Based on interview and record review the facility failed to report an allegation of neglect related to an elopement for one resident (#4) out of three residents reviewed for elopement risk. Findings included: An interview was conducted on 12/8/24 at 11:04 a.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON stated on 6/15/24 around 11:00 a.m. she was notified Resident #4 could not be found. The DON stated she had instructed staff to continue the search and notified the NHA. The NHA stated she instructed staff to notify the police. Review of the timeline prepared by the NHA at the time of the event showed: - On 6/15/24 at 11:00 a.m. notified by the facility Resident #4 was unable to be located. - A family member reported to the facility they saw Resident #4 sitting on the outside bench at the front of the facility. When staff went to the bench, Resident #4 was not there. The facility continued to search the building and surrounding areas. - At approximately 11:10 a.m. the facility contacted the police department for the missing resident. - At approximately 11:20 a.m. NHA arrived to the facility and an officer who was on site stated the police department would deploy a helicopter, drone and scent dogs. - At approximately 12:00 p.m. the police department contacted the facility and stated Resident #4 was found and unharmed. The police stated they would be taking Resident #4 to the local hospital per protocol. Review of the admission record of Resident #4 showed an admission date of 6/11/24 with diagnoses including malignant neoplasm of the lung and bones, congestive heart failure, hemiplegia and hemiparesis following cerebral infarction affecting the right side and other co-morbidities. Review of Resident #4's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 6/11/24 revealed in section C - Decision Making Capacity Patient [Resident #4] required a surrogate. Review of Resident #4's medical records showed a care plan with a focus dated 6/14/24, showing Resident #4 was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10. Resident #4 makes needs known but has impaired decision making due to alcohol abuse. Another focus dated 6/14/24 showed Resident #4 had a mood problem related to Admission, alcohol abuse, anxiety and disease process of adult failure to thrive. A baseline care plan for Resident #4 dated 6/11/24 showed, Summary long term care admitted . Diagnosis of lung cancer with metastasis to bone and spine. Malnutrition severe. Adult failure to thrive. Neurocognitive disorder. Receiving anti-psychotropic medications. Chronic pain. Fall while in the hospital. History of substance abuse and suicidal comments . Review of Resident #4's progress notes dated 6/13/24 showed, BIMS summary score: 10 meaning resident is moderately impaired. Resident stated knowing family unable to care for him. Resident #4 states owning a house, but family cannot assist. Resident is mildly depressed and will be seen by psych. Review of the facility's Reportable Log did not show any reports related to Resident #4. On 12/8/24 at 10:30 a.m. the Nursing Home Administrator (NHA) confirmed this was a complete list of reported incidents. An interview was conducted on 12/8/24 at 11:04 a.m. with the DON and the NHA. The NHA stated an elopement would meet the requirements of needing to be reported. On 12/8/24 at 10:30 a.m. the NHA stated the facility did not have a policy specific to Elopement. Review of a facility policy titled, Reporting Abuse to Facility Management dated revised February 2014, revealed: Policy Statement: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident of or suspected incidents of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Policy interpretation and implementation: . (f.) Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a discharge care plan was in place, a discharge summary was completed, and post care discharge plans were documented for one resident (#45) out of 3 residents sampled for discharge. Findings Include: A review of the face sheet revealed Resident # 45 was admitted to the facility on [DATE], and was discharged on 7/14/2023, with diagnosis to include but not limited to Parkinson's disease, Alzheimer's disease, unspecified, Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified, chronic obstructive pulmonary disease, and major depressive disorder. A review of the medical record revealed no physician discharge order, no discharge summary, and no post care discharge plan was present for Resident #45's discharge on [DATE]. On 10/4/2023 at 3:22 PM., an interview was conducted with the Director of Nursing (DON). The DON said when she reviewed Resident #45 medical record, she found no discharge physician order and no documentation indicating a post-discharge plan, and discharge summary was completed. The DON said the normal process was a discharge summary should have been completed with all the Interdisciplinary Team, the nurse would write a discharge note and the physician would provide a discharge order to permit the resident to leave the facility. On 10/4/2023 at 3:43 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO said she do not have a discharge policy because she has not had a chance to update the policy for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure laboratory results were completed as ordered and results were tracked for two residents (#27 and #9) out of 14 residents sampled. Findings included: Review of orders for Resident #27 showed an order for Warfarin 6 milligram (mg) every evening for atrial fibrillation with a PT (Prothrombin time)/INR (International normalized ratio) lab to be drawn every Monday, with a start date of 6/12/23. PT measures how long it takes for a clot to form in a blood sample and INR is a calculation based on PT results. The PT/INR is used to monitor the effectiveness of the anticoagulant Warfarin. On 10/1/23 a review of Resident #27's lab results showed a PT/INR result dated 9/18/23 as high at 20.3 with a reference range of 9.6-12.2. The results for the next lab, due to be drawn on 9/25/23, could not be found. Review of admission records showed Resident #27 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation and atherosclerotic heart disease of native coronary artery. The resident had a care plan in place for Anticoagulant Therapy, dated 2/16/21. Interaction/Approaches included Monitor labs as ordered and notify physician. Review of Resident #27's Medication Administration Record (MAR) showed the resident received Warfarin 6 mg every evening in September 2023 and October 2023 to date. Review of Resident #27's Treatment Administration Record (TAR) showed the PT/INR to be drawn on 9/25/23 was signed off as completed. Review of admission records showed Resident #9 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #9's orders showed the following: -Depakote Sprinkles 125 mg once a daily. 6/16/23 discharged [DATE]. -Depakote Sprinkles 125 mg three times a day. 9/22/23. -Depakote and Ammonia Levels every six months. September and March. 