no cautionary and safety signs indicating the use of oxygen posted outside the resident #126's room. Photographic evidence obtained. On 5/08/24 at 07:45 AM, Resident # 126 was in her room sitting in her wheelchair. She was dressed for the day and her oxygen tubing was connected to her portable oxygen tank on the back of her wheelchair. The tubing with the bright pink label with the date of 4/21/24 was not present. Resident #126 was admitted on [DATE]. Her pertinent diagnoses included, Allergic rhinitis (inflammation of the nose), Abnormal posture, Muscle weakness, Chronic Obstructive Pulmonary Disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), Acute respiratory failure with hypoxia (low oxygen in body tissues), Pneumonitis (lung inflammation) due to inhalation of food and vomit (aspiration pneumonia), and Candidal sepsis (a life-threatening condition that arises when Candida fungi contaminate the bloodstream and spread throughout the body, causing severe infection) (aspiration pneumonia). Resident #126's admission Minimum Data Set (MDS) with an Assessment Reference Date of 4/24/24 documented the resident's Brief Interview for Mental Status score as 9, which meant the resident had moderate cognitive impairment and there were no indicators of delirium. The assessment revealed that the resident needed substantial assistance with almost all Activities of Daily Living and the resident experienced shortness of breath when lying flat. The MDS also coded the resident was using oxygen while a resident. There was a Baseline care plan, dated 4/23/24, which identified the resident was at risk for respiratory distress. The resident's comprehensive care plan included a focus area that the resident was at risk for respiratory distress related to the diagnoses of COPD and recent respiratory failure. The care plan goal included that the resident would not exhibit signs and symptoms of respiratory distress. The care plan interventions included oxygen per orders, listen to lung sounds every shift and as needed, make Primary Care Physician aware of changes, provide rest periods as needed, oxygen saturations via pulse oximetry (measures the amount of oxygen in the blood) as ordered as needed, and observe and report signs of respiratory distress. Resident #126's Physician Orders included oxygen at 2 liters/minute via nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) twice a day and change oxygen tubing and cannula weekly once a day on Sundays. There were no issues identified in the medical record progress notes regarding the resident's oxygen use. During an interview with Licensed Practical Nurse, Staff M on 5/09/24 at 2:20 PM, she stated that the nurses change the oxygen tubing every Monday. During an interview with the Director of Nursing on 5/9/24 at 4:46 PM, she was informed about Resident #126's oxygen tubing not being changed weekly and the lack of cautionary and safety signs indicating the use of oxygen. She said the oxygen tubing should be changed weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to provide medications for one (#178) out of five residents sampled for unnecessary medications related to antihypertensive medications. Findings included: Review of Resident #178's Face Sheet revealed the resident was admitted on [DATE] and included diagnoses Type 2 Diabetes Mellitus with hyperglycemia, Unspecified cirrhosis of liver non-alcoholic, and essential (primary) hypertension. Review of Resident #178's May Medication Administration Record (MAR) revealed the following: - Losartan 25 milligram (mg) oral tablet once a day. Hold for systolic blood pressure (SBP) under 120, pulse under 60. The medication was administered on 5/5 for a documented blood pressure of 113/62 and on 5/7 for a blood pressure of 96/60. - Diltiazem 30 mg oral tablet three times a day. Hold for SBP less than 110 or pulse less than 60. The medication was administered on 5/1 at 9:00 p.m. for a blood pressure of 98/62 and held on 5/2 at 9:00 p.m. for blood pressure 110/69. - Spironolactone 100 mg oral tablet once day. Give one 50 mg tab and one 100 mg tablet. 150 mg daily. Hold if SBP less than 100. The MAR showed one 100 mg tablet was administered on 5/2 and the 50 mg tablet was held, the dose of 150 mg was held on 5/3 for a blood pressure of 108/60. During an interview on 5/9/24 at 5:55 p.m., the Director of Nursing (DON) reviewed Resident #178's MAR and confirmed the nurses had administered the antihypertensive medications outside of parameters. The DON stated the expectation was to administer (meds) per parameters. The staff member shook head when reviewing Losartan and the blood pressure taken for Diltiazem.

Based on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed and six (6) errors were identified for two (#8 and #126) of five residents observed. These errors constituted a 21.43% medication error rate. Findings included: 1. On 5/8/24 at 8:11 a.m., an observation of medication administration with Staff R, Registered Nurse (RN), was conducted with Resident #8. The staff member obtained a blood pressure of 119/70 and a radial pulse of 65. Staff R returned to the medication cart parked in the hallway and dispensed the following medications: - Vitamin D3 50 microgram (mcg) (2000 international units) - 2 over the counter (otc) tablets - Vitamin D 25 microgram (mcg) otc tablet - Eliquis 5 milligram (mg) tablet - Metoprolol Succinate Extended-Release 25 mg tablet - Multi-Vitamin otc tablet - Oxybutynin Extended-Release tablet - ClearLax mixed with approximately 4 ounces of water. - Tramadol 50 mg tablet Staff R confirmed dispensing 8 tablets, placing all in a plastic envelope and manually crushing them all together. Staff R placed in 2 spoonfuls of applesauce in the medication cup, stirring the concoction, entered the resident room and administered the medications. Review of Resident #8's Medication Administration Record (MAR) revealed the resident was ordered: - Multi Vitamin with minerals tablet - Metoprolol Succinate Extended Release 24 hour - 25 mg tablet once a day, hold for systolic blood pressure below 110 or pulse below 60 beats per minute. - Oxybutynin Chloride Extended Release 24 hour - 5 mg once a day. Review of Resident #8's physician orders revealed the following order: - May crush medications within pharmacy guidelines. Review of the facility provided pharmacy list of DO NOT CRUSH MEDICATIONS included the medications: Metoprolol (extended release) - Toprol XL and Oxybutynin (extended release) - Ditropan XL. During an interview on 5/9/24 at 12:52 p.m., the issues regarding crushing extended-release medications and the Multi Vitamin tablet dispensed did not contain minerals was discussed with the Director of Nursing (DON), the DON confirmed Metoprolol Succinate and Oxybutynin should not have been crushed. 2. On 5/8/24 at 11:26 a.m., an observation of medication administration with Staff R, Registered Nurse (RN), was conducted with Resident #126. Staff R obtained a blood glucose level of 229 prior to dispensing the following medications: - Senna 8.6 milligram (mg) otc tablet - Aspirin 325 mg otc tablet - Metformin 500 mg tablet - Humulin R 4 units Staff R mixed applesauce in the medication cup holding the three tablets then injected the insulin into Resident #126's left lower quadrant. Staff R stated the resident could take the medications whole but due to safety the tablets needed to be crushed. Staff R sat the medication cup on the in-room sink vanity, left the room and re-dispensed the Senna, Aspirin, and Metformin, crushing the medications together, re-entered the resident room and administered the medications. Review of Resident #126's MAR revealed the resident was to be administered Aspirin once a day at 10:00 a.m., Senna was scheduled for 10:00 a.m., and Metformin twice a day scheduled for 9:00 a.m., and 5:00 p.m. The review showed the Aspirin and Senna was administered approximately one hour and half after the scheduled time and the Metformin was administered approximately 2.5 hours after the scheduled time. During an interview on 5/9/24 at 1:00 p.m., the DON was notified of the lateness of Resident #126's medications. Review of the policy - Administering Oral Medications, revised October 2010, revealed The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy instructed staff to Check the label on the medication and confirm the medication name and dose with the MAR. Review of the policy - Administering Medications, revised December 2017, showed Medications shall be administered in a safe and timely manner, and as prescribed. The interpretation and implementation of the policy revealed: 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure one (#54) of one resident sampled for intravenous medication administration was free from significant medication errors. Findings included: A review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and infection and inflammatory reaction due to internal left knee prosthesis. A review of Resident #54's physician's orders revealed an order, dated 5/5/2024, for vancomycin 1 gram per 250 milliliters (ml), infuse 250 ml intravenously (IV) over 90 minutes at a rate of 166 ml per hour every other day for a diagnoses of infection and inflammatory reaction d/t internal left knee prosthesis. An observation was conducted on 5/6/2024 at 4:00 PM of Resident #54 in the resident's room. Resident #54 was observed resting in bed, positioned on his right side. An IV pole was observed in Resident #54's room. A 250 ml bag of vancomycin was observed hanging from the IV pole with IV tubing attached to it. The IV tubing was not observed to be labeled with the date it was hung. Approximately 75 ml of fluid was observed inside of the bag of vancomycin. During the observation, Staff H, Registered Nurse (RN) and Unit Manager (UM) entered Resident #54's room and an interview was conducted. Staff H, RN UM stated nursing staff would normally label IV tubing with the date it was hung and was not able to state why so much of the IV medication remained in the IV bag. Photographic evidence was obtained. A review of Resident #54's progress notes dated 5/5/2024 at 6:20 AM revealed Resident #54's IV vancomycin was infused with no adverse reactions. The progress not did not show documentation related to the amount of medication left in the bag of vancomycin after the administration. An interview was conducted on 5/9/2024 at 12:50 PM with Staff G, RN UM. Staff G, RN UM observed the photographic evidence of Resident #54's IV vancomycin medication and tubing captured on 5/6/2024 and stated there's about half a bag left in there when referring to the amount of medication left in the bag. Staff G, RN UM was not able to state why the IV tubing was not labeled with a date or why the IV vancomycin bag contained left over medication. Staff G, RN UM stated if the medication was not administered fully, it would be considered a medication error. An interview was conducted on 5/9/2024 at 7:04 PM with the facility's Director of Nursing (DON). The DON stated IV tubing and medication should be labeled with the date it was hung and could remain hung for 24 hours. The DON also stated IV medications should run via IV pump or a manual flow regulator until the medication is fully administered. The DON stated if a medication was not fully administered to a resident, it would be considered a medication error. A review of the facility policy titled Medication Errors, with no effective date, revealed under the section titled Definitions types of medication errors include wrong dose and omission (not administered before next scheduled dose due.) The policy also revealed under the section titled Policy residents shall remain free of any significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist one (Resident #17) of one resident in obtaining routine dental care. The findings included: During an observation on 5/6/24 at 1:18 PM, Resident #17 was observed to have several broken, chipped teeth and dental caries. On 5/8/24 at 8:40 AM, Resident #17 was observed during breakfast with multiple chipped teeth, one front tooth was a sliver. She said she fell backwards with a shopping cart and it hit her mouth. She had black gums around several teeth. She was on a regular diet. Resident #17 was admitted to the facility on [DATE]. She was [AGE] years old. Her pertinent diagnoses included Hypothyroidism; Local infection of the skin and subcutaneous tissue; Vitamin D Deficiency; Contracture, left hand; Encounter for attention to colostomy; and essential hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 4/26/24 documented the resident's Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact with no indicators of delirium. This assessment coded Resident #17 as requiring set up or clean up assistance with eating and oral hygiene and that she had no pain, no fever, no vomiting, and no dehydration. Resident #17 had no swallowing disorder, her height was 61, and she weighed 108# with no weight loss or gain or unknown. She was coded as being prescribed a therapeutic diet. The Dental status section of the MDS was coded as none of the above. The Quarterly MDS with an ARD of 2/9/24 documented the resident's BIMS score of 3, indicating she had severe cognitive impairment, and no indicators of delirium. This assessment coded Resident #17 as requiring set up or clean up assistance with eating and oral hygiene and that she had no pain, no fever, no vomiting, and no dehydration. Resident #17 had no swallowing disorder, her height was 61, and she weighed 108# with no weight loss or gain or unknown. She was coded as being prescribed a therapeutic diet. Dental status is not coded on quarterly MDSs. The Annual MDS with an ARD of 5/19/23 documented the Resident #17's dental status as none of the above. None of the MDSs reflected the resident's obvious or likely cavities or broken natural teeth and abnormal mouth tissue. Resident #17 did not have a care plan for dental status. The resident had a small gradual weight loss from 11/01/23 of 114.6 lbs. and a Body Mass Index (BMI) (A person's weight in kilograms divided by the square of height in meters. A high BMI can indicate high body fatness) of 21.65 (normal weight) to 106.5 lbs. on 5/1/24 and a BMI of 19.93 (lower range of normal weight). Meal intake for April 2024 averaged 76 to 100%. The Social History assessments dated 4/26/24 & 11/23/23 did not document any oral/dental issues and indicated that No referrals necessary. The Social services note dated 4/26/24 for Annual review included, She is alert and oriented and pleasant to speak with. She resides at Royal Care as a long term care resident. She is DNR (Do Not Resuscitate) Status. The Speech Therapy Screens dated 4/26/24 & 5/16/23 did not document any oral/dental issues. The Nutritional Evaluations dated 11/21/23 and 4/26/24 marked dental status as none of the above. Physician Orders included multivitamin with minerals, Stress Formula with zinc, offer 8 oz. fortified milkshake by mouth twice daily, at 10 AM and 2 PM, document amount of fluid consumed (include bedside water, activities, hydration cart and snacks) every shift, document food at dinner, and Regular diet, fortified foods. Progress Notes revealed the following: 3/25/22 Advanced Practice Registered Nurse note - Lips, teeth, gums - normal dentition. 12/11/23 Physician note - Normal dentition (the development of teeth and their arrangement in the mouth). 