Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 of 4 residents reviewed for skin conditions, Resident #3. Findings include: During an observation on 10/1/2024 at 9:09 AM, Resident #3 was lying in bed. Resident #3's left arm had bruising and scabbed skin tears. During an interview on 10/1/2024 at 1:20 PM, Staff B, Wound Care Licensed Practical Nurse (LPN), stated, [Resident #3's name] will get skin tears once a week. If she bumps against something her skin will open up and she will have a skin tear. Review of Resident #3's Weekly Skin Check/Nurse dated 9/2/2024 read, Description: Wound to left upper arm. Wound to left knee. Bruising to BUE [Bilateral Upper Extremities] and to BLE [Bilateral Lower Extremities]. Dry scabs to left hand and to bilateral feet/toes. Review of Resident #3's Wound Evaluation dated 9/17/2024 read, Site: Lt [Left] forearm. Type: Skin Tear . Describe Percentage of tissue type present in each wound: epithelial, granulation, slough, eschar. 3a. Wound #1: Epithelialized and resolved. Review of Resident #3's Wound Evaluation dated 9/23/2024 read, Site: Rt [Right] lateral knee. Type: Skin Tear . Describe Percentage of tissue type present in each wound: epithelial, granulation, slough, eschar. 3a. Wound #1: 15% granulation, 85% intact normal skin. Review of Resident #3's care plan did not document a focus for skin integrity. During an interview on 10/2/2024 at 1:50 PM, Staff C, MDS and Care Plan Coordinator, stated, [Resident #3's name] is not care planned for skin integrity and she needs it for potential skin integrity. Review of the facility policy and procedure titled Comprehensive Assessment and Care Plans with the last review date of 8/7/2024 read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS [Centers for Medicare and Medicaid Services] . Guidelines . 8. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c) (2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care according to standard of practice for 1 of 4 residents reviewed for skin condition, Resident #374, and for 1 of 3 residents reviewed for pain management, Resident #116. Findings include: 1) During an observation on 10/1/2024 at 9:46 AM, Resident #374 was sitting at the edge of his bed. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/1/2024 at 9:46 AM, Resident #374 stated, I do not know what happened to my leg. It probably happened while I was sleeping. During an observation on 10/2/2024 at 8:12 AM, Resident #374 was sitting at the edge of his bed with breakfast tray in front of him. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/2/2024 at 8:12 AM, Resident #374 stated, No one has come to change my bandage. During an observation on 10/2/2024 at 1:30 PM with the Director of Nursing (DON), Resident #374 was sitting in his wheelchair in his room. There was a bandage dated 9/27 on his left shin. The DON removed the bandage and observed a small open area on the resident's left shin. Review of Resident #374's physician order dated 9/27/2024 read, Clean area, apply Xeroform and Zinc to skin tear on left shin one time a day for skin tear. During an interview on 10/2/2024 at 1:31 PM, the DON stated, I expect nursing staff to follow the physician orders and do wound care according to those orders. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Procedure . 6. Wound care procedures and treatment should be performed according to physician orders. 2) Review of Resident #116's physician order dated 9/19/2024 read, Oxycodone HCl oral tablet 5 mg [milligram] (oxycodone HCl), Give 2 tablets by mouth every 4 hours as needed for severe 7-10/10) pain, non acute. Review of Resident #116's Medication Administration Record (MAR) for September 2024 for Oxycodone 5 mg showed the resident received the medication on 9/23/2024 at 6:57 AM for pain level of 5, on 9/24/2024 at 2:32 AM and at 6:38 AM for pain level of 5, and on 9/25/2024 at 9:26 AM for pain level of 6. During an interview on 10/2/2024 at 1:33 PM, the DON stated, It was a new nurse, and she was not following physician orders. The medication was given out of parameters. I expect nurses to look at the orders and follow them. Review of the facility policy and procedure titled Medication Administration with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medications by the resident. Review of the facility policy and procedure titled Pain Screening and Management with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to screen residents and attempt to provide effective pain and comfort management. Procedure . 4. Administer pain medications according to physician's orders and resident request for PRN [as needed] medications.