9/22/23 Review of Care plans for Resident #9 showed a plan in place for Seizure Disorder. Interactions/Approaches included monitor lab values per orders and report to physician. Review of the laboratory book showed the resident's Depakote level was drawn by the lab on 9/29/23. However, no results could be found in the medical record. An interview was conducted on 10/2/23 at 2:02 p.m. with the Director of Nursing (DON). The DON said she knows Resident #27's PT/INR was drawn on 9/25/23 because it was signed off in the lab book by the phlebotomist. (Lab book with phlebotomist initials observed). The DON reviewed the record as well as several other locations and said she didn't know where the results were. She said she would contact the lab to get the results of the PT/INR. The DON was observed reviewing the medical record of Resident #9. She confirmed she could not find the results for the Depakote level drawn on 9/29/23. The DON said the lab book shows it was drawn but she doesn't know where the results are and confirmed she had not seen any results. On 10/2/23 at 3:10 p.m. the DON provided a copy of the results of Resident #9's Depakote level drawn on 9/29/23. She said she had to call the lab and get them to send over the results. She stated the resident's Depakote level was low and she notified the doctor. Review of Resident #9's lab results showed the Depakote level (Valproic acid) was drawn on 9/29/23 and the results were reported on 9/29/23. The Valproic Acid level was low at 33.4 with a reference range of 50.0-100.0. The Valproic Acid lab measures the amount of anticonvulsant medication in the blood sample. On 10/2/23 at 3:50 p.m. the DON said she still did not have the results of Resident #27's PT/INR. She said the lab continues to only fax the results for her lab drawn on 9/18/23 and she didn't understand why. On 10/3/23 at 10:05 a.m. the DON confirmed she still does not have results for Resident #27's PT/INR from 9/25/23. A phone interview was conducted on 10/3/23 at 12:31 p.m. with the laboratory the facility uses for testing. The lab said all results are faxed to the facility since they do not use electronic charting. They said the PT/INR lab results are faxed first then all other labs follow. They also said the facility can login to the computer and see all lab results. The lab looked up Resident #27's record and said no lab was drawn on 9/25/23. An interview was conducted on 10/3/23 at 12:48 p.m. with the DON. When asked how the facility tracked labs to ensure they were completed and results returned she said they do not track that and added, we should. The DON said labs results are returned the same day they are drawn, typically on the 3:00-11:00 p.m. shift. The DON said if a nurse is administering Warfarin, they should make sure the lab results were ok. She confirmed the nurses continued to administer Warfarin to Resident #27 without having lab results to review. Staff A, Registered Nurse (RN) joined the interview. Staff A, RN said labs are drawn in the morning and it is usually passed down during nurse-to-nurse report at shift change since results typically come back on the 3:00-11:00 p.m. shift. The DON and Staff A, RN reviewed Resident #27's medical record and confirmed there was no documentation the resident had refused for the lab to be drawn. Neither the DON or Staff A, RN were aware no results had come back and agreed no one followed up with the lab to check on them. An interview was conducted on 10/3/23 at 12:52 p.m. with the Chief Nursing Officer (CNO). The CNO was notified of labs not being tracked to see if they were completed or if results came back. She stated, We will have to fix this. The CNO said the DON should take the lab book with her to every morning meeting to review what should have been completed the day prior. An interview was conducted on 10/3/23 at 3:56 p.m. with Resident #27's primary physician. He said he would have expected to have been notified if a lab had been missed and of abnormal lab results. Review of a facility policy titled Laboratory/Diagnostic Monitoring, dated 8/1/22, showed the following: Policy: Residents will have laboratory/diagnostic monitoring per physician order with documentation in the medical record. Procedure: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The licensed nurse will process test requisitions and arrange for tests per physician order. 3. The laboratory, diagnostic radiology provider, or other testing source will report will report test results to the facility. 4. The licensed nurse will notify the physician of abnormal and/or critical results with documentation in the medical record. 5. The licensed nurse will notify the resident and/or resident representative of abnormal and/or critical results with documentation in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to refer five residents (Residents #7, #16, #25 #40 and #41) of 14 residents reviewed for Pre-admission Screening and Resident Review (PASRR), for a newly evident or possible serious mental disorder, intellectual disability, or a related condition for a level II PASRR resident review upon a significant change in status assessment. Findings included: Review of Resident #7's admission record showed Resident #7 was re-admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder, recurrent, moderate. The level I PASRR dated 08/30/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident #16's admission record showed Resident #16 was re-admitted to the facility on [DATE] with a diagnosis of Anxiety disorder, unspecified, Unspecified mood [affective] disorder and Vascular Dementia, unspecified severity, with mood disturbances. The level I PASRR dated 01/24/22 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident #25's admission record showed Resident #25 was re-admitted to the facility on [DATE] with diagnoses of Vascular Dementia, unspecified severity, with agitation, Anxiety disorder, unspecified, Bipolar disorder, unspecified, and Schizoaffective disorder, bipolar type. The level I PASRR dated 06/06/2020 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) was marked for Bipolar Disorder and Depressive Disorder but not for Anxiety disorder or Schizoaffective disorder. Review of Resident #40's admission record showed Resident #40 was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, recurrent, unspecified, Anxiety disorder, unspecified and Vascular Dementia, severe, with mood disturbances. The level I PASRR dated 07/21/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident 41's admission record showed Resident #41 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, recurrent, moderate, Mood disorder due to physiological condition with depressive features, Unspecified mood [affective] disorder and Vascular Dementia, unspecified severity, with mood disturbances. The level I PASRR dated 06/16/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. During an interview on 10/03/23 at 3:30 p.m., the Director of Nursing (DON) stated, when a Resident gets a new psych diagnosis the Resident should be submitted for a level II PASRR review. The DON reviewed and confirmed the five PASRR's were not correct for Residents' #7, #16, #25, #40 and #41 and stated those Residents should have been submitted for a level II PASRR review upon being diagnosed with a new psych diagnosis. Review of the facility's Policies and Procedures titled, Preadmission Screening and Resident Review (PASRR), dated 11/08/2021 showed 4. If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical record and any recommendations for service will be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure five residents (Residents #10, #12, #18, #23 and #43) of 14 residents reviewed for Pre-admission Screening and Resident Review (PASRR) had a level I completed prior to admission and two residents (Residents #7 and #40) of 14 residents had a level I PASRR completed by an appropriate and authorized staff member. Findings included: Review of Resident #10's admission record showed Resident #10 was admitted to the facility on [DATE] with diagnoses of displaced interochanteric fracture of right femur, subsequent for closed fracture with routine healing, Iron deficiency, lack of coordination and abnormalities of gait and mobility. There was no PASRR available to review in Resident #10's medical chart. Review of Resident #12's admission record showed Resident #12 was admitted to the facility on [DATE] with diagnoses of psychotic disorder with delusions due to know physiological condition, major depressive disorder, recurrent, unspecified, generalize anxiety disorder and post Traumatic Stress Disorder, chronic. There was no PASRR available to review in