4/29/23 Physician note - Normal dentition. There was no documentation in the medical record to indicate that the resident had been referred for a dental consult or received any dental services The medical record documented that Resident #17's payer source was a Medicaid Health Maintenance Organization since 3/1/22. An interview with the Social Services Director on 5/9/24 at 2:56 PM revealed that residents were referred for a dental consult if there was a concern. The facility had a dental service that came to the facility monthly. Once the dentist saw a resident, the dental service would see the resident on subsequent visits. The SSD said they had 8 residents who had just seen the dental hygienist recently. The Social Services Director was informed that Resident #17 dental status and that the resident had not been referred to the dentist. On 05/9/24 at 4:37 PM, the facility Director of Nursing (DON) was asked how residents were referred to the dentist. She responded that If the staff saw or heard that a resident had a dental problem they told the social worker and the social worker would make a referral to their contract dental service that came to the facility. She said the contract dental service had a dental hygienist and dentist who came to the facility, but she could not say how often. The DON was informed about the resident's dental status and that the resident's MDSs were inaccurate for her oral/dental status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a clean and homelike environment, in that the facility was not free from offensive odors. This involved the front lobby area, the area in front of the [NAME] nurses' station, and four resident rooms (Rm103, Rm107, Rm109 and Rm110) out of 18 resident rooms on the [NAME] unit. Findings included: On 5/6/24 at 9:00 a.m. the lobby smelled of old urine when the survey team entered the facility. At 11:10 a.m. the area in front of the [NAME] nurses' station smelled of old urine. On 5/6/24 at 2:31 p.m. room [ROOM NUMBER] had a very offensive odor in the room, that was not urine. On 5/7/24 at 10:03 a.m. room [ROOM NUMBER] had an offensive odor that was not urine. On 5/7/24 at 10:38 a.m. room [ROOM NUMBER]'s bathroom had a strong urine odor in it. On 5/8/24 at 7:43 a.m. room [ROOM NUMBER] had a strong odor of urine. On 5/8/24 at 8:21 a.m. room [ROOM NUMBER] room had a strange offensive odor that was not urine, but it was improved from the day before. On 5/9/24 at 5:51 p.m. an interview with the Environmental Services Director revealed that he conducted a monthly room check, such as gaps between the mattress and the beds, call lights functioning, etc. His audit doesn't include checking for offensive odors in rooms. He said, if they notice an odor they do a deep clean. They cleaned room [ROOM NUMBER]B recently. They replaced the whole bed in 110B the day before (5/8/24). If the staff observe environmental concerns, the nurses can put in an IT ticket into a computer and then the Environmental Services Director receives the ticket. After that, he prioritizes the ticket and addresses the concern. When Environmental Services responds to the concern and resolves it, an email is sent to the person who submitted it to let them know that the concern has been resolved. The system alerts him when tickets are overdue. The Environmental Services Director was informed about the urine odor on the first day in front of the [NAME] nurses' station, the front lobby, and resident rooms. He said he would take care of it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASARR) was accurate for four residents (#15, #26, #28, #38) of 17 residents sampled for PASARR review. Findings included: Review of the electronic medical record (EMR) revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia severe, bipolar disorder, and major depressive disorder. Review of the Level I PASARR, dated 7/31/23, showed qualifying diagnoses were not checked or indicated, and that no Level II PASARR was required. Review of the EMR revealed Resident #26 was initially admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, and anxiety disorder. Review of the Level I PASARR, dated 7/28/20, showed qualifying diagnoses of depressive disorder and anxiety were checked, bipolar disorder was not checked and that no Level II PASARR was required. Review of the EMR revealed Resident #28 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD), epilepsy, unspecified intracranial injury with loss of consciousness of unspecified duration (TBI), unspecified mood disorder, schizoaffective disorder, and anxiety disorder. Review of the Level I PASARR, dated 10/05/18, showed Part A qualifying diagnoses (anxiety, schizoaffective, depressive disorder) were not checked, and Part B Intellectual Disability conditions (epilepsy, PTSD, and TBI) were not checked and that no Level II PASARR was required. An interview was conducted on 05/09/24 at 5:10 p.m. with the Director of Nursing (DON). She stated their process for PASARR is to receive it prior to admission from the hospital. She said it is part of the resident preadmission paperwork the facility requires. She stated the facility will review the PASARR and if incorrect they will contact the hospital to complete a new one. She stated Residents #15, #26 and #28 PASARRs were all incorrect, as diagnoses should have reflected the diagnoses in their medical record and not left blank. It should have been corrected at admission to determine if a Level II PASARR was warranted. Review of the facility policy titled, admission Information: Reference - PASSR [PASARR], undated, revealed: All persons needing admission to a nursing facility must first be screened (Preadmission Screening) for possible mental illnesses (Level I). If a mental illness or intellectual disability appears to exist, the person must be referred for further evaluation (Level II) before admitted to a nursing facilty . Review if there is a substantial change in their mental status. This warrants a referral for an evaluation (Level II) to either the [state agency A] contracted PASRR provider, or the [state agency B]. On 5/07/24 at 1:20 p.m. Resident #38's Level I PASARR was reviewed in the electronic medical records. The Level I PASARR screening (to screen for suspected serious mental illness and/or intellectual disability) was completed on 3/4/19 prior to Resident #38's admission on [DATE]. The PASARR form only listed depressive disorder on the form, therefore no Level II PASARR was needed (copy obtained). According to the medical record, on 3/7/19, there was a new diagnosis of schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors) added for Resident #38. Resident #38's Level I PASARR was not revised to reflect this new diagnosis, which is a serious mental illness that would trigger a Level II review (An in-depth evaluation that results in the determination of need, the determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care). On 5/9/24 at 3:04 p.m. during an interview with the Social Services Director (SSD), she was informed that Resident #38's Level 1 PASARR was not revised after her new diagnosis of schizoaffective disorder. The SSD agreed that Resident #38 needed a revision of the PASARR. The SSD was asked if she or any other facility staff audit records to ensure that resident PASARRs are accurate, she replied that she couldn't speak to any audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record reviews, the facility failed to provide wound care and treatment in accordance with professional standards of practice for four (#67, #328, #177, and #36) of five residents sampled for skin conditions, and failed to ensure physician's orders were obtained for application of splints for one (#41) of one resident sampled for range of motion. Findings included: 1. A review of Resident #67's medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of sepsis and arthroscopic surgical procedure converted to open procedure. An interview was conducted on 5/7/2024 at 12:07 PM with Resident #67 in the resident's room. Resident #67 stated he had a procedure done on his right knee prior to his admission at the facility, which resulted in a wound infection to the area and required dressing changes to the wound. An observation of Resident #67's wound dressing to the upper right leg revealed no documented date on the wound dressing. A review of Resident #67's physician's orders showed an order, dated 4/30/2024, to cleanse Resident #67's right upper leg wound with normal saline, pat dry, insert silver rope dressing, cover with an abdominal pad, and secure with a (brand name) transparent dressing. Change every other day and as needed. A review of Resident #67's 5-Day Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/31/2024 showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #67 was cognitively intact. 2. A review of Resident #328's medical record showed Resident #328 was admitted to the facility on [DATE]. Resident #328 had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and cellulitis of the right finger. A review of Resident #328's physicians orders showed an order, dated 5/3/2024 to clean the resident's right middle finger wound with [brand name] solution, paint with betadine, and cover with a dry dressing once daily. An interview was conducted on 5/7/2024 at 11:48 AM with Resident #328 in the resident's room. Resident #328 stated he had a bad infection on his right middle finger, which was previously treated with antibiotics. Resident #328's right middle finger was observed with no dressing and appeared slightly red in color with minimal swelling. A follow up interview was conducted on 5/8/2024 at 4:25 PM with Resident #328 in the resident's room. Resident #328 stated the wound on his right middle finger previously had a dressing on it, but he did not think he needed it anymore and took the dressing off. Resident #328 was not able to state when he removed the dressing from his right middle finger but stated the facility staff had stopped putting a dressing on his right middle finger. A review of Resident #328's 5-day MDS assessment, with an ARD of 4/8/2024 revealed under Section C - Cognitive Patterns, a BIMS score of 14, which indicated Resident #328 was cognitively intact. The MDS assessment also revealed under Section E - Behavior, Resident #328 did not exhibit behaviors of rejection of care at any time during the assessment period. A review of Resident #328's progress notes with a date range of 5/3/2024 to 5/8/2024 did not show documentation related to Resident #328 refusing wound treatment or removing wound dressings from his right middle finger wound. An interview was conducted on 5/9/2024 at 12:39 PM with Staff G, Registered Nurse (RN) and Unit Manager (UM). Staff G stated Resident #328 had cellulitis of his right middle finger and the wound to the area was nearly healed but the resident kept squeezing it and messing with it so they wanted to keep the wound covered. Staff G reviewed Resident #328's wound treatment orders and addressed the resident had physicians orders for wound dressing changes to the right middle finger. Staff G reviewed Resident #328's medical record and was not able to find documentation related to Resident #328 removing the wound dressing or refusing to have the wound treatment done. Staff G stated if a resident refused to have a wound dressing treatment completed, the refusal should be documented in the resident's medical record. Staff G said nursing staff should attempt to reapply a wound dressing if a resident took dressing off or compromised the integrity of the dressing. Staff G stated when a wound treatment was done, the nurse completing the wound dressing change should label the dressing with the date and their initials. An observation was conducted on 5/9/2024 at 3:37 PM of Resident #328 in the resident's room. Resident #328 was observed resting in bed. No wound dressing was observed to Resident #328's right middle finger. An interview was conducted on 5/9/2024 at 6:58 PM with the facility's Director of Nursing (DON). The DON stated she would expect nursing staff to document completion of wound care treatments in the residents Treatment Administration Record (TAR) and any refusals of wound care treatments should be documented in the resident's medical record. The DON also stated if a resident removed a wound dressing or the dressing was not present as ordered, she would expect the nurse to find out why the wound dressing was not there and offer to reapply the wound dressing. The DON stated wound dressings should be labeled with the date the dressing change was completed and nursing staff should notify the resident's physician if the wound dressing was no longer needed. A review of the facility policy titled Wound Care, last revised in October 2010 revealed under the section titled Documentation the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The name and title of the individual performing the wound care. - All assessment data when obtained when inspecting the wound. - Any problems or complaints made by the resident related to the procedure. - If the resident refused the treatment and the reason(s) why. The policy also revealed under the section titled Reporting, notify the supervisor if the resident refuses the wound care and report other information in accordance with facility policy and professional standards of practice. 3. On 05/06/24 1:41 PM, Resident #36 was observed sitting in a power wheelchair on the outdoor patio with 4 x 6 white adhesive dressing on the anterior aspect of the right shin. The dressing was visibly soiled with yellow/brown drainage. The dressing was not dated to show when the dressing was last changed. Photographic evidence was obtained. Review of electronic medical record (EMR) for Resident #36 revealed an admission date of 03/04/2021 with diagnoses that included hereditary idiopathic neuropathy, atherosclerotic heart disease, pneumonia, and hyperlipidemia. Review of minimum data set (MDS) dated [DATE], revealed: -Section C Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. Review of nurse's progress note showed on 05/03/24, Resident was found on the floor in resident bathroom. Resident stated, 'I was trying to go to the bathroom'. Resident is alert and oriented x 3 and denies hitting head. Skin tears to right elbow and abrasion to left lower shin were noted. Area cleaned and dressed by wound care nurse. MD and emergency contact notified. Review of treatment administration record (TAR) revealed: -Skin tear cleanse with normal saline, apply xeroform and cover with dry dressing every other day until resolved. Special instruction box documented right elbow and right lower leg. With a start date of 05/03/24. 4. On 5/6/24 at 4:00 PM, Resident #177 was observed sitting up in bed, the observation revealed the resident was wearing gray stockings over bilateral below the knee amputations. The resident reported still having sutures/staples in the bilateral surgical sites. On 5/9/24 at 11:42 AM, Resident #177's bilateral below knee surgical site (BBKA) wound dressing changes was observed with Staff K, Registered Nurse (RN). The nurse removed 2 packages of rolled gauze, a vial of Normal Saline (NS), 2 packages of 4 x 4 inch gauze, and used a pair of scissors to cut off 4 lengths of woven tape retrieved from the treatment cart. The resident removed bilateral gray stockings from BBKA and reported the left stump felt like wasp stings, rubbing the area below the suture line. The suture lines to BBKA revealed slight redness. Staff K washed hands, opened packages of rolled gauze and placed them on a previously placed barrier on top of the resident's over-the-bed table. Staff K opened the packages of 4 x 4 gauze and with bare hands removed the squares of gauze, placing them on the barrier. Staff K applied gloves and used scissors to cut off the previously applied rolled gauze from the residents bilateral extremities. Staff K used minimal normal saline to clean the sutured surgical site, used a square of gauze to pat dry then placed two 4 x 4 squares of gauze over the sutures and wrapped the area with a roll of gauze, using the scissors to cut off the very end of the roll before securing with tape. Staff K cleaned the right stump with normal saline, patted the area dry with squares of gauze, placing a couple squares of gauze along suture line then wrapped the stump with rolled gauze, cutting off the end of the gauze and securing the gauze with woven tape. The observation showed Staff K had removed the 4 x 4 squares of gauze from 2 packages with bare hands, then used scissors previously utilized to cut off the previously applied dressings to cut off the ends of the rolled gauze without cleaning the scissors between removing the dirty dressing and applying the clean gauze. An interview was conducted with Staff K on 5/9/24 at 2:14 PM, the staff member confirmed the scissors should have been cleaned in between cutting the old dressing and cutting the end of the new one. Review of the policy - Dry/Clean Dressings, revised October 2010, revealed the purpose of the procedure was to provide guidelines for the application of dry, clean dressings. The steps of the procedure included: 4. Position resident and adjust clothing to provide access to affected area. 5. Wash and dry your hands thoroughly. 6. Put on clean gloves. Loose tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time and initials. Place on clean field. 11. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 12. Wash and dry your hands thoroughly. 13. Put on clean gloves. 5. On 5/6/24 at 12:55 PM, a therapist was observed setting up Resident #41 at a dining table on the East wing. During an interview on 5/6/24 after the meal, the resident was wearing bilateral hand splints with Velcro very loosely attached along top of the resident's hands. On 5/9/24 at 8:48 AM, Resident #41 was observed lying in bed and the person feeding him was going to tell the nurse about a cramp in the resident's right foot . The resident reported receiving therapy and therapy was putting splints onto bilateral hands after each session. The resident showed three fingers on each hand was contracted. On 5/9/24 at 2:17 PM, Resident #41 was observed playing a board game with his daughter while wearing bilateral hand splints. Review of Physician Orders for Resident #41 did not reveal an order for the use of bilateral hand splints. The orders did reveal an order, 3/18/24 - open ended for clarification Occupational Therapy (OT) to evaluate and (&) treat as indicated: 3 times/week (x/wk) x 8 wks skilled services: Activities of Daily Living (ADL)/Self-Care Training, Thera Exercises & Thera Activities in order to facilitate increase in independence; improve client performance skills of strength, coordination, functional activity tolerance, & balance in order maximize/improve efficiency & safety during ADL performance & functional mobility. Long Term Goal (LTG): Assisted Living Facility (ALF) setting placement. Review of a Physician order, dated 3/18/24 and discontinued on 5/8/24, revealed clarification Occupational Therapy (OT) to evaluate and (&) treat as indicated: 3 times/week (x/wk) x 8 wks skilled services: Activities of Daily Living (ADL)/Self-Care Training, Thera Exercises & Thera Activities in order to facilitate increase in independence; improve client performance skills of strength, coordination, functional activity tolerance, & balance in order maximize/improve efficiency & safety during ADL performance & functional mobility. Long Term Goal (LTG): Home setting placement. Review of Resident #41's physician orders revealed an order, dated 5/1/24 to end on 6/14/24, which showed the physician had reviewed and approved the physician orders, care plan, activities, and discharge plans to continue for 45 days. I have reviewed all diagnosis, and they are all active at this time. Review of the treatment orders revealed the resident was to wear Heel Protectors when in bed. Review of Resident #41's care plan revealed the following problems: - ADL Functional Status/Rehabilitation Potential: Mobility, Strength, Endurance, (and) Balance. OT 3x wk for 8 wks. Started 3/18/24 and last reviewed and revised by Staff S, Occupational Therapist (OT). The approaches included Adapted equipment as needed and did not show the type of adaptive equipment utilized or if any equipment was being used. - Risk for skin impairment/pressure ulcers related to (r/t) impaired mobility, weakness, and needs assist with ADL. Hands are partially contracted and is at risk of skin impairment to palms of hands. He has bowel/bladder (b/b) incontinence. The approaches included Heel protectors per orders. The interventions did not include the use of bilateral hand splints. An interview was conducted with Staff S, Occupational Therapist (OT) on 5/9/24 at 2:18 PM Staff S reported putting splints on Resident #41, to gradually increase tolerance, looked for redness, and trims nails. Staff S reported the resident was wearing splints up to 7 hours a day and if the OT was not at the facility other staff roll a towel and place it in the palm of hand. (Review of orders and care plan did not show an order or a care plan for staff to do this). Staff S reviewed physician orders and confirmed not putting the verbiage of splints in the order and the resident should be care-planned for splints also. Staff S confirmed (hand) splints were not part of the care plan. Review of Resident #41's OT Evaluation and Plan of Treatment, certification period of 3/18/24 to 5/14/24, revealed the Treatment Approaches May Include: Initial Encounter: Orthotic Management and training. - A new goal - short term goal (STG) showed the resident would increase compliance with orthotic management instructions to partial/moderate assistance in order to maintain joint integrity, facilitate joint mobility, prevent contractures, achieve proper joint alignment, and improve skin integrity and hygiene. Target date 3/31/24. The baseline, 3/18/24 revealed the resident was dependent for orthotic management. - A new goal - STG revealed the Patient will increase ability to donn/doff splint to Partial/Moderate Assistance using wearing schedule of during daily tasks in order to improve skin integrity and hygiene, achieve proper joint alignment, maintain joint integrity, and prevent contractures. Target: 3/31/24. The resident's baseline, 3/18/24, was dependent. The OT Evaluation revealed the goals were for OT interventions to improve client performance skill deficits for balance, strength, and endurance in order to increase level of (I) and safety for ADL performance and functional mobility. Staff S signed the document on 3/18/24, the Director of Rehab signed the revision on 3/27/24 and the physician certified I certify the need for these medically necessary services furnished under this plan of treatment while under my care from 3/18/204 through 5/14/24 on 4/2/24. The therapy Initial Assessment/Current Level of Function & Underlying Impairments, with a start of care 3/18/24 revealed the Musculoskeletal System Assessment revealed the Current Orthotic Device = Hand roll. The management revealed tolerance was N/A, Donn/Doff = Dependent; Orthotic Hygiene = Dependent; Functional Use = Dependent; Orthotic Compliance = Dependent. The Assessment Summary revealed a Splint/Orthotic Recommendations: BMI Slim Grip Hand Splints for both hands. The summary of Daily therapy notes showed on 5/6/24, pt's two set of BMI Slim Grip Hand Splints were adjusted for fit and applied to both hands. The note on 5/7/24, revealed pt's two set of BMI Slim Grip Hand Splints were adjusted for fit and applied to both hands, and on 5/9/24 at 3:49 PM, Staff S documented The pt's two sets of BMI Slim Grip Hand Splints were adjusted for fit and applied to both hands. Pt tolerated 5 hours with no complaints of pain/discomfort. Review of the policy Comprehensive Care Plans, revised September 2010, showed An Individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. The interpretation and implementation of the policy revealed: 1. Our facility's care planning/ interdisciplinary team, in coordination with the resident, his/ her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect the residents expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables, and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/ or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions. 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or care area triggers in isolation may have little, if any, benefit for the resident. 6. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that required careful data gathering, proper sequencing of advance, and complex clinical decision making. No single discipline can manage the task in isolation. The residence physician (or Primary Health care provider) is integral to this process. 8. Assessments of residents are ongoing in care plans are revised as information about the resident and the resident's condition change.

Based on observations and interviews, the facility failed to ensure proper storage of drugs and biologicals related to 1.) failing to ensure treatment carts remained locked and secured when not in use on one (South) of three units of the facility on two of four days during the survey and 2.) failing to ensure medications were stored in facility medication carts and not inside of resident rooms for one (#26) of five residents observed during medication administration. Findings included: During a tour of the South unit on 5/7/2024 at 9:29 AM, a treatment cart was observed unlocked in the unit hallway without staff present at the treatment cart. Staff U, Registered Nurse (RN) was observed conducting medication administration in the unit hallway. Staff U, RN stated she just unlocked the treatment cart because items from pharmacy were delivered that morning, which she put in the treatment cart. Staff U, RN addressed she left the treatment cart unlocked and stated she was going to lock the cart. Staff U, RN was observed locking the treatment cart before continuing with medication administration. During a tour of the South unit on 5/8/2024 at 9:26 AM, a treatment cart was observed unlocked in the unit hallway without staff present at the treatment cart. The facility's Infection Preventionist (IP) and Assistant Director of Nursing (ADON) was observed walking up to the treatment cart and closing the trash can lid on the cart. The IP ADON did not lock the treatment cart before walking away from it. An interview was conducted with the IP ADON following the observation. The IP ADON stated she did not see the treatment cart was unlocked and stated the carts should be kept locked at all times. The IP ADON was observed locking the cart before walking down the unit hallway. 2. On 5/8/24 at 11:26 a.m. an observation of medication administration with Staff R, Registered Nurse (RN), was conducted for Resident #126. The staff member obtained a blood glucose level of 229 from the resident's right thumb, the observation showed a bottle of store brand nasal spray sitting on the bedside dresser next to the bed. Staff R left the room and dispensed three tablets of oral medication and drew up 4 units of Humulin R insulin from a vial. The staff member injected the 4 units into the left lower quadrant of the resident and stated, as stirring applesauce with the oral medications, the resident could take the medications whole in applesauce however due to safety the tablets needed to be crushed. Staff R placed the medication cup containing the 3 oral tablets and applesauce on the in-room vanity and left the room. The staff member dispensed the oral medications prior dispensed, crushed the medications together, mixed them with applesauce, re-entered Resident #126's room, and administered the medications before leaving the room, leaving the nasal spray at bedside. An interview was conducted with Staff R on 5/8/24 at 11:46 a.m., regarding Resident #126 having nasal spray at bedside. The staff member entered Resident #126's room for a fourth time and removed the nasal spray from the bedside dresser reporting not knowing who put it there and it must have been a family member. The staff member, again, stated it must have been a family member and did not answer if the medication was supposed to be kept at bedside. During an interview on 5/9/24 at 1:00 p.m., the Director of Nursing (DON) stated the nurse had informed her about the nasal spray and no one in the facility was allowed to self-administer (medications). An interview was conducted on 5/9/2024 at 6:54 PM with the facility's Director of Nursing (DON). The DON stated she would expect medications and biologicals to be stored inside of the medication and treatment carts and the carts should be kept locked when not in use. The DON also stated if a resident wishes to administer their own medications, they would provide education to the resident and assess them to ensure they are able to properly administer the medications to themselves, but the medication would still be stored in the facility medication cart. The DON stated if the resident or the resident's family wished to have an over-the-counter medication that was brought in, they must have a physician's order for the medication. Review of the facility policy titled Storage of Medication, last revised in April 2007, revealed under the section titled Policy Statement the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy also revealed under the section titled Policy Interpretation and Implementation compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to maintain food safety standards, such as maintaining clean floors and walls; not store ready-to-eat refrigerated Time/Temperature Control for Safety (TCS) food too long; thawing frozen TCS food (meat) properly under cold running water; and maintaining equipment in good condition. These findings have the potential to cause foodborne illness for 74 out of 76 residents who consume the facility's food. Findings included: During the initial brief tour of the kitchen on 5/06/24 at 9:29 a.m., the perimeter of the floor in the walk-in refrigerator had black soil. In addition, at 9:46 a.m., the perimeter of the floor in the walk-in freezer had black soil. (Photographic Evidence Obtained) Also, during the kitchen tour at 9:51 a.m. there was a quart container of egg salad in the [vendor name] double door reach-in refrigerator in the food preparation area. The container of egg salad had a label with a date that was written use by 5/4/24. The egg salad was made on the premises. (Photographic Evidence Obtained) The Kitchen Manager discarded the egg salad on her own volition. A continued observation revealed, in the dry storage area at 9:59 a.m., a black substance that appeared to be biogrowth on one wall. (Photographic Evidence Obtained) Additionally during the kitchen tour, at 10:03 a.m., a 10 pound log of frozen ground beef was being thawed in the prep sink. The frozen meat was floating in water in the sink. Staff O, Dietary Aide turned off the faucet to the sink, so that there was no water flowing over the meat in the sink. (Photographic Evidence Obtained) The Dietary Director was told about this and she turned the water back on and drained the sink. While observing the frozen meat in the sink, it was noted there was a large spatula with burnt edges hanging from the rack above the prep sink. (Photographic Evidence Obtained) During a follow up visit to the kitchen on 5/08/24 at 11:17 a.m., the wall in the dry storage area was cleaned and painted. (Photographic Evidence Obtained) In addition at 11:38 a.m., the same spatula with burnt edges was observed again hanging from a rack. (Photographic Evidence Obtained) There were three scoops in which the plastic handles were a rough surface, which was no longer easily cleanable. One was just washed and the other two were stored in a drawer. (Photographic Evidence Obtained) The Dietary Director disposed of these on her own volition. On 5/8/24 at 12:16 p.m. the facility dietitian stated that Staff P, Dietary Aide put the date she made the egg salad on the label. An observation of the [NAME] unit resident nourishment mini refrigerator on 5/08/24 at 12:59 p.m., revealed two thermometers present in the refrigerator. One was an analogue dial thermometer and the other was a hanging analogue liquid filled tube thermometer, which was broken. The hanging tube thermometer was filled with water. (Photographic Evidence Obtained) On 5/9/24 at 3:25 p.m. to 3:47 p.m., the kitchen observation findings were discussed with the facility's Dietitian and the Dietary Director. The facility's Dietitian stated that Staff O, Dietary Aide had previously been trained in thawing frozen food. He further stated the Food and Nutrition Service staff had been trained in food storage, which he provided a copy of the in-service education report, dated 4/21/24. He stated the eggs used in the egg salad that was labeled as use by 5/4/24 were pasteurized shell eggs. The facility's Dietitian added that they have purchased a new spatula and scoops. He says he looks at kitchen sanitation during his consultation visits and documents them on his consultation reports which are given to the Nursing Home Administrator. The facility's Dietitian provided the consultation reports dated 3/4/24 and 4/21/24, which included various food safety concerns, but did not include any of the concerns identified during this survey. He provided documentation of employee training on food storage and thawing on 5/7/24 and equipment maintenance and cleaning floors and walls on 5/8/24. He also provided documentation of Performance Improvement Plans (PIPs) for the identified kitchen concerns. These PIPs included dating prepared food with a target date of 7/21/24; cleaning floors and wall with a target date of 8/6/24; and equipment maintenance with a target date of 10/8/24. The Kitchen Weekly Cleaning Schedule showed that one staff is responsible for sweeping and mopping the walk-in refrigerator and the another to sweep and mop the walk-in freezer. The Weekly Cleaning Schedule included sweep and mop storage room. The facility policy on Sanitization, revised on October 2020, included the following: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects . The facility policy on Food Storage, revised on 10/1/20, included the following: Policy: Food and supplies shall be received and stored in proper areas . Ready-to-eat food shall be marked with a discard dated at the time of opening or preparation. The discard date shall be seven (7) days after the food has been opened if the food has been refrigerated at 41 degrees F [Fahrenheit] or less .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and maintain an effective infection prevention and control program to control the spread of infection by 1.) failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for four residents (#326, #64, #328, and #67) of seven residents with COVID-19 infection in the facility, 2.) failed to ensure staff doffed PPE before exiting the rooms of residents under transmission based precautions for two residents (#328 and #67) of seven residents with COVID-19 infection in the facility, 3.) failed to ensure residents were assisted with hand hygiene before meals during observation of meal service, and 4.) failed to ensure urinary catheters were stored in a sanitary manner for one resident (#30) of one resident sampled for urinary catheter use. Findings included: During a tour of the South unit on 5/6/2024 at 11:30 AM, a call light was observed on for the room of Resident #326 and Resident #64. An observation of the room door revealed signage indicating the residents were on transmission based precautions for contact and droplet isolation. Staff B, Certified Nursing Assistant (CNA) and Staff D, CNA were observed donning isolation gowns and glove in preparation to enter the room. Staff B, CNA was observed wearing a surgical mask with an N95 mask over it and did not don eye protection before entering the resident's room. Staff D, CNA donned an N95 mask but did not don eye protection before entering the resident's room. An interview was conducted following the observation at 11:41 AM with Staff B, CNA. Staff B, CNA stated Resident #326 and Resident #64 were under contact and droplet isolation precautions and staff were to don an isolation gown, N95 mask, and gloves before entering the room. Staff B, CNA stated eye protection was not required to enter the room. Staff B, CNA read the signage posted to the door and addressed eye protection was required to enter the resident's room. Staff B, CNA stated she was not aware eye protection was needed to enter the room of a resident on contact and droplet isolation precautions and stated I don't even know if we have goggles. A review of Resident #326's medical record revealed Resident #326 was admitted to the facility on [DATE]. A review of Resident #326's physician's orders revealed an order dated 5/5/2024 for droplet isolation related to the resident being positive for COVID-19. A review of Resident #64's medical record revealed Resident #64 was admitted to the facility on [DATE]. A review of Resident #64's physician's orders revealed an order dated 5/5/2024 for droplet isolation related to the resident being positive for COVID-19. An observation was conducted on 5/6/2024 at 12:11 PM during lunch meal tray pass on the facility's South unit. Staff E, CNA was