Resident #12's medical chart. Review of Resident #18's admission record showed Resident #18 was admitted to the facility on [DATE] and then re-admitted to the facility on [DATE] with diagnoses of anxiety disorder, unspecified, major depressive disorder, recurrent, moderate and unspecified dementia, severe without behavioral disturbance. There was no PASRR available to review in Resident #18's medical chart. Review of Resident #23's admission record showed Resident #23 was admitted to the facility on [DATE] and then re-admitted to the facility on [DATE] with diagnoses of anxiety disorder, unspecified and insomnia. There was no PASRR available to review in Resident #23's medical chart. Review of Resident #43's admission record showed Resident #43 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of the cerebrum, unspecified without loss of consciousness and bipolar disorder, unspecified. There was no PASRR available to review in Resident #43's medical chart. During an interview on 10/03/23 at 4:07 p.m., the Director of Nursing (DON) stated that if there was no PASRR in the hard copy medical chart then there was not a PASRR available. The DON reviewed Residents #10, #12, #18, #23 and #43 medical charts and confirmed there were no PASRRs available for review. Review of Resident #7's admission record showed Resident #7 was re-admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder, recurrent, moderate. The level I PASRR dated 08/30/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident #40's admission record showed Resident #40 was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, recurrent, unspecified, Anxiety disorder, unspecified and Vascular Dementia, severe, with mood disturbances. The level I PASRR dated 07/21/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. During an interview on 10/03/23 at 3:30 p.m., the Director of Nursing (DON) stated when a Resident gets a new psych diagnosis the Resident should be submitted for a level II review. The DON stated that she had never completed a PASRR in the facility because she had never been given access to the system and allowed to complete PASRR. The DON stated the previous Nursing Home Administrator (pNHA) always completed them because the pNHA was the only person in the facility who had access to the PASRR system. The DON reviewed Resident #7's PASRR dated 08/30/23 and Resident #40's PASRR dated 07/21/23 and confirmed both were not correct and Resident #7 and #40 should have been submitted for a level II review. During the review of Resident #7 and #40's PASRRs the DON noticed the PASRRs were electronically signed with the DON's name and credentials. The DON shook her head no and again stated she never had access to the PASRR system and these PASRRs had been signed falsely. The DON stated she never discussed with anyone information about these two PASRRs and these PASRRs had been signed with her name and credentials without her permission and her knowledge. During an interview on 10/03/2023 at approximately 3:50 p.m., the DON called the Social Service Director (SSD) on the phone for a phone interview. While on speaker phone with the survey team the SSD stated the only person in the facility who had completed any PASRR was the previous NHA (pNHA) and no PASRR was needed to be completed since the pNHA left in September 2023. The SSD confirmed all PASRRs were completed in the state portal and that only the pNHA had ever had access to that portal. Review of the Kepro FL [Florida] PASRR Provider Portal Frequently Asked Questions (FAQ) website on 10/03/23 (https://floridapasarr.kepro.com) Level 1 Review showed Who is able to complete a Level I screening? Anyone who works for a hospital or nursing facility and holds the following credentials: Masters of Social Work, or license in the State of Florida as a Clinical Social Worker (LCSW), Mental Health Counselor (LMHC), Physician (MD/DO), Physician Assistant (PA), Registered Nurse (RN), or Psychologist. During an interview on 10/03/2023 at 4:20 p.m., the previous Nursing Home Administrator (pNHA) stated she had worked for the facility for two years prior to leaving on 09/08/2023. The pNHA stated most of the time PASRRs did not need to be completed at the facility as most residents came to the facility with the PASRRs completed by the hospital prior to admission to the facility. The pNHA stated she was the only staff member in the facility that had access to the PASRR portal in Kepro. The pNHA stated she only remembered a couple of PASRRs she had to complete because the Residents did not come with a PASARR. The pNHA stated she remembered both she and the DON sat down and completed the PASARR together but the pNHA had to submit the PASARR as the DON did not have access to the PASRR online system. The pNHA stated when signing the PASRR electronically it was submitted by just typing the name down and submitting the form. During an interview on 10/03/23 at 4:35 p.m., The DON stated,No, I never did any PASRRs with [name of previous Nursing Home Administrator] The DON stated I never talked about any PASRRs with the pNHA and never sat down with her. The pNHA was the only person with access to the PASRR system and the pNHA signed my name falsely without my permission and without my knowledge. Review of the facility's policy Preadmission Screening and Resident Review (PASRR) dated 11/08/2021 showed 1. It is the responsibility of the center to assess and assure the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical record and any recommendations for service will be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/01/23 during an interview Resident #12 said the facility no longer uses Styrofoam cups and pointed to a pink plastic water pitcher on her bedside table, labeled with her room number and bed assigned. (Photographic evidence obtained) On 10/01/23 a Certified Nurse Assistant (CNA) was observed refilling pink plastic hydration pitchers and returning them to residents. On 10/02/23 CNAs were observed removing, sometimes rinsing in the bathroom sink, refilling, and returning pink plastic hydration pitcher to residents. On 10/03/23 during a random interview a CNA said that she rinses out the pink plastic hydration pitchers, refills and returns them to the residents. During an interview on 10/03/23 at 10:20 a.m., the Dietary Manager said most residents use Styrofoam cups and We do not have to wash for hydration the pink plastic hydration pitcher should be washed in the Dietary department after every use. During an interview on 10/03/23 at 10:25 a.m., Staff A, Dietary Assistant said, No, we don't wash those pink pitchers, I haven't seen them. During an interview on 10/03/23 at 10:30 a.m. with Staff C, CNA , about the pink plastic hydration pitcher said, When I fill them, I usually wash the pitcher out myself first and then refill. On 10/04/23 during a tour of the Laundry Department (LD) clean linen was observed in a room between the washing machines and the maintenance and housekeeping hallway with two doors propped open. (Photographic evidence obtained) On 10/04/23 at 02:38 p.m., during an interview the DON stated the process to wash the pink plastic hydration pitchers had not been determined prior to distributing to each resident and she had not observed the clean linen storage in the LD. A review of the facility's policy titled, Cleaning and Disinfecting of Resident Care Items and Equipment, dated 12/2008, revealed the following: Policy statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations, for disinfection and OSHA Bloodborne Pathogen Standard. Procedures to include: 2) Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment) use 3) Durable Medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4) Equipment that is designated reusable shall be used by more than one resident A review of the facility's policy titled Handwashing/ Hand Hygiene policy, revised April 2012, revealed the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Procedures: 5. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact; i. Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse of blood pressure); v. After completing duty. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for the following situations: a. Before and after direct contact with residents; d. Before preparing or handling medications; g. After contact with a resident's intact skin; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. Based on observations, interviews, and record review the facility failed to ensure proper infection control practices related to handwashing, cleaning of reusable equipment, and washing of reusable water pitches in two of two resident halls. Findings included: An observation was made on 10/1/23 at 9:18 a.m. of a bedpan sitting in a basket in the bathroom of Resident #7. The bedpan was uncovered, and wet washcloths were in the basket with it. Resident #7 said the bedpan had been sitting in her bathroom like that since she had to give a urine sample several days ago. (Photographic evidence obtained.) Review of admission records showed Resident #7 was admitted on [DATE] with diagnoses including urinary tract infection (UTI). Review of Resident #7's quarterly Minimum Data Set (MDS,) dated 7/14/23, Section C, Cognitive Patterns showed her Brief Interview for Mental Status (BIMS) score was 12, indicating she had moderately impaired cognition. Review of Resident #7's laboratory documents showed she had a urinalysis collected on 9/25/23. An interview was conducted on 10/4/23 at 3:25 p.m. with Staff A, Registered Nurse (RN.) She said Resident #7 uses the toilet in her room and she didn't know why the bedpan was there. She said it is possible the resident uses it at night. An interview was conducted on 10/4/23 at 2:22 p.m. with the Director of Nursing (DON.) She reviewed the photo of the bedpan in the bathroom of Resident #7. The DON confirmed the bedpan and used washcloths should not have been left in the bathroom. She said a straight catheter should have been used for the urine sample. An observation was made on 10/3/23 at 9:01 a.m. of Staff A, RN using a blood pressure cuff on two different residents during medication pass without cleaning the blood pressure cuff between residents. The blood pressure cuff was observed to be a wrist cuff that was made of a cloth material. The cloth was observed to have soiled spots on it. (Photographic evidence obtained.) During this same medication pass, Staff A, RN took a resident's blood pressure, returned to the cart without performing hand hygiene, gathered medications, realized a medication was not in the cart, called a provider from her cell phone, went to the medication room to access the emergency drug kit, signed out the medication, returned to the cart, then went to the resident room to administer medications. Throughout this process no hand hygiene was performed. An interview was conducted on 10/4/23 at 2:20 p.m. with Staff A, RN. Staff A, RN said the blood pressure cuff should be cleaned between each resident. She said she usually wipes it with the cleaning wipes in her cart. Staff A, RN confirmed the blood pressure cuff was cloth on the inside portion that touches the residents. She said you can't use sanitizer or anything liquid because the cuff will stay wet. She said the wipes work ok. An interview was conducted on 10/4/23 at 2:22 p.m. with the DON. The DON said the blood pressure cuffs should be cleaned between every resident. When asked about the wrist cuffs being used, she said those are the nurses' personal blood pressure cuffs, they do not belong to the facility. The DON looked at the blood pressure cuff and acknowledged the cloth could not be sanitized. The DON also confirmed staff should be performing proper hand hygiene every time they go in and out of a resident room. An observation was made on 10/2/23 at 10:55 a.m. of a Certified Nursing Assistant (CNA) refilling resident's pink plastic water pitchers for the morning. The CNA was observed picking up a water pitcher from a resident's bedside table, dumping the water in the sink, taking it to a cooler in the hallway, filling it with ice and water, and she then returned it to the resident's tray table. The CNA did not wash the pitcher prior to refilling. The pitcher did not have a date or label on it. The CNA finished in one resident's room and proceeded to another resident's room to repeat the process without completing any hand hygiene.

Based on interviews and record review, the facility failed to ensure the residents' medical records included documentation 1)indicating the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations, and 2) the resident had received or had not received the immunization due to medical contraindications or refusal for five (# 7, #12, #37, #246 and #296) out of five resident for immunizations. Findings included: A review of the facility's admission forms, provided to all new admissions, did not reveal influenza and pneumococcal immunization education, or consents related to vaccines. A review of the medical records for Residents #7, #12, #37, #246, and #296 revealed no documentation indicating 1) the resident or the resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations, or 2) the resident had received or had not received the immunizations due to medical contraindications or refusal were located in the medical records. On 10/03/23 at 2:36 p.m. an interview was conducted with the Director of Nursing (DON), she stated vaccine status can be found in the admission section of the medical record. During a review of Resident # 12's medical record with the DON, she verified vaccine information was missing. The DON said she would check the Online Immunization Information System for documentation regarding immunizations for Residents #7, #12, #37, #246, and #296. On 10/04/23 at 1:00 p.m. the DON confirmed she did not find 2022 influenza vaccine or pneumonia vaccine documentation for Residents #7, #12, #37, #246, and #296. The facility did not provide a requested policy related to resident vaccines by the exit of the survey team on 10/4/23 at 4:45 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure interventions in the comprehensive care plan were implemented for eight residents (#27, #7, #8, #10, #29, #31, #37, and #41) out of nine residents sampled for anticoagulant medications. Findings included: Review of admission records showed Resident #27 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). The resident had a care plan in place for Anticoagulant Therapy, dated 2/16/21. Interaction/Approaches included Monitor labs as ordered, notify physician, and monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of orders for Resident #27 showed an order for Warfarin 6 milligram (mg) every evening for atrial fibrillation, with a start date of 6/12/23. Review of Resident #27's Medication Administration Record (MAR) showed the resident received Warfarin 6 mg every evening in September 2023 and October 2023 to date. Review of Resident #27's MAR and Treatment Administration (TAR) did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #7 was admitted on [DATE] with diagnoses including chronic atrial fibrillation. Review of orders showed Resident #7 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for atrial fibrillation. Start date 4/10/23. -Aspirin 81 mg. Give one tablet by mouth once daily for heart failure. Start date 4/10/23. Review of Resident #7's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 4/20/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #7's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #8 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage. Review of orders showed Resident #8 had the following orders: -Eliquis 2.5 mg. Give one tablet by via peg tube twice daily for atrial fibrillation. Start date 10/7/22. Review of Resident #8's MAR showed the resident received Eliquis as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 11/25/19. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #8's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #10 was admitted on [DATE] with diagnoses including acute embolism and thrombosis of left popliteal vein and iron deficiency anemia secondary to blood loss. Review of orders showed Resident #10 had the following orders: -Eliquis 2.5 mg. Give one tablet by mouth twice daily for deep vein thrombosis prevention. Start date 10/7/22. Review of Resident #10's MAR showed the resident received Eliquis as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 1/27/22. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #10's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #29 was admitted on [DATE] with diagnoses including history of thrombophlebitis. Review of orders showed Resident #29 had the following orders: -Xarelto 20 mg. Give one tablet by mouth one daily for bilateral lower extremities thrombophlebitis. Start date: 12/26/22. Review of Resident #29's MAR showed the resident received Xarelto as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 1/4/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #29's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #31 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). Review of orders showed Resident #31 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for deep vein thrombosis. Start date 10/7/22. -Aspirin 81 mg. Give one tablet by mouth once daily for CAD clot prevention. Start date 11/19/21. Review of Resident #31's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 12/2/21. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #31's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #37 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). Review of orders showed Resident #37 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for deep vein thrombosis. Start date 5/3/23. Review of Resident #37's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 5/17/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #37's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #41 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation. Review of orders showed Resident #41 had the following orders: -Xarelto 15 mg. Give one tablet by mouth once daily for atrial fibrillation. Start date: 7/6/23. Review of Resident #41's MAR showed the resident received Xarelto as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 7/18/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #41's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. An interview was conducted on 10/3/23 with Staff A, Registered Nurse (RN.) Staff A, RN said they do not have side effect monitoring documentation for residents on anticoagulants. An interview was conducted on 10/4/23 at 10:01 a.m. with Staff B, RN. Staff B, RN said they do not have a flow sheet or monitoring to sign on specific to anticoagulant use or signs and symptoms of bleeding. An interview was conducted with the Director of Nursing (DON) on 10/4/23 at 9:57 a.m. The DON said there is not a flow sheet for nurses to monitor for signs and symptoms of bleeding for residents on anticoagulants. She confirmed there is no documentation for anticoagulants triggered on the MAR or TAR. The DON said she would have to check and see if it is noted on the right side of the order sheets. She was observed pulling out an order sheet and confirmed nothing is noted on the order sheet for the nurses to watch for signs and symptoms of bleeding related to anticoagulant use. The DON said there should be monitoring and documenting for signs and symptoms of bleeding for residents on anticoagulant therapy. Review of a facility policy titled Laboratory/Diagnostic Monitoring, dated 8/1/22, showed the following: Policy: Residents will have laboratory/diagnostic monitoring per physician order with documentation in the medical record. Procedure: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The licensed nurse will process test requisitions and arrange for tests per physician order. 3. The laboratory, diagnostic radiology provider, or other testing source will report will report test results to the facility. 4. The licensed nurse will notify the physician of abnormal and/or critical results with documentation in the medical record. 5. The licensed nurse will notify the resident and/or resident representative of abnormal and/or critical results with documentation in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to provide written notification of Transfer/Discharge to Resident Representatives for two (Resident #19 and Resident #12) of four sampled residents for hospitalizations. Findings included: 1) On 9/8/21 at 10:40 a.m., Resident #19 was observed lying in the bed covered with a blanket. An attempt to interview the resident revealed the resident to be confused and unable to answer any questions related to care and services. A review of the Resident Face Sheet (undated), revealed that Resident #19 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, hypertension, chronic obstructive pulmonary disease, dysphasia, anxiety, Diabetes Mellitus, chronic kidney disease, and dementia. A review of Minimum Data Set, dated [DATE], for Resident #19 revealed a Brief Interview of Mental Status score of 03, indicating severe cognitive impairment. A review of the medical record revealed Resident #19 had an order to send to the emergency room for evaluation due to a fall dated 6/6/21. A review of the nursing notes indicated on 6/6/21 at 5:48 a.m., the resident was sent to the emergency room for further evaluation via 911 call for an ambulance. A review of transfer documents provided by the facility revealed a Nursing Home Transfer and Discharge Notice completed on 6/6/21 for Resident #19. The first page of the form indicated a Resident Representative with name, address, and phone number listed. The reason for discharge/transfer was listed as needs cannot be met in this facility. The second page of the form had the name of the Resident Representative written in and a date of 6/6/21. Verbal Consent was written under the signature line. On 9/10/21 at 11:09 a.m., a telephone interview was conducted with the Resident Representative for Resident #19. The Representative stated he did not recall seeing any written letters regarding the transfer that took place on 6/6/21. He stated the facility always called him, but he could not state that he received anything officially in writing. 2) On 9/09/21 at 4:11 p.m., Resident #12 was observed lying in the bed with the head of the bed elevated. The resident was observed with a tube feeding running via pump at 45 milliliters per hour. The resident was moaning continuously. The resident was not able to communicate or answer any questions related to care and services. A review of the Resident Face Sheet (undated), revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis after cerebral vascular accident (right side), aphasia, dysphasia, abnormal posture, gastrostomy, and dementia. A review of Minimum Data Set for Resident #12, dated 6/13/21, revealed a Brief Interview of Mental Status score unable to be determined due to the resident being rarely/never understood. A review of the medical record revealed Resident #12 had an order to transfer to the emergency room for evaluation and treatment dated 8/5/21. A review of the nursing notes indicated on 8/5/21 at 5:15 p.m., the resident was sent to the emergency room for further evaluation via ambulance. A review of transfer documents provided by the facility revealed a Nursing Home Transfer and Discharge Notice completed on 8/5/21 for Resident #12. The first page of the form indicated