observed entering the room of Resident #328 wearing an isolation gown, gloves, an N95 mask, and goggles. An observation of the room door revealed signage indicating the resident was on transmission based precautions for contact and droplet isolation. Staff E, CNA was observed exiting Resident #328's room carrying the goggles in her left hand, using a paper towel as a barrier between her hand and the goggles. Staff E, CNA placed the goggles on top of the isolation cart outside of Resident #312's room, not using the paper towel as a barrier. Staff E, CNA donned clean gloves, picked up the goggles, and used a cleaning product to sanitize the goggles for approximately one minute. Staff E, CNA then placed the goggles back on top of the isolation cart. An interview was conducted with Staff E, CNA following the observation. Staff E, CNA stated the facility was previously utilizing face shields as eye protection, which were disposed of after each use, and she was not sure what the facility protocol was for using goggles as eye protection. Staff E, CNA also stated the facility reused the goggles and stored them in paper bags at one point in time, but she was not sure if the process was the same or if the facility was reusing PPE. A review of Resident #328's medical record showed Resident #328 was admitted to the facility on [DATE]. A review of Resident #328's physician's orders revealed an order, dated 5/5/2024 for droplet isolation related to the resident being positive for COVID-19. An observation was conducted on 5/6/2024 at 12:31 PM in the South hall of the facility. Staff D, CNA was observed entering the room of Resident #328. An observation of the room door revealed signage indicating the resident was on transmission based precautions for contact and droplet isolation. Staff D, CNA was observed donning an isolation gown, goggles, gloves, and an N95 mask. Staff D, CNA was observed donning the N95 mask over 2 surgical masks before entering the resident's room. When Staff D, CNA exited the room, she was observed carrying the N95 mask out of the room, using a piece of plastic as a barrier, and had 2 surgical masks donned. An interview was conducted with Staff D, CNA following the observation. Staff D, CNA was not able to state why she donned her N95 mask over the 2 surgical masks and was not able to explain the facility process for doffing PPE appropriately, stating I'm new. An observation was conducted on 5/8/2024 at 12:12 PM on the facility's South unit during the lunch tray pass. Staff F, CNA was observed exiting the room of Resident #328 and Resident #67 wearing an N95 mask, which was donned over a surgical mask, and a face shield. An observation of the room door revealed signage indicating the residents were on transmission based precautions for contact and droplet isolation. Staff F, CNA was observed entering the unit's soiled utility room to dispose of the N95 mask and face shield. Staff F, CNA was observed exiting the room wearing a surgical mask. An interview was conducted following the observation with Staff F, CNA. Staff F, CNA stated when entering the room of a resident on contact and droplet isolation precautions, staff are to don an isolation gown, gloves, eye protection, and an N95 mask. Staff F, CNA also stated when she exits a room of a resident on contact and droplet isolation precautions, she doffs the isolation gown and gloves, but keeps the eye protection and N95 mask on, then disposes of the PPE in the soiled utility room. Staff F, CNA was not able to state why she donned an N95 mask over a surgical mask but stated it was her normal process to do so. A review of Resident #67's medical record revealed Resident #67 was admitted to the facility on [DATE]. A review of Resident #67's physician's orders revealed an order, dated 5/7/2024 for droplet isolation related to the resident being positive for COVID-19. An interview was conducted on 5/9/2024 at 5:34 PM with the facility's Infection Preventionist (IP). The IP stated residents who are diagnosed with COVID-19 are placed on droplet isolation precautions. Personnel entering the resident's room should don an isolation gown, N95 mask, eye protection, and gloves before entering the resident's room. The IP also stated staff had the option to don a surgical mask over their N95 mask, but donning an N95 mask over a surgical mask would not be appropriate because it would not provide a proper fit for the N95 mask. The IP stated staff should doff all PPE before exiting the resident's room and should not be reusing any PPE. An interview was conducted on 5/9/2024 at 7:15 PM with the facility's Director of Nursing (DON). The DON stated when entering the room of a resident on contact and droplet isolation precautions, staff should don an isolation gown, N95 mask, gloves, and eye protection before entering the resident's room. Staff should also be doffing all PPE before exiting the room. The DON also stated the N95 mask would not be effective if a surgical mask was worn underneath and stated the facility does not reuse PPE. A review of the facility policy titled Infection Prevention and Control Program, last revised in January 2021, revealed under the section titled Policy the facility's Infection Prevention and Control Program shall ensure that this organization develops, implements, and maintains an active, organization wide program for the prevention, control, and investigation of infections and communicable diseases in order to reduce the risks of endemic infections in residents, visitors, and healthcare workers, and to optimize use of resources. The Infection Prevention and Control Program shall be conducted in accordance with all applicable federal and state rules and regulations, accrediting body standards, as well as nationally recognized infection prevention and control practices and guidelines. All staff shall participate and support the Infection Prevention and Control Program through compliance with infection prevention and control practices, policies and procedures, reporting infection prevention and control concerns, and cooperation with the Infection Preventionist/Infection Prevention and Control Committee. On 5/8/24 at 8:11 a.m., an observation of medication administration was conducted with Staff R, Registered Nurse (RN), for Resident #8. The staff member removed a manual blood pressure (BP) cuff from the bottom drawer of the medication cart, entered the resident room and placed it on the resident's right arm. Staff R obtained a BP of 119/70 and with the use of a non-contact thermometer a temperature of 97.4. The staff member used a pulse oximeter to obtain a heart rate of 70 and a oxygen saturation of 100%. Staff R, RN removed the cuff from the resident and left the room. The staff member used a disinfecting wipe to clean the BP cuff and another to clean the thermometer and pulse oximeter. Staff R did not remove the stethoscope used for BP measuring from around the neck to clean it. The staff member prepared Resident #8's medications and administered them. On 5/6/24 at 12:45 p.m., Resident #30 was observed sitting in the East Dining Room with the urinary drainage bag attached to the underside of the wheelchair, and the catheter tubing lying on the floor. On 5/7/21 at 5:01 p.m., Resident #30 was observed lying in bed with the catheter tubing lying on the floor next to the bed. Review of Resident #30's clinical record showed the resident was admitted on [DATE] and re-admitted on [DATE]. The Minimum Data Set (MDS), dated [DATE], revealed diagnoses not limited to uropathy and urinary tract infection (UTI). Review of Resident #30's care plan showed the resident had a problem involving increased potential for complications/infection related to has a urinary catheter in place. Diagnosis (Dx) urinary retention with obstruction, start date 5/2/24. The goal was the resident will not have complications or infection related to catheter during review. The approaches included Keep drainage bag below waist and free of kinks in tubing and off floor. Review of the policy - Indwelling Urinary Catheter Insertion and Maintenance - Male Resident, effective 2010, revealed the goal was to Promote single or continuous bladder elimination by insertion of a sterile catheter into the urinary bladder and provide a sterile closed receptacle system. The policy revealed The facility shall ensure that a licensed nurse catheterized male residents, preferably a licensed male nurse. The procedure instructed staff to Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. During the Dining Observation at lunch on 5/6/24 at 12:30 PM in the [NAME] unit common area, none of the 7 residents present were offered hand hygiene before eating. These resident's eating assistance varied from supervision to feeding. During an interview with the Director of Nursing on 5/9/24 at 4:46 PM, the concern about the staff not offering hand hygiene before eating was discussed. The facility policy was requested at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to equip corridors with securely affixed handrails on 2 of 3 units of the facility (West and South). Findings included: During a tour conducted on 5/6/2024 at 9:48 AM on the facility's [NAME] unit, a handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. A tour conducted on 5/6/2024 at 10:59 AM on the facility's South unit revealed the following: - A handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. - A handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. - A handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. An interview was conducted on 5/6/2024 at 11:11 AM with Staff I, Licensed Practical Nurse (LPN) on the facility's South unit. Staff I, LPN stated if a maintenance concern was identified on the unit, she would communicate the concern to the Unit Manager, who would then relay the concern to facility maintenance staff. Staff I, LPN observed the unsecured handrails on the South unit and addressed the rails were loose and not firmly secured to the wall. Staff I, LPN stated she did not notice the handrails were loose and unsecured and stated the handrails were not safe. An interview was conducted on 5/6/2024 at 11:19 AM with the facility's Director of Environmental Services (DES). The DES stated he conducted inspections of the facility's handrails at least weekly and any staff member can document a maintenance concern in the electronic maintenance system. The DES addressed the handrails on the South unit were loose and not firmly secured to the wall. A review of the facility's Weekly Hand Rail Checks for 5/6/2024 revealed no issues with handrails on the facility's [NAME] unit. During a tour conducted on 5/8/2024 at 11:03 AM on the facility's [NAME] unit, the handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. A review of the facility policy titled Maintenance Service, last revised in December 2009, revealed under the section titled Policy Statement maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy also revealed under the section titled Policy interpretation and Implementation the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include, but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, maintaining the building in good repair and free from hazards, and providing routinely scheduled maintenance service to all areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to failing to ensure a medication administration error rate of less than 5%. A total of forty-three medication administration opportunities were observed with twenty-two errors for three (#5, #10, and #12) of five residents observed (F759). This resulted in a medication administration error rate of 51.16% during the revisit survey conducted 7/17/2024. Findings included: A review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE]. A review of Resident #5's physician orders revealed the following orders: - An order, dated 6/10/2024, for allopurinol 100 milligrams (mg) one tablet by mouth (PO) once a day at 8:00 AM. - An order, dated 6/10/2024, for calcitrol 0.5 micrograms (mcg) one capsule PO once a day at 8:00 AM. - An order, dated 6/26/2024, for dapagliflozin propanediol 5 mg one tablet PO once a day at 8:00 AM. - An order, dated 6/10/2024, for apixaban 5 mg one tablet PO twice a day at 8:00 AM and 8:00 PM. - An order, dated 6/10/2024, for gabapentin 100 mg one capsule PO twice a day at 8:00 AM and 8:00 PM. - An order, dated 6/15/2024, for hydrocodone-acetaminophen 5 mg - 325 mg one tablet PO twice a day at 8:00 AM and 8:00 PM. - An order, dated 6/10/2024, for iron 325 mg one tablet PO once a day at 8:00 AM. - An order, dated 6/10/2024, for furosemide 20 mg one tablet PO once a day at 8:00 AM. - An order, dated 6/11/2024, for metoprolol tartrate 50 mg one tablet PO twice a day at 8:00 AM and 8:00 PM. - An order, dated 6/11/2024, for multivitamin with minerals one tablet PO once a day at 8:00 AM. - An order, dated 6/10/2024, for potassium chloride 20 milliequivalents (mEq) one tablet PO twice a day at 8:00 AM and 8:00 PM. - An order, dated 6/11/2024, for spironolactone 25 mg 1/2 tablet (12.5 mg) PO once a day at 8:00 AM. - An order, dated 6/10/2024, for venlafaxine 75 mg one tablet PO twice a day at 8:00 AM and 8:00 PM. An observation of medication administration was conducted on 7/17/2024 at 9:29 AM for Resident #5, with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN prepared the following medications for administration to Resident #5: - Allopurinol 100 mg one tablet. - Calcitrol 0.5 mcg one capsule. - Dapagliflozin propanediol 5 mg one tablet. - Apixaban 5 mg one tablet. - Gabapentin 100 mg one capsule. - Hydrocodone-acetaminophen 5 mg - 325 mg one tablet. - Iron 325 mg one tablet. - Furosemide 20 mg one tablet. - Metoprolol tartrate 50 mg one tablet. - Multivitamin with minerals one tablet. - Potassium chloride 20 mEq one tablet. - Spironolactone 25 mg 1/2 tablet (12.5 mg). - Venlafaxine 75 mg one tablet. After gathering and preparing the medications for Resident #5, Staff A, LPN entered Resident #5's room. Staff A, LPN administered the medications to Resident #5 without difficulty and exited the room. All thirteen medications were administered late. A review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE]. A review of Resident #10's physician orders revealed an order, dated 5/15/2024 for insulin aspart 100 units per milliliter (ml) via (brand name) pen injector subcutaneously before meals and at bedtime, amount to administer per sliding scale: - If blood sugar is less than 60, call Medical Doctor (MD). - If blood sugar is 0 to 150, give 0 units. - If blood sugar is 151 to 200, give 2 units. - If blood sugar is 201 to 250, give 4 units. - If blood sugar is 251 to 300, give 6 units. - If blood sugar is 301 to 350, give 8 units. - If blood sugar is 351 to 400, give 10 units. - If blood sugar is greater than 400, give 12 units and call MD. An observation of medication administration was conducted on 7/17/2024 at 11:50 AM for Resident #10, with Staff B, Registered Nurse. After collecting a blood sample from Resident #10 and obtaining a blood sugar reading of 359, Staff B, RN removed Resident #10's insulin aspart pen injector from the medication cart. Staff B, RN also removed an insulin pen injector needle and alcohol preparation pads from the medication cart. Staff B, RN dialed the dosage selector on the insulin aspart pen to 10 units and entered Resident #10's room with the insulin pen, insulin pen injector needle, and alcohol preparation pads. Staff B, RN cleansed the top of the insulin pen injector with alcohol and applied an insulin needle to the pen injector. After explaining the procedure to the resident, performing hand hygiene, and donning clean gloves, Staff B, RN verified the dosage selector on the insulin aspart injector pen was still set to 10 units and administered the insulin to Resident #10. Staff B, RN did not prime the insulin pen injector before administering the insulin to Resident #10. After removing the gloves, disposing of the needles in the sharps container, and performing hand hygiene, Staff B, RN exited Resident #10's room. An interview was conducted with Staff B, RN following the observation. Staff B, RN addressed she did not prime the insulin pen injector needle prior to insulin administration to Resident #10. Staff B, RN stated the purpose of priming the insulin pen injector needle is to ensure the needle was filled with insulin and not air, which ensures a proper dose would be administered. The facility's Director of Nursing (DON) arrived during the interview and stated insulin pen injector needles should be primed prior to administration. A review of Resident #12's medical record revealed Resident #12 was admitted to the facility on [DATE]. A review of Resident #12's physician orders revealed the following orders: - An order, dated 7/9/2024 for amantadine hydrochloride (HCl) 100 mg one capsule PO once a day at 10:00 AM. - An order, dated 7/9/2024 for amlodipine 10 mg one tablet PO once a day at 10:00 AM. - An order, dated 7/9/2024 for aspirin 81 mg one tablet PO once a day at 10:00 AM. - An order, dated 7/9/2024 for clopidogrel 75 mg one tablet PO once a day at 10:00 AM. - An order, dated 7/9/2024 for glipizide 5 mg one tablet PO twice a day at 10:00 AM and 10:00 PM. - An order, dated 7/9/2024 for levetiracetam solution 100 mg per ml, amount to administer 500 mg/5 ml PO twice a day at 10:00 AM and 10:00 PM. - An order, dated 7/9/2024 for metformin 500 mg one tablet PO twice a day at 10:00 AM and 10:00 PM. - An order, dated 7/9/2024 for metoprolol tartrate 25 mg one tablet PO twice a day at 10:00 AM and 10:00 PM. - An order, dated 7/16/2024 for multivitamin with minerals one tablet PO once a day at 10:00 AM. An observation of medication administration was conducted on 7/17/2024 at 12:09 PM for Resident #12, with Staff A, LPN. Staff A, LPN prepared the following medications for administration to Resident #12: - Amantadine HCl 100 mg one capsule. - Amlodipine 10 mg one tablet. - Aspirin 81 mg one tablet. - Clopidogrel 75 mg one tablet. - Glipizide 5 mg one tablet. - Levetiracetam solution 500 mg/5 ml. - Metformin 500 mg one tablet. - Metoprolol tartrate 25 mg one tablet. - Multivitamin with minerals one tablet. After gathering and preparing the medications for Resident #12, Staff A, LPN entered Resident #12's room. Staff A, LPN administered the medications to Resident #12 without difficulty and exited the room. All nine medications were administered late. An interview was conducted with Staff A, LPN following the observation. Staff A, LPN stated if medications were administered to a resident after the ordered time, she tries to pick up the pace to ensure all of the remaining resident medications are administered and she should notify the resident's physician of the medications being administered late. Staff A, LPN also stated she would notify the resident's physician after the medication was administered, not before the medication is administered. Staff A, LPN stated she received in-service education related to medication errors and the rights of medication administration, including the right time. Staff A, LPN also stated if the rights of medication administration are not followed, it would result in a medication error. An interview was conducted on 7/17/2024 at 3:36 PM with the DON. The DON stated facility nursing staff received in-service education related to medication administration by the contracted pharmacy staff, who reviewed different types of medication routes including by mouth and by pen injector. The DON also stated facility nursing staff were educated on how to properly prime the insulin pen injector needle by placing the needle on the injector pen, dialing the dosage selector to 2 units, and injecting the 2 units of insulin through the needle prior to dialing the ordered dose for the resident. The DON stated nursing staff should notify the resident's physician if a medication is going to be administered after the ordered time and before the medication is administered. A review of the facility policy titled Administering Medications, revised December 2012, revealed under the section titled Policy Statement, medications shall be administered in a safe and timely manner, and as prescribed. The policy also revealed under the section titled Policy Interpretation and Implementation, medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). A review of the facility policy titled Insulin Pens, with no effective date, revealed under the section titled Policy the facility shall ensure that insulin pens are used in accordance with manufacturer instructions and not used for multiple residents. A review of the (brand name) insulin aspart injector pen manufacturer instructions for use revealed the following under the section titled Giving the airshot before each injection before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - Turn the dose selector to select 2 units. - Hold your (brand name) insulin pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the (brand name) insulin pen. A review of the facility policy titled QAPI Plan, last revised on 4/1/2014 revealed under the section titled Purpose the purpose of the QAPI plan at the facility is to ensure that the administrative, medical staff, and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal resident care and services in an environment of minimal risk. The policy also revealed under the section titled Goals of QAPI the primary goals of the organizational QAPI Plan is to continually and systematically plan, design, measure, assess, and improve performance of critical focus areas, improve healthcare outcomes, and reduce and prevent medical/health care errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the splinting program was clarified and implemented as physician ordered for one (Resident #61)) of six residents on the restorative nursing splinting program. Findings included, An interview on Monday 12/20/21 at 11:18 a.m., with Resident #61's Responsible Party, revealed the resident was completely numb on the left side of the body and was unable to move very much. The Responsible Party stated the resident had a splint, however, I have not seen a brace (splint) in a while on [Resident #61]. An observation of Resident #61 on Monday 12/20/21 at 11:38 a.m., revealed the resident lying in bed curled onto the left side of her body with the left leg tucked underneath her right leg and the left hand curled into a fist. Resident #61 was not wearing splints on any part of the body during the observation. Resident #61 did not respond to English, however, upon asking how the resident was feeling in Spanish, Resident #61 responded in Spanish stating she had pain in her hand, while slightly lifting her left-hand outward towards the interviewer. Resident #61's Resident Face Sheet, revealed medical diagnoses of contractures of the left hand, elbow, and wrist with spastic hemiplegia affecting the left nondominant side, pain, and adult failure to thrive. Resident #61's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Resident #61's functional status revealed a total dependence on staff for bed mobility, transferring, eating, dressing, and personal hygiene. Resident #61's Care Plan revealed a problem area on page 1 of 25, started on 11/24/21, She wears a splint to left elbow/risk for contracture formation. Approaches for this problem area included maintaining proper body alignment and applying devices/splints as ordered by the physician. A physician general order review, started on 08/23/21, revealed an order description, Apply L [left] Elbow splint/L resting hand splint use for flexion contractures 3 x [times] week up to 6 hours a day as patient tolerates. Disciplines to carry out this order included restorative nursing and certified nursing assistants. Frequency of the order was Once A Day. Start time for this physician order was 7:00 a.m. with an end time of 7:00 p.m. A record review of Resident 61's Observation Detail List Report . Restorative Initial & [and] Quarterly Observation, observation date of 11/30/21 and completed by Staff C, LPN, revealed on page 4, Does Resident require the use of splints, braces, or other devices . splint left hand daily. An observation of Resident #61 on Tuesday 12/21/21 at 5:27 a.m., revealed the resident lying in bed with her left hand clenched into a fist against her body. The resident was not wearing a left-hand splint. An observation of Resident #61 on Tuesday 12/21/21 at 7:38 a.m. revealed the resident sitting in the dining and activities area by the nursing station being served breakfast without a left-hand splint in place. An interview on 12/21/21 at 7:29 a.m., with Staff C, Licensed Practical Nurse (LPN), revealed in the morning time a restorative program list is printed out and given to the restorative Certified Nursing Assistants (CNAs). The duties for the restorative CNA include placing a splint onto a resident per their therapy physician order. Staff C stated splints were normally applied daily to a resident but recalled there was one resident who only got a splint placed onto their person like twice a week for up to four hours or something like that. An interview on 12/21/21 at 9:44 a.m. with Staff D, CNA revealed a restorative splint list was provided to her the morning of 12/21/21. Staff D stated she completed placing all splints onto the required residents. The CNA stated after completing the task, she must go into the online medical kiosk system to mark the task as complete. An observation was made of the CNA's restorative splint program list with a checkmark placed next to Resident #61's name. The CNA stated a checkmark indicated the splint was placed onto the resident. An observation of Resident #61 on Tuesday 12/21/21 at 10:00 a.m. revealed the resident sitting in a high-back chair with a splint on the left hand. During an interview on 12/21/21 at 11:37 a.m., Staff E, Occupational Therapist Registered (OTR) stated an evaluation of a long-term care resident was completed prior to obtaining a physician's order for a splint which was used to address contractures. Staff E, stated how often and when a splint was placed onto a resident, Depends on the flexion contracture. If it [the contracture] is moderate or severe it [a splint] has to be on 6-7 days a week with max [maximum] 4 hours depending on if it [a splint] is tolerated. After the splint is applied, we will then do a skin evaluation . A minor contracture still needs to be monitored to make sure it doesn't become more severe. A follow-up interview on 12/21/21 at 11:49 a.m. with Staff E, OTR revealed a rehabilitation department referral form to restorative nursing would have been completed and passed to the nursing department for a physician order to be generated. A review of Resident #61's physician order stated a splint to be applied 3 x a week without day specifications. Staff E stated it was not within his control to decide what days the splint would be applied. An interview on 12/21/21 at 11:57 a.m. with Staff A, LPN confirmed she was the original LPN who entered the physician order related to the splint for Resident #61. Staff A stated the process was to directly transcribe the therapy department recommendation into a physician order. Once that was completed, the original therapy department recommendation was given to the restorative department to be carried out. During a follow-up interview on 12/21/21 at 12:09 p.m. with Staff C, LPN, Resident #61's splinting physician order was reviewed and revealed that the order did not specify what days the splint should be placed onto the resident. Staff C stated it was not up to the discretion of the CNA for what days a splint was placed onto the resident, normally when an order stated 3 x weekly then it was placed onto the resident Monday's, Wednesdays, and Fridays. Staff C stated the task to place a splint onto a resident should generate in the CNA's task kiosk for check off once it is completed. Staff C stated it was the restorative department's responsibility to clarify a splint physician order and designate what days a resident's splint should be placed onto their person. A record review of Resident #61's POC [point of care] Responses, dated 11/01/2021 to 11/30/2021 and 12/15/2021 to 12/21/2021 revealed under section Restorative Nursing: Splint or Brace Assistance, the task for placing a splint onto Resident #61 was marked as completed on 11/18/2021 and 12/21/2021. An interview was conducted on Tuesday 12/21/21 at 12:20 p.m. with Staff C, LPN and Staff D, CNA. Staff D stated the reason a splint was placed onto Resident #61 today was because normally splints were placed onto a resident daily, so, Staff D just assumed the splint needed to be put onto Resident #61. Staff D stated she did not see the order instructions that the splint was to be placed onto Resident #61 3 x a week. Staff C, LPN stated Resident #61's splinting order for frequency was marked to be placed onto the resident daily, however, the order selection should be every other day for it to generate on Mondays, Wednesdays, and Fridays. Staff C, LPN stated Resident #61 would be placed onto a Tuesday, Thursday, Saturday splinting rotation instead. An interview on 12/21/21 at 12:26 p.m. with the Director of Nursing (DON), confirmed the physician order for Resident #61's splinting program should have been clarified as to what days the splint was placed onto the resident. The DON stated it was not up to the discretion of the CNA to decide what days the splint was placed onto the resident. The DON stated one of the issues was that the task was not selected to generate into the point of care system and therefore would not generate into the CNA task list. A policy review of Rehabilitative Nursing Care, revised December 2020, revealed .Rehabilitative nursing care is provided for each resident admitted during routine ADL [activities of daily living] care and through individualized plans as needed . 1. General rehabilitative nursing care is that which does not require the use of a qualified Professional Therapist to render such care. 2. Nursing personnel are trained in rehabilitative nursing care. Out facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. 3. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence Assisting residents to adjust to their disabilities, to use their prosthetic devices, splints and other restorative care . An interview on Monday 12/20/21 at 11:18 a.m., with Resident #61's Responsible Party, revealed the resident was completely numb on the left side of the body and was unable to move very much. The Responsible Party stated the resident had a splint, however, I have not seen a brace [splint] in a while on [Resident #61].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure breakfast was delivered to one (Resident #25) of one hemodialysis resident within a timely manner prior to leaving to the dialysis center on one of one observable survey days. Findings included, During an interview on 12/20/21 at 11:55 a.m., Resident #25 stated he went to the dialysis center to receive treatment three days a week: Tuesdays, Thursdays, and Saturdays. Resident #25 stated he left early in the morning and did not always get a meal or snack when going to the dialysis center for treatment. The resident stated upon returning from the dialysis center he was normally really hungry. Resident #25 said, [I] wish that was fixed because I come back starving. Resident #25's Resident Face Sheet revealed medical diagnoses of end stage renal disease, type 2 diabetes, muscle weakness, unspecified protein-calorie malnutrition, and metabolic encephalopathy. Resident #25's MDS, dated [DATE] revealed the resident had a BIMS score of 9, indicating moderate cognitive impairment. A functional status review revealed Resident #25 required extensive assistance from staff with eating, personal hygiene, and dressing. Resident #25's Physician Order Report revealed a dietary order, started on 12/06/21, . RENAL Special Instructions: FOOD IN BOWLS . DOUBLE PORTION BREAKFAST. Further review revealed a general order type, started on 12/11/21 to 12/22/2021 for dialysis on Tuesdays, Thursdays, and Saturday with a transportation pickup time of 6:00 a.m., for a chair time at the dialysis center at 7:00 a.m. Resident #25's Care Plan, revealed problem areas of: 1. Started on 10/30/20, [Resident #25] has hx [history] of cerebral infraction and is at risk for declines with ADL (activities of daily living) related to weakness, impaired mobility endurance varies related to fatigued at times on dialysis days. 2. Started on 10/23/20, [Resident #25] is at nutritional risk related to Dx (diagnosis) of end stage renal disease and on dialysis, dx Diabetes, hx (history) of weight loss. His weight may fluctuate r/t (related to) he is on a diuretic, and dialysis and also on fluid restrictions. Approaches to this problem area included providing a renal diet with double portions at breakfast per orders. 