a Resident Representative with name, address, and phone number listed. The reason for discharge/transfer was listed as needs cannot be met in this facility. The second page of the form had the name of the Resident written in and unable to sign with a date of 8/5/21. On 9/9/21 at 4:21 p.m., an interview was conducted with the Administrator and the Director of Nursing. The Administrator stated the transfer document and Ombudsmen notice was her responsibility once a resident was transferred. She stated she got the transfer document ready, and she faxed the document to the Ombudsmen's office. The Administrator stated she did not send a copy of the transfer form to the Resident Representative in the event the Resident did not have capacity for health care decision. The Administrator and the Director of Nursing stated they were not aware the documents needed to be sent in writing to Resident Representatives. The Administrator confirmed she had not sent the written notifications for transfer to either Resident Representative for Resident #19 or Resident #12. On 9/9/21 at 4:45 p.m. a telephone message was left for the Resident Representative listed for Resident #12. The call was not returned. A facility policy was requested from the Administrator and Director of Nursing regarding requirements for written notification of transfer/discharge. The facility stated there was no such policy for this requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to provide written notification of the Bed Hold Policy to Resident Representatives for two (Resident #19 and Resident #12) of four sampled residents for hospitalizations. Findings included: 1) On 9/8/21 at 10:40 a.m Resident #19 was observed lying in the bed covered with a blanket. An attempt to interview the resident revealed the resident to be confused and unable to answer any questions related to care and services. A review of the Resident Face Sheet (undated), revealed that Resident #19 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure, hypertension, chronic obstructive pulmonary disease, dysphasia, anxiety, Diabetes Mellitus, chronic kidney disease, and dementia. A review of Minimum Data, dated 6/28/21, Set for Resident #19 revealed a Brief Interview of Mental Status score of 03, indicating severe cognitive impairment. A review of the medical record revealed Resident #19 had an order to send to the emergency room for evaluation due to a fall dated 6/6/21. A review of the nursing notes indicated on 6/6/21 at 5:48 a.m., the resident was sent to the emergency room for further evaluation via 911 call for an ambulance. A review of the Bed Hold Policy indicated on 6/6/21, the policy was verbally communicated to the Resident Representative at 5:18 a.m. On 9/10/21 at 11:09 a.m., a telephone interview was conducted with the Resident Representative for Resident #19. The Representative stated he did not recall seeing any written letters regarding the transfer that took place on 6/6/21. He stated the facility always calls him, but he could not state that he received anything officially in writing. 2) On 9/09/21 at 4:11 p.m. Resident #12 was observed lying in the bed with the head of the bed elevated. The resident was observed with a tube feeding running via pump at 45 milliliters per hour. The resident was moaning continuously. The resident was not able to communicate or answer any questions related to care and services. A review of the Resident Face Sheet( undated), revealed that Resident #12 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis after cerebral vascular accident (right side), aphasia, dysphasia, abnormal posture, gastrostomy, and dementia. A review of Minimum Data Set, dated [DATE], for Resident #12 revealed a Brief Interview of Mental Status score unable to be determined due to the resident being rarely/never understood. A review of the medical record revealed Resident #12 had an order to transfer to the emergency room for evaluation and treatment dated 8/5/21. A review of the nursing notes indicated on 8/5/21 at 5:15 p.m., the resident was sent to the emergency room for further evaluation via ambulance. A review of the Bed Hold Policy indicated on 8/5/21 the policy was given to the resident and sent to the emergency room with resident. The signature line of the bed hold policy had resident unable to sign written on it. On 9/9/21 at 4:21 p.m. an interview was conducted with the Administrator and the Director of Nursing. The Administrator stated nursing was responsible for sending the bed hold policy with the resident if they could sign the document. The Administrator stated she did not send a copy of the bed hold policy to the Resident Representative in the event the Resident did not have capacity for health care decision. The Administrator and the Director of Nursing stated they were not aware the bed hold policy needed to be sent in writing to Resident Representatives. The Administrator confirmed she had not sent the bed hold policy to either Resident Representative for Resident #19 or Resident #12. On 9/9/21 at 4:45 p.m., a telephone message was left for the Resident Representative listed for Resident #12. The call was not returned. facility policy was requested from the Administrator and Director of Nursing regarding requirements for written notification of the bed hold policy. The facility stated there was no such policy for this requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure respiratory equipment was stored appropriately for four (Residents # 191, #192, #193 and #194) of seven sampled residents. Findings included: 1) During a facility tour on 09/08/21 at 10:38 a.m., Resident #191's Nebulizer machine was observed on top of the nightstand, not covered. Resident #191 stated that he used his machine two times daily to take his medicine. Resident #191 said, they don't clean it. On subsequent tours on 09/08/21 and 09/09/21, the nebulizer machine was observed on the same spot, on top of the nightstand. Review of Resident #191's face sheet revealed diagnoses to include COPD (chronic obstructive pulmonary disease), presence of cardiac pacemaker, presence of automatic (implanted) cardiac defibrillator, and chronic congestive heart failure An initial MDS (minimum data set) dated 09/02/21, revealed a BIMS (brief interview for mental status) score of 15, indicating intact cognition. Review of Resident #191's physician's order sheet with a print date of 08/30/21, revealed that Resident #191 received Albuterol 0.5 soln. inhale via nebulizer b.i.d (2 times per day) for COPD (chronic obstructive pulmonary disease) and Budesonide Sulphate 0.5mg/2ml inhale 1 vial nebulizer, b.i.d for COPD. 2) During multiple tours on 09/08/21 and 09/09/21 an observation was made of Resident # 192's nebulizer machine sitting on top of the nightstand uncovered. A review of Resident #192's physician order sheet printed on 08/26/21, revealed an order; Ipratropium / sol albuterol dated 08/21/21. Inhale one pre-mixed vial via nebulizer every six hours as needed - diagnosis shortness of breath. Ipratropium / sol albuterol 0.5 - 2.5mg/3ml dated 08/30/21. Give one vial via nebulizer every 6 hours for COPD. Review of Resident #192's face sheet revealed diagnoses including acute respiratory failure, unspecified whether with hypoxia or hypercapnia, end stage renal disease, acute embolism, and tracheostomy status. An initial MDS (minimum data set) dated 08/26/21, revealed a BIMS (brief interview for mental status) score of 13, indicating intact cognition. 