3. Started on 10/26/20, [Resident #25] is at risk for s/s (signs/symptoms) of hypo/hyperglycemia r/t dx of Diabetes. An observation of Resident #25 on Tuesday 12/21/21 at 5:30 a.m. revealed him lying in bed under the covers. All lights in the resident's room were off. Resident #25 eyes were closed without a response to a knock on his bedroom door. An interview on 12/21/2021 at 5:47 a.m. with Staff F, CNA confirmed Resident #25 was a dialysis receiving resident and prior to leaving for treatment she would clean and dress him. Staff F stated sometimes Resident #25 would eat breakfast, and sometimes would not. Staff F stated Resident #25 had not eaten breakfast yet and said, Yes . he goes with a . lunch . we send him with a snack and he gets sent with lunch that gets packed . I'm going to get it now. Staff F walked away towards the kitchen area. Staff F returned at 5:55 a.m. carrying two individual serving size packages of cereal and a milk carton. Staff F stated this was going to be Resident #25's breakfast and that the kitchen cook had a note stating the resident was not going to be leaving until 6:30 a.m., so that was why Resident #25 had not been served breakfast yet. An interview on 12/21/21 at 5:58 a.m. with Staff G, Dietary [NAME] revealed the breakfast tray for Resident #25 needed to be ready at 6:30 a.m. Staff G was going to prepare the tray at 6:15ish or 6:20ish. Staff G stated the kitchen had a note stating that the resident would be leaving for dialysis at 6:30 a.m. A review of the note, kept in the kitchen, revealed [Resident #25] Dialysis Tue (Tuesday)-Thurs (Thursday)-Sat (Saturday) leaves @ (at) 6:30 AM . needs early breakfast these days. Thursday was crossed off with Wednesday written above it, indicating the resident would be leaving for dialysis on Wednesday rather than Thursday. Photographic evidence was obtained of the note. On 12/21/21 at 6:00 a.m., two transportation workers were observed walking with a stretcher down the hallway, stopping outside of Resident #25's room. An interview on 12/21/21 at 6:02 a.m. with a Transportation Employee revealed the transportation company was scheduled to pick-up Resident #25 at 6:00 a.m. They usually arrived to the building around 5:55 a.m. or 6:00 a.m. to transport the resident to the dialysis center. The Transportation Employee stated their schedule was to pick up Resident #25 at 6:00 a.m. and did not say before or after breakfast . so even if he doesn't get breakfast, we would take the resident. On 12/21/21 at 6:04 a.m., the Director of Nursing (DON) was observed carrying a breakfast tray with a covered lid into Resident #25 bedroom. On 12/21/21 at 9:18 a.m. an interview with a Charge Nurse at Resident #25's dialysis treatment center revealed Resident #25 was scheduled to be at the facility from 7:00 a.m. to 10:45 a.m. A problem that had been occurring was transportation arrived late to pick up the resident after dialysis treatment, usually get here past 11:00 a.m., closer to 12:00 p.m. So, by the time they get here [Resident #25] can be really cranky because he is hungry so we will give him a lollipop. The Charge Nurse stated due to COVID-19, the dialysis center strongly discouraged eating at the center and did not recommend food be brought in with the resident. So, they recommended a resident ate 30 minutes prior to their assigned chair time. The Charge Nurse stated there had been two occasions this month that she remembered Resident #25 stated he had not eaten breakfast prior to coming to treatment. An interview on 12/21/21 at 9:36 a.m. with the Certified Dietary Manager (CDM) revealed the CNA's would leave a note for the kitchen for what days and times a resident would be going for dialysis treatment. The CDM stated normally, Resident #25 left for the dialysis center at 6:00 a.m. so the breakfast tray should be ready at 5:30 a.m. The CDM provided the note which indicated Resident #25 would be leaving for dialysis at 6:30 a.m. The CDM stated Thursday was crossed off because Resident #25 would be going to dialysis on Wednesday this week due to the holiday schedule. A physician order, started on 12/22/21, revealed DIALYSIS ON TUESDAY, THURSDAY, AND SUNDAY . CHAIR TIME @ 7:00 AM, PICK UP @ 6:00 AM . THIS IS HIS HOLIDAY SCHEDULE [DX [diagnosis]: End stage renal disease]. On 12/22/21 at 9:52 a.m. during an interview, the Registered Dietician (RD) stated Resident #25 requested double portions at breakfast. The RD stated a dialysis resident should receive a meal before leaving for the treatment center and upon their return. During an interview with the DON on 12/22/21 at 1:09 p.m., she stated the kitchen would deliver a breakfast meal tray to Resident #25 about 30 minutes prior to the resident's pick-up time and this week we verified that he would be going to dialysis on Tuesdays, Thursdays, and Sunday. The DON stated transportation . cannot just take Resident #25 . if he is eating then they have to wait for him to finish before picking him up. The process was that the nurse would notify the kitchen on what days Resident #25 would be picked up to go for dialysis treatment. A policy review of End-Stage Renal Disease, Care of a Resident with, revised on September 2020, revealed Residents with end-stage renal disease (ESRD), will be treated for according to currently recognized standards of care . 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents . 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the residents care will be managed, including: a. How the care plan will be developed and implemented; b. How information will be exchanged between the facilities . 5. The residence care comprehensive care plan will reflect the residents need related to ESRD/dialysis care. A dialysis contract review, . OUTPATIENT DIALYSIS SERVICES AGREEMENT, signed by the Nursing Home Administrator (NHA) on 3/31/2014, revealed on page 3, 3. Preparation of ESRD Residents. The Nursing Facility shall ensure that ESRD Residents are prepared to spend an extended length of time at the ESRD Dialysis Unit and have received proper nourishment and any medications prescribed, as applicable, before coming to the ESRD Dialysis Unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the face sheet revealed Resident #39 had diagnoses that included type II diabetes. On 3/10/20 at 11:00 a.m. Resident #39 was observed in her room lying in bed, watching TV (Television). In an interview she stated, I have something like a big paper cut on my thigh from the mechanical lift happen in the last two weeks. They lifted me and I said I felt some pulling in my thigh. They checked but said they didn't see anything. Then in a couple of days they saw it and called the wound doctor. Now they provide care for it. Review of the physician order report dated 3/12/20 - 3/12/20 revealed there were no active orders physician orders for wound care. An order for a weekly skin check on Sunday 7P (PM) -7A (AM) was entered on 2/27/20. An initial review of the active care plan on 3/10/20 showed there were no interventions for skin impairments. An additional review of the active care plan on 3/11/20 revealed a problem start date of 3/11/20 for, Res. (Resident #39) receiving TX (treatment) to Bilat (bilateral) Inner Thighs. Review of Skin/Weekly note and Skin -- Weekly Nurses note and Skin Check, assessments reflected the following information: 3/8/20 at 07:08 PM under weekly skin audit: No open areas. 3/2/20 at 09:23 AM revealed under weekly skin audit: No open areas. 2/22/20 at 01:00 AM revealed under weekly skin audit: No open areas. A nursing progress note dated 3/06/2020 at 12:55 a.m. stated, Resident inner rt (right) thigh has an old skin tear that has reopened. Cream barrier applied. Will let wound nurse know in the morning. Further review of progress notes from the month of February 2020 revealed a Wound Care note from 2/17/2020 at 12:54 AM stating, Res (resident) noted with areas of irritation red in color to bilat[bilateral] posterior thighs areas noted to be areas of irritation caused by [mechanical lift] pad. MD notified and treatment orders in place per MD. Staff educated on placing a sheet between res. And Mechanical pad prior to transfers to aid in skin impairments. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed: Section M Skin Conditions - Risk of pressure ulcer/injuries: YES Other ulcers, wounds and skin problems: coded NONE OF THE ABOVE. Section G: Functional Status- Activities of daily living (ADL) Assistance. Transfer: Total dependence, Two + person assist On 3/11/20 at 10:26 a.m. an interview with Staff F, Licensed Practical Nurse (LPN) confirmed there were no orders for skin treatment for Resident #39. On 3/11/20 at 2:30 p.m. an observation was conducted with Staff A, Certified Nursing Assistant, (CNA) during a skin check. Staff A, CNA entered Resident #39's room and asked for Resident #39's consent to observe the skin tear on Resident #39's right inner thigh. Staff A, CNA asked Resident #39, This was with the Mechanical lift, right? Resident #39 answered, Yeah, they know. Resident #39 confirmed this happened about a week ago. A 3-inch thin curved red line was observed on Resident #39's right inner thigh, partially covered with a white substance. An interview was conducted on 3/11/20 at 2:53 p.m. with Staff N, Wound Care Nurse. The Staff N stated that when a CNA observes something, they report it to the nurse. The nurse then verifies, observes, documents and calls the doctor for orders. Staff N reviewed the skin observation notes for 3/8/20 at 7:08 p.m. and confirmed the documentation indicated no open areas. Staff N was not aware of the injury until today. Staff N said, I went to see her. The resident was on the phone at the time. Staff N reviewed the nurse's note from 3/6/20 and confirmed it indicated a skin tear in right inner thigh. Staff N said it happened on Friday going on Saturday. The weekend wound care nurse gets in later in the day. If she was informed, she would have treated the area. The nurse on the shift should have called the doctor or reported it. An interview was conducted with the Assistant Director of Nursing, (ADON) on 3/12/20 at 8:36 a.m. She stated, Yes, I was aware that the resident had stated it was with the [mechanical] lift. The ADON then stated, . I'm not aware of the skin tear from 3/8/20. I know about an excoriation. Barrier cream is applied on that general area when resident is being assisted with perineal care. The process is for the nurse to write up an incident, and then we follow up with an investigation. An interview was conducted with Staff B, LPN on 3/12/20 at 9:05 a.m. Staff B, LPN said, She had a red line, and he pointed to his right inner thigh. There was no opening. I guess I should of used another word, like maybe excoriation. I should have called the doctor, and I failed to do that. I left a note for the wound nurse. Usually the wound nurse comes early, so I left a note on her computer. She must have come later that day. Review of the policy titled, Pressure Ulcer and Skin Assessments, L III revised September 2013, revealed the following: Section: Assessments 2. Skin Assessments. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis and more frequently if indicated. 3.b. Nurse are to be notified to inspect the skin if the skin changes are identified. c. Nurse will conduct skin assessments at least weekly to identify changes. Section: Identifying Residents at Risk: b. Shear- shearing force is the sliding movement of skin and subcutaneous tissue while the underling muscle and bone are stationary. d. Friction- the rubbing of one body against another or the force that relative motion between two bodies in contact and or material elements sliding against each other. Section: Steps in the Procedure: 4. Once inspection of skin is completed proceed to the admission assessment or weekly skin integrity tool (depending on whether this is a new admission or and existing resident) and complete documentation of findings. 5. If a new skin alteration is noted, initiate (pressure or non-pressure) form related to the type of alteration in the skin. 6. Proceed to care planning and interventions individualized for the resident and their particular risk factor 7. Notification (refer to below reporting) 8. Document the procedure. Section: Documentation: The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment conducted 2. The time and date of skin care provided. 4. Any changes in the residents' condition. 5. the condition of the resident skin 7. Any problems or complaints made by the resident related to the procedure. 13. Documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care if indicated. 14. Documentation in the medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care if indicated. Section: Reporting 3. notification of attending MD if new skin alteration noted. 4.notification of family, guardian or resident update is new skin alteration noted. Review of the policy titled, Wound Care, Level III revised September 2017, reflected the following information: Documentation: The following information should be recorded in the resident's medical record. 1. The type of wound care given 3. the date and time the wound care was given. 4. The name and the tile of the individual performing the wound care. 5. any changes in the resident condition. Based on observation, interview and record review, the facility failed to assess and treat skin conditions for two residents (#72 and #39) of three sampled residents. Findings included: 1. During observation and interview with Resident #72 on 3/10/20 at 1:41 p.m. the resident was observed with scabs all over his face. The resident stated he is unsure of what the scabs are from or how long he had them. During an interview on 3/12/20 at 4:17 p.m. with Staff F, Licensed Practical Nurse (LPN) she stated he has ointment on his bedside table the daughter brings him for his extremely dry skin and doxycycline for his ear. She confirmed he had scabs all over his face and some newer ones around his mouth. Staff F, LPN lifted the covers and looked at his feet after removing his soft boots. Both heels were free of wounds, the right foot had black scabs on top of four toes where the sheets would rub on the foot. Staff F, LPN stated the wound care nurse would take care of those. During an interview on 3/12/20 at 4:52 p.m. with Staff M, Certified Nursing Assistant (CNA) he stated the resident usually has scabs on his face but has not given him a bed bath or put lotion on today. Staff M, CNA said he did not tell the nurse about the scabs. Staff M, CNA stated he had not looked at the resident's toes. During an interview on 3/12/20 at 6:25 p.m. with the Administrator, she stated she went down to evaluate the resident and saw that his toes have scabs on the right foot and she agreed that there should be some documentation related to his skin condition, a care plan related to his skin condition and some lotion for his dry skin. The Administrator confirmed his daughter brings in lotion to put on his body and we did not have an order for staff to apply the ointment. Review of the resident's face sheet reflected he was admitted on [DATE], his diagnoses included rash and other skin eruption, and seborrheic dermatitis. Review of the Physician Order Report dated 2/5/20 - 3/12/20 reflected a physician order for ammonium lactate 12% topical to be applied to bilateral lower extremity and bilateral upper extremity twice a day, once in the morning and once in the evening dated 3/12/20. Weekly skin check Thursday 7p-7a once a day on Thu; Eve/Nights 07:00 pm - 7:00 AM 2/27/20 - open ended. Bilat Feet/Heels: Apply Skin Prep Daily as prophylactic TX Once a Day; 05:00 AM - 07:00 PM started 9/4//19 - open ended. Review of the resident's care plan updated on 3/12/20 reflected the resident receiving treatment for xerosis cutis, and scabs on right second third and fourth toe. Review of the Skin/Weekly note and Skin - Weekly Nurses Note and Skin Check, revealed: 3/6/20 reflected a scab to the right side of the neck and no other open areas. 2/28/20 reflected no open areas. Review of the nursing progress notes dated 3/12/20 at 4:31 p.m. reflected Resident #72 evaluated and noted to have dark red spots to forehead and side of face. Dermatology consult in place. Review of the nursing progress notes dated 3/1/20 reflected the resident with redness and irritation to his abdominal folds, area cleaned with normal saline, barrier cream for comfort. Call out to physician. Review of the nursing progress notes dated 2/26/20 at 11:09 a.m. reflected the right side of the resident's neck underneath his ear is swollen and hanging with a scab. Review of the nursing progress notes dated 2/26/20 at 2:03 p.m. reflected the physician called back and ordered ointment to right side of ear and face. start doxycycline 100 mg twice a day for 21 days. During an interview with the Director of Nursing (DON) on 3/13/20 at 4:21 p.m. she confirmed that she was not aware of the scabs on Resident #72's toes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, policy review, and the State Agency Surveyor Guidance for Hot Water Temperatures related to the Federal regulations, the facility did not ensure water temperatures were maintained at a safe level for four resident bathrooms of twelve resident bathrooms sampled, and for one nursing unit (300 hallway) of two nursing units, with the potential to affect six residents (#56, #47, #139, #50, #140, #65) of eight residents who were capable of using the bathroom. Findings included: 1. Resident #56 was admitted to the facility with a diagnosis of CKD (chronic kidney disease) stage 5 according to the admission record. The Minimum Data Set (MD) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #56 was cognitively intact. Further review of the MDS assessment, Section G, Functional Status, indicated Resident #56 required extensive assistance of one person to use the toilet, bathe, and perform personal hygiene activities. Resident #56 also used a walker and wheelchair for mobility with extensive assistance of one person. The assessment showed Resident #56 had an indwelling catheter and was frequently incontinent of bowel. 2. Resident #47 was admitted to the facility with a diagnosis of type 2 diabetes mellitus according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] reflected Resident #47 had a BIMS score of 15, indicating she was cognitively intact. Further review of the assessment revealed Resident #47 required extensive staff assistance for locomotion, bathing and toileting, with the use of a walker or wheelchair. Resident #47 was capable of performing personal hygiene with supervision of one staff member. Section H, Bladder and Bowel, showed Resident #47 was always continent of bladder, and always continent of bowel. On 3/10/20 at 11:52 a.m. an observation was conducted in Resident #56 and Resident #47's shared bathroom. The hot water in the bathroom sink was so hot the surveyor had to pull her hand out. There was steam coming from the water. On 3/10/20 at 12:18 p.m. an observation was conducted with the Director of Maintenance in Resident #47 and Resident #56's bathroom. The Director of Maintenance used a thermometer to assess the temperature of the hot water in the bathroom sink. The thermometer read 115.9 degrees Fahrenheit. An interview with the Director of Maintenance was conducted during the observation. He said he hasn't had a problem with the water temperatures before and, It's a very easy fix. I can just adjust the mixer. On 3/10/20 at 2:19 p.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA) She said Resident #47 and Resident #56 are both alert and oriented. Staff C, CNA said Resident #56 has a nephrostomy tube and wears a brief. Resident #47 uses the bathroom. 3. Resident #139 was admitted to the facility with a diagnosis of CHF (congestive heart failure) according to the face sheet in the admission record. Review of the admission Observation dated 3/3/20 for Resident #139 revealed that she was oriented to person, place, and time. Resident #139 had no weakness or musculoskeletal problems and was capable of using a walker for mobility. The observation also indicated Resident #139 was continent of bladder and bowel, and capable of using the bathroom unassisted. 4. Resident #50 was admitted to the facility with a diagnosis of type 2 diabetes mellitus, according to the face sheet in the admission record. A review of the MDS assessment in the medical record revealed Resident #50 had a BIMS score of 15, indicating she was cognitively intact. Further review of the assessment reflected that Resident #50 required extensive staff assistance of one person for locomotion using a wheelchair, toileting, and bathing. Resident #50 was capable of performing personal hygiene activities with supervision and set up help only. Section H, bladder and bowel reflected Resident #50 was occasionally incontinent of bladder, and frequently incontinent of bowel. On 3/10/20 at 11:59 a.m. an observation was conducted in the shared bathroom for Resident #50 and Resident #139. The hot water in the bathroom sink was too hot for the surveyor to keep her hand under the running water. There was also steam noted to be coming from the faucet. On 3/10/20 at 12:15 p.m. an observation was conducted with the Director of Maintenance. The Director of Maintenance placed a thermometer under the running water in the bathroom sink in the bathroom shared by Residents #50 and #139. The thermometer read 116 degrees Fahrenheit. In an interview with the Director of Maintenance during the observation he said the temperature are running a little high. They are not supposed to be less than 105 degrees and not over 115 degrees. He said the facility has a mixer in the laundry room that feeds the new section of the building. He said he checks the mixer daily. He said he does not keep a log. 5. Resident #140 was admitted to the facility with a diagnosis of COPD (chronic obstructive pulmonary disease) according to the face sheet in the admission record. Review of the MDS assessment dated [DATE], in the medical record reflected a BIMS score of 15, indicating Resident #140 was cognitively intact. A review of Section G Functional Status in the MDS assessment revealed Resident #140 needed extensive assistive of one person with use of a walker or wheelchair for mobility. Resident #140 also needed extensive assistance of one staff member to use the toilet and bathe. He required supervision of one person to carry out personal hygiene activities. Section H Bladder/Bowel - Catheter, Ostomy, Incontinence of the MDS assessment was also reviewed and indicated Resident #140 was continent of bladder and bowel. An observation was conducted on 3/10/20 at 12:02 p.m. in Resident #140's bathroom. The hot water in the bathroom sink was so hot the surveyor had to pull her hand out of it. There was steam coming from the water. On 3/10/20 at 12:09 p.m. an observation was conducted with the Director of Maintenance. The Director of Maintenance used a thermometer to check the hot water temperature in Resident #140's bathroom sink. The thermometer was noted to peak at 115.9 degrees Fahrenheit. In an interview conducted at the time of the observation, the Director of Maintenance said the 300 nursing unit has been open since the end of January. All the inspections were done, and everything was 100%. He said the water is checked monthly. We go to the rooms and check the temperature in the sink and the shower in every room. He also said once a month they do a full room inspection and check everything. When residents are discharged , they do a room inspection again. On 3/10/20 at 2:21 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She said Resident #140 uses the bathroom and he is alert and oriented. His roommate doesn't use the bathroom. He wears a brief. 6. Resident #65 was admitted to the facility with a diagnosis of encephalopathy, according to the face sheet in the admission record. A review of the MDS assessment in the medical record dated 2/20/20 revealed a BIMS score of 9, indicating cognitive impairment. Further review of the MDS assessment reflected that Resident #65 required extensive assistance of one person for locomotion with a walker or wheelchair. Resident #65 required extensive assistance of one person for toileting and bathing, and supervision of one person for personal hygiene activities. Section H Bladder/Bowel - Catheter, Ostomy, Incontinence showed Resident #65 was occasionally incontinent of bladder, and frequently incontinent of bowel. An immediate audit of the 300 halls was requested. The audit showed that the hot water temperature in Resident #65's bathroom sink was 115.9 degrees Fahrenheit on 3/10/20 at 1:17 p.m. On 3/10/20 at 12:23 p.m. an observation was conducted of the mixer in the laundry room, with the Director of Maintenance. The mixer was located above the water heater on the wall. The reading on the hot water heater read 112 degrees Fahrenheit. The mixer temperature gauge on the water line above the hot water heater was set to 100 degrees Fahrenheit. On 3/10/20 at 12:35 p.m. an interview was conducted with the Director of Maintenance. He said he was going to reset the mixer and if it continues to be an issue, they will put a new mixer under all the sinks. He said he should be able to drop the temperature a quarter and that should fix the problem. It will probably take 45 minutes to reset because it's a big water tank. If it's at a time when we're not doing laundry, it's going to take a minute because the hot water heater is insulated. This mixer is only for this building (referring to the 300 nursing unit). He turned the mixer temperature down, and he also turned the hot water heater down. A review of the policy titled, Water Temperatures, Safety of, revised December 2009, reflected the following information: Policy Statement Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set temperatures of no more than 115 degrees Fahrenheit (F)., or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats a d temperature controls in the facility and recording these in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. A review of the State Agency surveyor guidance related to the code of Federal regulations for hot water temperatures (https://ahca.myflorida.com/MCHQ/Field_Ops/Protocols/General/Fiels/Hot_Water-Protocol.pdf) showed the following: (page 2-3) The following are some regulatory requirements for hot water temperatures in health care facilities: Nursing home, 42 CFR483.25 only requires that water temperature is safe. 105 degrees Fahrenheit to 115 degrees Fahrenheit. (page 4) High Risk Population for Scald Burns Although anyone can be affected by scalds, certain people are at increased risk. These high risk groups include infants and young children, older adults and people with any type of disability. Males are about twice as likely to be scalded as females in all age groups. Older Adults Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. People with Disabilities or Special Needs Individuals who may have physical, mental, or emotional challenges require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize something is too hot. Changes in a person's intellect, perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove his or herself from danger. While the principles of scald prevention that apply to the general population also apply to this high risk group, there are additional concerns that must be addressed. Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. The number of deaths from scalds is 100 annually in all age groups. Tap water scalds are often more severe than cooking related scalds. Nationwide, tap water scalds result in more inpatient hospitalizations, generally cover a larger percent of the person's body, and result in more fatalities than other types of scalds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively monitor bowel elimination and patterns for one resident (#35) of three sampled residents. Findings included: A review of the Face Sheet for Resident #35 revealed and admission date of [DATE] and that the resident was receiving hospice services. Diagnoses included Parkinson's disease, unspecified dementia and constipation. An alert was documented as refusal of treatment waiver, no intubation, no ventilation, no CPR, no tube feeding, no daily, weekly, or monthly weights. A review of Resident #35's Vital Results recording in the medical record from [DATE] to [DATE] reflected the resident's bowel movements (BM) from [DATE] to [DATE] as None. Further review of the Vital Results recording showed: -[DATE] a small bowel movement was documented at 2:03 p.m. -[DATE] at 2:57 a.m. reflected a small bowel movement and at 2:21 p.m. reflected a small bowel movement -[DATE] at 12:10 a.m. a bowel movement of none/120 ml (milliliter) was documented and at 2:45 p.m. a medium bowel movement was reflected -[DATE] at 1:48 p.m. a small bowel movement/ 0 ml was documented and at 11:37 p.m. a bowel movement of none/120 ml documented -[DATE] at 11:48 p.m. a bowel movement of none/120 ml was documented -[DATE], [DATE], [DATE], [DATE] bowel movements were recorded as none -[DATE] at 11:42 p.m. a bowel movement of none/120 ml documented During an interview on [DATE] at 6:24 p.m. with Staff E, Licensed Practical Nurse (LPN) stated the Certified Nursing Assistant (CNA) documents on a form (Vital Signs Recording) then the nurse transfers the bowel movements to a Bowel Protocol form. Staff E, LPN confirmed the Bowel Protocol form was not completed from [DATE] to [DATE] and stated she was unaware of when Resident #35 last had a bowel movement as the documentation was not completed. Staff E stated she had not completed her documentation for the day ([DATE]) and retrieved the Vital Signs Recording form to track Resident #35's bowel movements. After the documentation was completed, Staff E confirmed the resident's last bowel movement was [DATE] and stated she was not aware of this. Staff E stated they were told to document on these forms and if they are not updated then it is hard to track the bowel movements and will look at Resident #35's bowel protocol. During an interview on [DATE] at 6:25 p.m. with the Director of Nursing (DON), she confirmed the CNAs document on the Vital Signs document for bowel movements and the nurse transfers them to the BM form (Bowel Protocol Form). During an interview on [DATE] at 8:30 a.m. with the Hospice Nurse, she confirmed the resident does not eat much and may not have a bowel movement every day. The Medical Director walked up at that time and stated she does not eat much and is on hospice, but her belly is soft, and he would not expect daily bowel movements as she eats around 25%. During an interview on [DATE] at 11:44 a.m. after providing a bowel movement timeline completed by the Administrator to track Resident #35's bowel movements. The DON stated Resident #35 had a BM on [DATE] and reconfirmed the Administrator completed the BM timeline form. The DON stated the hospice nurse was called and asked when Resident #35 last had a BM. The DON provided documentation that the nurse was contacted on [DATE] at 9:43 a.m. The DON stated the resident had a BM on [DATE] that was not documented so they added it today. The DON and Assistant Director of Nursing (ADON) stated, hospice aides will tell the nurse and the nurse should document the BM. The DON and ADON stated the nurses look at the vital signs document and transfers the BMs to the BM protocol paper to know when the residents last had a bowel movement. The DON stated that document should have been filled out daily. During an interview on [DATE] at 12:14 p.m. with the Administrator stated that she completed the timeline to show Resident #35's bowel movements. The Administrator stated the nurses should be looking at the CNA flow sheet to see when the resident last had a BM. The Administrator stated that she did not know what the bowel protocol document was and had not seen it before. The Administrator stated that the nurses should be documenting on the computer and from now on they will be using the computer to document all vital signs, BM and intake. The DON walked in and the Administrator asked why the nurses are not using the computer to document BMs. The DON stated that she has the nurse fill out the BMs on the paper form and stated they will be using the computer for documentation from now on. The DON stated that the facility does not have a bowel protocol. A review of the policy titled, Bowel Management, undated, revealed: Monitoring of Bowel Movements -Nurses on the evening shift are responsible for monitoring resident's bowel by checking logs and or reports -Residents who have not had a bowel movement in three days will be assessed for constipation and treated accordingly per physician orders and recommendations . Review of the policy titled, Medical Record Documentation Audit Reference #9007, revised 11/27, reflected: The provision of nursing care is based on the resident's care plan and shall be documented in the resident's medical record. The facility will perform admission and random audits on medical records to ensure accuracy and compliance. The resident's medical record shall include the following nursing documentation: -Nursing care provided, as reflected in the interdisciplinary care plan -Resident response to nursing care -Evaluation of nursing care . -Resident's current status -Changes in resident's physical or behavioral condition, including symptoms -A summary of the resident's condition, to include the extent nursing goals are achieved. .Nurse managers shall use admission checklist and audit tools for chart audits, any missing/incorrect documentation shall be addressed through education.

Based on observation and interview the facility failed to ensure safe and secure storage and labeling of medications related to 1. high-risk medications were stored at the resident bedside for one resident (#192) of a total sample of 31 residents, 2. one medication cart (Northwest) and one treatment cart (300-hall) were unlocked while unattended, 3. eye drops were stored with oral medications in two medication carts(Southwest and Northwest) of four medication carts, and 4. high risk medications stored in an unlabeled bag in one medication room of two medication rooms. Findings included: 1. On 3/10/20 at 1:05 p.m., two pre-filled syringes were observed in plastic packaging lying on an over-the-bed table of Resident #192. The resident was sitting in a wheelchair with the table in front of the wheelchair and the syringes were within reach of the resident. Staff D, Licensed Practical Nurse (LPN), confirmed the pre-filled syringe with a yellow cap was Heparin and the white capped syringe was normal saline. The staff member stated Heparin syringes were not stored at the bedside, they are kept in the medication room and, it must be left over from last night. (Photographic Evidence Obtained) 2. At 1:47 p.m. on 3/10/20, an observation on the 300-hall revealed a treatment cart which contained prescribed topical medications was in front of the nursing station, unlocked and unattended. Staff D, LPN was observed walking past the cart with a glass of water. The Assistant Director of Nursing (ADON) came from the hallway and noticed the treatment cart was unlocked. The ADON confirmed the treatment cart was unlocked and unattended. (Photographic Evidence Obtained) 3. On 3/11/20 at 4:20 p.m., the Southwest (SW) medication cart was observed with Staff E, LPN. The observation revealed a bottle of Tums and a box of Loperamide was stored in the same undivided area as eye drops. The staff member stated eye drops should not be stored with oral medications. At 4:29 p.m. on 3/11/20, the Northwest (NW) medication cart was observed with Staff E, LPN. The observation indicated a box of Loperamide in the same undivided area as eye drops in the top drawer. On 3/12/20 at 4:50 p.m., an observation of the Northeast medication cart was conducted with Staff F, LPN. The observation revealed a box of Genteal eye drops was stored in between bottles of oral over-the-counter medications. The staff member confirmed different routes of medications should not be stored together. (Photographic Evidence Obtained) 4. On 3/11/20 at 4:43 p.m., an observation of the [NAME] medication preparation room with Staff E, LPN, revealed a plastic bag with an assortment of pre-filled syringes in a drawer that also contained influenza testing swabs and dressing change kits. The plastic bag contained four pre-filled syringes with 5 milliliters of Heparin and two syringes with 10 milliliters of normal saline. The bag was unlabeled and did not indicate which resident was prescribed the Heparin. (Photographic Evidence Obtained) The policy titled, Medication Storage in the Facility, dated April 2018, indicated medications and biologicals are stored safely, securely, properly, and following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy identified the following: - medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. - all medications dispensed by the pharmacy are stored in the container with the pharmacy label. - orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, and etc. Eye medications are stored separately per facility policy. - Controlled substances that require refrigeration are stored within a locked box within the refrigerator and the box must be attached to the inside of the refrigerator. An interview was conducted, on 3/13/20 at 9:52 a.m., with the Consultant Pharmacist. The Consultant Pharmacist confirmed that medication carts were to be locked when unattended and oral medications are to be stored separate from eye drops. The Consultant Pharmacist stated bags of pre-filled medication syringes need to have a label on the bag identifying the medication and the prescribed resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure appropriate infection prevention measures were maintained related to maintaining a nasal cannula, oxygen tubing, a wound vacuum and wound vacuum tubing off the floor for one resident (#140) of two residents reviewed for infections. Findings included: Resident #140 was admitted to the facility with a diagnosis of cutaneous abscess of groin, AAA (abdominal aortic aneurysm) surgery, s/p (status post) right groin surgery infection with E coli, and COPD (chronic obstructive pulmonary disease), according to the face sheet in the admission record. A review of Resident #140's Physician Order Report for 2/24/20 to 3/12/20 in the medical record revealed the following: 2/24/20 ensure left groin surgical site is functioning properly at 125 mm (millimeter) HG continuous suction. May apply N.S. (normal saline) wet to dry dressing prn (as needed) if unable to get machine to function properly. 