3) Resident #193 was admitted to the facility on [DATE], with diagnoses including heart failure unspecified, unspecified atrial flutter, and chronic pulmonary disease unspecified. During multiple tours on 09/08/21 and 09/09/21, Resident # 193's nebulizer was observed stored inside an opened nightstand drawer, noted uncovered and unlabeled. Review of Resident #193's Physician orders sheet printed on 08/30/21, revealed an order dated 08/28/21 for Budesonide 0.5mg/2 inhale one nebule via nebulizer twice daily for COPD. Ipratropium sol albuterol dated 8/28/21, inhale one nebule via nebulizer every six hours for COPD An initial MDS (minimum data set) dated 09/02/21 revealed a BIMS (brief interview for mental status) score of 14, indicating intact cognition. 4) During multiple tours on 09/08/21, 09/09/21 and 09/10/21, Resident #194's nebulizer was observed inside a drawer on his nightstand noted uncovered and not labeled. Resident # 194 was admitted to the facility with a diagnoses including pneumonia, unspecified organism, allergic rhinitis, chronic obstructive pulmonary disease, rhabdomyolysis, and unspecified heart failure. Review of Resident #194's Physician orders sheet printed on 08/26/21, revealed an order Ipratropium / sol albuterol dated 08/23/21. Inhale one pre-mixed vial via nebulizer twice daily at 9:00 a.m. and 9:00 p.m. Budesonide Sulphate 0.5mg/2ml (order date 08/23/21) inhale one pre-mixed vial via nebulizer twice daily at 9:00 a.m. and 9:00 p.m. A Baseline care plan for Resident # 194 revealed cognitive status alert and oriented. A Care plan dated 09/06/21 with a target date of 12/06/21 revealed a goal under chronic obstructive pulmonary disease, related to COPD. The goal identifies that Resident #194 will have no shortness of breath and will actively participate in therapy through the next review date. Interventions include to monitor for shortness of breath and increased respirations. Treatment / medications as ordered. On 09/10/21 at 12:50 p.m., an interview was conducted with Resident #194. Resident #194 stated that since he moved into the facility, his nebulizer machine sat in the drawer or on top. He stated he never saw it in a bag or anything. He stated that he used his nebulizer machine two times daily. On 09/10/21 at 12:56 p.m., an interview was conducted with Staff A, LPN. Staff A walked into the resident rooms with the surveyor and made the observations of the nebulizers. She said, It [nebulizer] should not be laid on top of the nightstand. It should be covered. Staff A said she would get a bag. She stated, All of them [nebulizers] should be stored in a dated bag. A follow-up interview was conducted with the NHA (Nursing Home Administrator) on 09/10/21 at 1:33 p.m. The NHA stated, They [nebulizers] should be stored per policy. The facility's policy was requested. On 09/10/21 at 4:24 p.m., an interview was conducted with the Regional Director (RD). The RD stated that the facility did not have a policy related to Nebulizer equipment, use, maintenance, and storage. An interview was conducted on 09/10/21 at 2:58 p.m. with the DON (Director of Nursing). She said, We are supposed to have a bag for each equipment, store the face mask and nebulizer mouth pieces in a bag. The nurses should clean the equipment after each use and store accordingly. I will in service and train the staff. She further stated that she would implement a procedure for cleaning masks, changing tubing, and dating the bag.

Based on observations, interviews, and record review, the facility did not ensure the kitchen was maintained in a sanitary manner and food was stored appropriately related to cleanliness of the walk -in cooler and freezer, storage and dating of opened foods, and repair of a leaking pipe in the dishwashing area. Findings included: An initial kitchen tour was conducted on 09/08/21 from 9:15 a.m. to 9:45 a.m., facilitated by Staff E, Cook. Photographic evidence of the following observations was obtained. During the tour of the walk -in cooler a 1-gallon bottle of soy sauce was noted with bio growth inside, dated opened 5/14/2020. A carton of French vanilla coffee mixer noted please do not use, for Christmas party dated 12/12/19. A bottle French vanilla coffee mix next to the carton was noted with bio growth inside. Staff E who saw the bio growth stated, That is not good. we will throw them out. In the walk-in cooler, a tube of ground beef thawing in a shallow pan was observe on the bottom shelf noted leaking blood, overflowing to the floor of the cooler. Above the ground beef that was thawing, a pipe going through the cooler wall was noted with bio-growth on the base of the pipe. Bio- growth was also observed on the door to the main freezer within the cooler. The inside of the freezer was observed with plastic dividers on the doorway, mounted with built up frost and icicle formations. Staff E said, Be careful, the floor is slippery because of the melting ice. Staff E stated that this had been an on-going problem. The floor of the freezer was noted with brown-looking matter, food crumbs, and red-saucy paste dried on the floor. On the freezer shelves, yellow looking-icy melting formations were observed dripping on an opened box of ice-cream cups. An unlabeled, undated small bowl with a yellow frozen food item was observed wrapped in plastic food wrap. Staff E stated, It looks like ice-cream. It should not be there. She stated she would toss it. Staff E stated that all food items should be labeled and dated. Staff E was asked how often the freezer and walk -in cooler were cleaned. Staff E said, We should clean more. Staff E stated that CDM (Certified Dietary Manager) oversees the scheduling. During a tour of the dry good storage area, a bag of noodles not labeled, dated, or properly sealed was observed on the shelf. A tour of the main kitchen area revealed a pipe leaking underneath the dishwashing table. A blue tub was noted collecting the dripping water and towels laid around to catch the overflow. On 09/08/21 at 9:39 a.m., an interview was conducted with Staff F, Dietary Aide. Staff F stated that the pipe had been leaking for a few days, but she could not remember how long. Staff F said, it was recent. The CDM is aware. On 09/08/21 at 12:41 p.m., an interview was conducted with the CDM. He stated that they would throw out the expired food items and clean the freezers. He said that they have called a plumber for the leaking pipe and are awaiting parts for repairs. The CDM stated that the pipe had been leaking only a few days. On 09/09/21 at 12:06 p.m., a review of kitchen concerns was discussed with CDM and RD (Registered Dietician). After reviewing photographic evidence, the CDM stated that he cleaned out the freezer and cooler and threw out all the items that were expired and that were with bio growth. The CDM said, We should not have kept it there. It should not be served to the residents. The CDM stated that the freezer door did not close very well and hence the built-up frost and melting ice. He said he was aware of the on-going concern. The RD said, All food that is open should be tightly sealed and dated. On 09/10/21 at 1:33 p.m., an interview was conducted with NHA (nursing home administrator). She said she was notified by the RD and the CDM of the concerns identified in the kitchen. The NHA said she understood there was a problem with excessive frosting and some food items not properly stored. She said her expectation was that the facility maintained a clean and sanitary environment. Review of an undated facility policy titled, Food Storage revealed that food items should be stored, thawed, and prepared in accordance with good sanitary practice. Procedure: all products should be dated upon receipt and when they are prepared. Leftovers should be dated according to the leftover policy. Remember to cover, label and date Storage: (3.) Foods to be frozen should be stored in airtight containers or wrapped in heavy duty aluminum foil or special laminated papers. Label and date all food items. Thawing: (4.) Thaw meat by placing in deep pans and setting on lowest shelf in refrigerator. Storage: (2.) The walls, ceiling and floors should be maintained in good repair and regularly cleaned.