2/24/20 O2 (oxygen) at 2L (liters) via nc (nasal cannula) continuous to keep O2 sats >90% (saturation greater than 90 percent). On 3/10/20 at 2:07 p.m. an observation was conducted of Resident #140 in his bed, and the tubing from the wound vac was resting on the floor on the resident's left side of the bed. The wound vac was in a blue bag sitting on the floor on the resident's left side of the bed. The oxygen tubing was attached to the concentrator on the resident's right side of the bed. The tubing and nasal cannula were also sitting on the floor of the resident's right side next to the bed. On 3/11/20 at 3:22 p.m. an observation was conducted of Resident #140 lying on his bed on his back. He was clean and dressed and without odor. His wife was at the bedside visiting. The nasal cannula was on the floor on the resident's right side of the bed. The wound vac with the tubing were also observed on the floor on the resident's left side of the bed. On 3/11/20 at 3:24 p.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C confirmed the wound vac and tubing were on the floor. She also confirmed the oxygen tubing was on the floor. She said she didn't even know he had a wound vac. Staff C, CNA also said they weren't supposed to be on the floor. She removed the wound vac from the floor and put it on Resident #140's bed. She picked up the nasal cannula and placed it in a bag on the bed side table. She exited the room and went into the supply room and brought a new nasal cannula with tubing to the room. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #140 was cognitively intact. A review of Section G Functional Status of the MDS assessment revealed Resident #140 needed extensive assistive of one person with use of a walker or wheelchair for mobility. Resident #140 also needed extensive assistance of one staff member to use the toilet and bathe. He required supervision of one person to carry out personal hygiene activities. On 3/12/20 at 9:23 a.m. an interview was conducted with Resident #140's family member. The ADON (assistant director of nursing) was present during the interview. The family member of Resident #140 reported that Resident #140 wears continuous oxygen and that Resident #140 told her he had taken it off to go the bathroom. The family member also said Resident #140 told her that he put the wound vac (vacuum) on the floor when he came back from the bathroom. She said he already knew he wasn't supposed to put the wound vac and oxygen tubing on the floor. The ADON said he has been educated not to put the oxygen tubing or wound vac on the floor. A review of Resident #140's current care plan dated 2/24/20 revealed a care plan had not been created regarding Resident #140's removal of his nasal cannula or placing the wound vac on the floor, until 3/11/20. On 3/12/20 at 4:45 p.m. an interview was conducted with the ADON. She said residents remove their oxygen and put tubing on the floor and the facility educates them and they still do it. Staff can't be in their rooms all the time. A review of the policy titled, Infection Control, revised on July 2014, documented the policy statement as, 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 diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one dialysis resident (#10), of three sampled dialysis residents, was free from a significant medication error by failing to obtain and dispense a dialysis medication from January 17, 2020 to March 13, 2020. Findings included: A review of the Face Sheet for Resident #10 revealed that she was admitted on [DATE] with diagnoses to include acute and chronic diastolic heart failure, dementia, anorexia, end stage renal disease, and dependence on renal dialysis. On 3/11/20 at 5:06 p.m. during an interview with the Resident #10, she confirmed she received dialysis and she stated that she does not get medication while at dialysis. Review of the Physician Progress Note from the dialysis center dated 2/6/20 reflected the resident's parathyroid level goal was not met after a review of labs obtained 1/23/20. It reflected the parathyroid hormone level was 1096 and the phosphorus level on 2/4/20 was 6.3. The intervention reflected Sensipar 60 mg (milligrams) once a day. A fax sheet from the dialysis center noted to give Sensipar 60 mg once a day. A handwritten note on the fax sheet reflected, Already on since 1/17/20, and Renvela 800 mg tabs three times a day with meals, was documented as, Done. This document was faxed from the dialysis center on 2/25/20 at 2:09 p.m. Review of the prescription order dated 1/17/20 reflected the medication (Cinacalcet 60 mg once a day) was ordered on 1/17/20 at 6:36 a.m. and a new order faxed to the pharmacy dated 3/13/20 at 11:23 a.m. The medication ordered (Cinacalcet/Sensipar) treats hyperparathyroidism due to kidney failure. Review of the nursing progress notes dated 1/17/20 at 7:38 a.m. by Staff I, Unit Manager (UM) reflected, Received new orders for cinacalcet 60 mg daily from nephrologist at dialysis center, resident was currently taking 30 mg and new orders to increase to 60 mg, Medical Director agrees and new orders put into computer. Review of the nursing progress notes dated 1/28/20 at 5:32 p.m. by Staff J, Licensed Practical Nurse (LPN) reflected, medication cinacalcet has not been available. call made to pharmacy multiple days in a row. Pharmacy stated the first time called that they needed a signature from unit manager to sign for medication. Medication was signed and faxed to pharmacy. Medication was still not sent the next day. 1/27/20 the nurse called pharmacy again and pharmacist stated that they have a note from billing company that resident's insurance isn't paying for it and dialysis center is. We are supposed to get medication from dialysis center. Call made to dialysis center and they are unsure if they send medication to a facility but do sent it home with patients. Night nurse informed of situation and to pass information on to day nurse. Review of the Medication Administration Record (MAR) history dated 1/15/20 to 2/15/20 reflected Cinacalcet 60 mg once a day with a start date of 1/17/20. Review of the MAR documented by Staff J, LPN reflected the following notes: - 1/22/20 at 5:27 p.m. reflected, drug/item not available, call to pharmacy. - 1/23/20 at 5:39 p.m. reflected, call to pharmacy, said script needed to be signed by unit manager to send medications. - 1/27/20 at 5:05 p.m. reflected, call to pharmacy, said it will be on next run. - 1/28/20 at 5:32 p.m. call made to pharmacy and dialysis. - 2/5/20 at 5:44 p.m. reflected, call made to pharmacy, stated manager needed to sign waiver to approve to be sent due to cost. - 2/6/20 at 6:31 p.m. reflected, call made to pharmacy stated she will fax waiver to pharmacy direct for unit manager and DON (Director of Nursing) to sign. Review of the MAR for 1/24/20, 1/29/20, 2/1/20, 2/2/20, 2/3/20, 2/4/20, 2/10/20, 2/11/20, 2/12/20, 2/15/20 reflected Cinacalcet was unavailable. Further review of the MAR for February 2020 revealed: - 2/16/20 documented by Staff J, LPN reflected, call to pharmacy, stated they would fax over waiver to sign by unit manager or DON. - 2/18/20 documented by Staff K, LPN reflected resident refused medication. - 2/19/20 and 2/20/20 reflected item was unavailable. - 2/23/20 reflected, sent reorder to pharmacy. - 2/24/20 to 2/28/20 reflected item was unavailable. Further review of the MAR for March 2020 revealed: - 3/1/20 reflected item unavailable - 3/2/20 reflected resident refused related to upset stomach - 3/3/20 reflected administered on time by Staff K, LPN. - 3/4/20 and 3/5/20 reflected the item was unavailable. - 3/6/20 reflected the medication was given on time by Staff L, LPN. - 3/7/20 to 3/13/20 reflected item was unavailable. Review of the nursing progress notes dated 3/9/20 at 12:43 p.m. documented by Staff I, UM reflected the labs and orders were received from the dialysis center. Review of the nursing progress notes dated 3/10/20 at 3:09 p.m. documented by Staff I, UM reflected medication was reviewed by the Advanced Registered Nurse Practitioner (ARNP) and new orders were added to the computer. During an interview on 3/13/20 at 12:26 p.m. with the ARNP she stated staff told her the resident was refusing Cinacalcet and the nephrologist was advised that the resident was refusing the medication. The ARNP was unaware the medication was not available since 1/17/20 and stated the facility was telling her the resident was refusing the medication and she had no idea the medication was not ordered. During an interview on 3/13/20 at 12:22 p.m. with the Medical Director, he stated it was concerning that her parathyroid level is going up and was told the resident was refusing her medication. The Medical Director stated he would have referred her to her nephrologist if he knew her levels were continuing to rise. He confirmed he was not aware the facility did not obtain and dispense the medication. He was informed that she was refusing the medication and at one point suggested hospice. During an interview on 3/13/20 at 11:23 a.m. with Staff I, UM he stated if a medication is not available the physician should be notified after the first dose was missed. During an interview with Staff G, LPN UM on 3/13/20 at 10:39 a.m., she stated that she did not have the Cinacalcet in her cart this morning and reordered the medication. She stated the resident (Resident #10) was out to dialysis yesterday so she was not supposed to give it to her then and was unaware yesterday it was not in the cart but did order the medication and showed the steps she took to order the medication on the computer. During a phone interview on 3/13/20 at 12:34 p.m. the Consultant Pharmacist stated she was unaware the medication was documented as unavailable since January 17, 2020. She could see it was ordered, but not sent or billed to the facility and stated she would find out and call back. She stated she reviewed her medications but did not see that the medication was unavailable all of that time. During an interview on 3/13/20 at 12:50 p.m. with the DON and ADON. The DON stated the medication was unavailable and the resident should have received the medication at dialysis. The DON stated we knew the resident was refusing medications at times but never noticed that the medication was marked unavailable since January 17th (2020) with the exception of two nurses documenting they gave the medication once or twice. The ADON stated if a nurse had an issue obtaining medication the situation should have been escalated. The ADON stated we look at orders daily, random charts. The ADON stated Staff I, UM reviews the dialysis residents. He would be the one to contact the nephrologist if we had an issue. Staff I, UM joined them at this time. During the same interview, the DON, ADON and Staff I were asked how they could determine if all of the residents were receiving medication as ordered. The DON stated, nurses, the pharmacist and others look at the records on a daily basis. The DON could not answer why Resident #10 did not receive Cinacalcet starting January 17th and no one noticed, but the one nurse that documented she was trying to obtain the medication. The DON repeated she only knew the resident had a history of refusing medications. In addition, during the interview with the DON, ADON and Staff I, UM on 3/13/20 at 1:07 p.m. Staff I, UM stated the Medical Director usually looks at the labs but does not usually sign the labs reflected they were reviewed. Staff I, UM stated the pharmacy never contacted him regarding Cinacalcet and he was unaware it was not ordered. During an interview on 3/13/20 at 2:29 p.m., the DON confirmed all of the residents in the building were receiving medications as ordered except Resident #10. During a phone interview on 3/13/20 at 2:32 p.m. with Staff K, LPN, he stated he gave Resident #10, two 30 mg tablets of Cinacalcet on 3/3/20 at 7:43 p.m. Staff K, LPN was asked where he obtained the medication since the resident had not received any other doses from 1/17/20. Staff K, LPN did not answer. During a phone interview on 3/13/20 at 2:35 p.m. with Staff J, LPN stated she spoke to the pharmacy and dialysis multiple times. The pharmacy stated insurance does not approve. Dialysis stated the medication cannot be dispensed to the resident if in a nursing home. She called back and spoke to the manager and they gave a one time a dose while the resident was at dialysis. Staff J, LPN called the pharmacy and they said they would send the medication if the document was signed by the manager. They said they would send a seven day supply. Then the pharmacy said they would have billing send a document to Staff I, UM's phone since that is how he received information from the pharmacy. Staff I, UM was asked several times if he received a fax and stated he never did, but stated he gets the information on his phone. Staff I, UM stated again he had not received anything on his phone. Staff J, LPN stated she spoke to dialysis many times. Staff J, LPN confirmed the DON and Staff I, UM knew Resident #10 was not receiving the medication. Review of the care plan reflected an evaluation date of 3/13/20, revised on 3/13/20 at 10:09 a.m. by the Social Service Director for a problem area with a start date of 12/13/19 that the resident will self-determine not to take medications. Approach start date 12/13/19 reflected to notify the primary care physician and responsible party of changes/self determination to not participate with care. Review of the care plan evaluation notes dated 12/11/19, last revised on 3/10/20, reflected a problem area at risk for hypertension, failure to thrive, end stage renal disease. An Approach, dated 6/22/19, included labs/meds (medications) per order. Review of the Facility Order Audit (matrix), undated, reflected: Dialysis resident's med (medication) times are checked for times, orders for site care and management are present and fluid restrictions if applicable are documented correctly with alerts in [electronic medical record]. Review of the policy and procedure titled, Medical Record Documentation Audit Reference #9007, revised 11/2017, reflected: the provision of nursing care is based on the resident's care plan and shall be documented in the resident's medical record. The facility will perform admission and random audits on medical records to ensure accuracy and compliance. The resident's medical record shall include the following nursing documentation: Nursing care provided, as reflected in the interdisciplinary care plan, medications administered and any untoward reactions. Review of the policy related to routine nursing documentation audit, undated, reflected two pages: Orders - Complete orders so they are transmitted to the pharmacy to be filled ASAP (as soon as possible). Progress notes should be used on all residents when needed to explain what is going on with the resident i.e. labs, order changes, appointments. Review of the policy for the consultant pharmacist IIIA1, 143 to 145: dated April 2017 reflected: D. In performing medication regiment reviews, the consultant pharmacist incorporates federally mandated standards of care. E. The consultant pharmacist identifies irregularities through a variety of sources including medication administration records (MARS), prescriber orders; progress notes of prescribers, nurses and or consultants; 5) Laboratory results, diagnostic studies, or other medication therapy measurements are obtained by staff/prescriber and are acted upon. Review of the policy IIIB2: Medication Management dated April 2017, pages 151 to 154 reflected: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/ prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify assess, address, advocate for and monitor the residents needs and changes in condition. Review of the policy and procedure IIIB3:preventing and detecting adverse consequences and medication errors reflected: The facility employs a system to assure that medication usage is evaluated on an ongoing basis. Significant medication related problems are assessed, documented and reported as appropriate to the resident's attending physician. F. In the event of a significant medication-related or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as 3. Requiring treatment with a prescription medication.