Based on observations, interviews, record review, policy review, and manufacturer's instructions the facility did not ensure the medication error rate was below 5% for two (#21 and #199) of three sampled residents who were administered medications. This resulted in two errors from 26 medication administration opportunities for a medication error rate of 7.69%. Findings included: 1. On 2/18/20 at 9:07 a.m., Staff A, Registered Nurse (RN), was observed administering medications for Resident #21. Staff A unlocked the medication cart and poured medications for Resident #21, including Carbamazepin 200 mg ER (extended release) capsule . Resident #21 took the pills whole with water. Staff A exited the resident's room and signed the medication sheet. A review of the physician's orders in the medical record for Resident #21 revealed the following: 11/26/18 Carbamazepin cap 200 mg ER on e capsule every night at bedtime-diagnosis: seizures 11/26/18 Carbamazepin tab 100 mg ER on e tablet by mouth in the morning-diagnosis: seizures On 2/18/20 at 1:25 p.m., an interview was conducted with Staff A. The surveyor asked Staff A to retrieve the medication, Carbamazepin, that she had dispensed to Resident #21 that morning. Staff A handed the surveyor the 200 mg Carbamazepin blister pack. There were instructions on the label to give one every night at bedtime. Staff A confirmed she had given 200 mg Carbamazepin that morning. On 2/19/20 at 11:35 a.m., the Consultant Pharmacist stated Tegretol (name brand for Carbamazepin) was an extended release so the resident was getting the same dose, 300 mg in the 24 hour period. The facility did contact the doctor, and the next dose to be given was 100 mg. The consultant pharmacist said the nurse reversed the administration times. She also said, the facility tries to identify the different dosages with highlighting, coloring it differently. On 2/20/20 at 8:46 a.m., the Regional Director of Clinical Services stated they spoke to the physician, and he said that as long as we give the smaller dose of Carbamazepin in the evening there was no ill effect. Review of the policy titled Administering Medications, revised December 2012, revealed the following: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications must be administered in accordance with the orders, including any required timeframe. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 2. On 2/18/20 at 12:02 p.m., Staff B, Licensed Practical Nurse (LPN), was observed administering medications for Resident #199. Staff B performed a blood glucose check with a result of 302. Staff B retrieved Resident #199's Lispro Kwikpen and dialed the device to 20 units. Staff B administered the 20 units of Lispro into the resident's right lower abdomen, without priming the insulin pen prior to administration. A review of the physician's orders in the medical record for Resident #199 revealed the following: 1/30/20 Insulin Lispro Kwikpen Inj (injection) fingerstick blood glucose monitoring QID (4 times a day) before meals and at bedtime. Inject sub-q (subcutaneous) per sliding scale: 301-350=8 units. 1/31/20 Insulin Lispro 12 units 3 times daily AC (before) meals - diagnosis: Diabetes Mellitus On 2/20/20 at 8:46 a.m., the Interim Director of Nursing (DON) stated the facility has the pharmacy consultant do medication pass with the nurses. She agreed, the insulin pen needed to be primed. She reported that when she conducted in-servicing, most of the nurses knew to prime the pen. It was just Staff B who was not aware the pen needed to be primed. Review of the Insulin Lispro Kwikpen's manufacturer's instructions at http://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf revealed: Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8.

Based on observation, interviews, record review, and manufacturer's instructions the facility did not ensure one (#199) of three residents observed during medication administration were free from a significant medication error. Findings included: A review of Resident #199's face sheet revealed a diagnosis of type 2 diabetes mellitus. On 2/18/20 at 12:02 p.m., an observation was conducted with Staff B, Licensed Practical Nurse (LPN), during medication administration for Resident #199. Staff B performed a blood glucose test on Resident #199 with a result of 302. After performing hand hygiene, Staff B reviewed Resident #199's insulin order and removed a Lispro Kwikpen from the medication cart. Staff B prepared her supplies and returned to the resident. Staff B properly cleaned the top of the Kwikpen, attached the needle to the device, and dialed the device to 20 units, without priming the pen. Staff B performed hand hygiene and donned gloves. Staff B used an alcohol prep to clean Resident #199's right lower abdomen with the prep, placed the end of the needle onto the area she had cleaned, and pressed the end of the device to release the insulin. Staff B held it against Resident #199's abdomen for a few seconds. She then released it and removed the needle from the top. Staff B disposed of the needle in the sharps container, removed her gloves, and performed hand hygiene. A review of Resident #199's physician's orders revealed the following: 1/30/20 Insulin Lispro Kwikpen Inj (injection) fingerstick blood glucose monitoring QID (4 times a day) before meals and at bedtime. Inject sub-q (subcutaneous) per sliding scale: 301-350=8 units. 1/31/20 Insulin Lispro 12 units 3 times daily AC (before) meals - diagnosis: Diabetes Mellitus The following instructions were found on the manufacturer's website for Insulin Lispro Kwikpen at http://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf. Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. On 2/19/20 at 11:35 a.m., an interview was conducted with the Consultant Pharmacist related to the failure to prime the Kwikpen prior to administering the insulin. She stated, I don't know if I would consider it a significant med error. It's not significant because of the volume of coverage. If she was only getting 6 units it would be significant. The Pharmacist reported that a consultant nurse comes to the facility, but she wasn't sure if the consultant trains staff on insulin. On 2/20/20 at 8:46 a.m., an interview was conducted with the Regional Director of Clinical Services and the Interim Director of Nursing (DON). The DON said the facility has the pharmacy consultant do medication pass with the nurses. She agreed, the insulin pen needed to be primed. She said that when she conducted in-servicing, most of the nurses knew to prime the pen. It was just Staff B that was not aware the pen needed to be primed.