Based on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 1 of 4 residents reviewed for skin conditions, Resident #374. Findings include: During an observation on 10/1/2024 at 9:46 AM, Resident #374 was sitting at the edge of his bed. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an observation on 10/2/2024 at 8:12 AM, Resident #374 was sitting at the edge of his bed with breakfast tray in front of him. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/2/2024 at 8:12 AM, Resident #374 stated, No one has come to change my bandage. During an observation on 10/2/2024 at 1:30 PM with the Director of Nursing (DON), Resident #374 was sitting in his wheelchair in his room. There was a bandage dated 9/27 on his left shin. The DON removed the bandage and observed a small open area on the resident's left shin. Review of Resident #374's physician order dated 9/27/2024 read, Clean area, apply Xeroform and Zinc to skin tear on left shin one time a day for skin tear. Review of Resident #374's Treatment Administration Record (TAR) for September 2024 showed the resident received wound care on his left shin on 9/28/2024, 9/29/2024, and 9/30/2024 at 6:00 PM. Review of Resident #374's TAR for October 2024 showed the resident received wound care on his left shin on 10/1/2024 at 6:00 PM. During an interview on 10/2/2024 at 1:31 PM, the Director of Nursing stated, Nursing were documenting as performing wound care when they had not done the wound care. The documentation was not accurate. Nurses are expected to only sign off on orders when they have done the wound care. I expect nurses to have accurate documentation. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Procedure . 6. Wound care procedures and treatment should be performed according to physician orders . 10. Document in the clinical record when treatments are performed.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing wound care according to the practice standard for 1 of 4 residents reviewed for skin conditions, Resident #76, and failed to ensure staff used appropriate personal protective equipment (PPE) while providing high-contact care for 1 of 6 residents reviewed, Resident #274, to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 10/2/2024 at 1:20 PM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, was inside Resident #274's room adjusting the IV (intravenous) tubing and turning the IV pump off. Staff A did not have gloves or gown on. There was a signage on the resident's room that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. Review of Resident #274's physician order dated 10/2/2024 read, Enhanced barrier precautions related to L [left] arm picc [Peripherally Inserted Central Catheter]. During an interview on 10/3/2024 at 1:02 PM, the Infection Preventionist sated, Staff should have donned a gown when going into the resident room if she was going to be handling the IV tubing. Enhance barrier is a constant battle, we keep educating. During an interview on 10/3/2024 at 1:25 PM, Staff A, LPN, Unit Manager, stated, I should have donned a gown before entering [Resident #274' name] room but the IV pump had been beeping for some time and I went in quickly. 2) During an observation on 10/3/2024 at 11:30 AM, Staff B, Wound Care Licensed Practical Nurse (LPN), performed hand hygiene before entering Resident #76's room. Staff B donned a pair of gloves and removed dressing from Resident #76's buttock area. Without changing her gloves or performing hand hygiene, Staff B cleaned Resident #76's wound. Staff B removed her gloves and donned a glove on her right hand without performing hand hygiene. A therapy staff member knocked and stated she needed to take Resident #76's roommate to therapy and Staff B, with her left hand which did not have a glove, pulled Resident #76's curtain to provide privacy while the therapy staff member removed the roommate from the room. Staff B proceeded to apply hand sanitizer to her left hand and donned the other glove she was holding with her right hand. Staff B applied the treatment and applied the new wound care dressing. Staff B removed her gown and gloves and washed her hands. During an interview on 10/3/2024 at 11:40 AM, Staff B, Wound Care LPN, stated, I did hand hygiene outside by the cart when we were first coming in. I do not like using the hand sanitizer in the room. I like using my own. If I removed my gloves making sure not to touch anything and keep sterility, then I can don a new pair of gloves and do not need to hand sanitize. During an interview on 10/3/2024 at 1:20 PM, the Infection Preventionist sated, Staff should have performed hand hygiene after removing the old dressing and before cleaning the wound. After removing a pair of gloves, staff should preform hand hygiene before donning a new pair of gloves. During an interview on 10/4/2024 at 8:12 AM, the Director of Nursing (DON) stated, While the nurse is dirty, she does not have to remove her gloves. While she is dirty, she is dirty, and while she is clean, she is clean. The staff did not need to change her gloves after removing the old dressing before cleaning the wound because she is in her dirty filed. The staff should sanitize her hands after removing gloves and before donning new pair of gloves. The staff should don gloves and a gown if she will be in contact with the IV tubing of a resident. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 8/7/2024 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 5. Use an alcohol-based hand rub containing 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . g. Before handling clean or soiled dressings, gauze pads, etc. k. After handling used dressing, contaminated equipment, etc. m. After removing gloves. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure . 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact care activities that have been found to increase risk for transmission of multidrug-resident organism. Procedure . 4. For residents for whom EBP are indicated, EBP is employed when performing the following High-contact resident care activities . g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received copies of their medical records in a timely manner for 1 of 3 residents reviewed, Resident #1. Findings include: During an interview on 4/26/2024 at 11:26 AM, Resident #1's Daughter stated, I still have not received the medical records. I requested them in January 2024 and still get excuses. Review of the Durable Power of Attorney signed by Resident #1 on 7/28/2004 showed the resident appointed Resident #1's Daughter as the attorney-in-fact to manage all her affairs. Review of the email communication between Resident #1's Daughter and the Admissions Assistant dated 3/4/2024 read, I am touching base back with you since I had the meeting with the care plan staff on [DATE]. I discussed a few things and asked some questions that I have not gotten a response to yet . 2. Where are the copies of my dad's medical records that I have already requested to you since there has not been a medical records staff person yet? Review of email communication between Resident #1's Daughter and the Director of Nursing dated 3/19/2024 read, I am just checking to find out what is happening with getting the copies of my dad's records to me . I still do not know who is responsible for medical records since I first requested them back in January. Can you get all that together for me soon? During an interview on 4/26/2024 at 10:52 AM, the Administrator stated, I accept responsibility. There was a delay in providing medical record. Once the request is made, we should provide the medical records within 48 hours. When a record is requested, we have to send the request to corporate, and the legal team will review, and we provide the records. During an interview on 4/26/2024 at 11:18 AM, the admission Assistant stated, [Resident #1's name] daughter did request medical records. The request was made probably at the beginning of this year. She requested the record from me personally and I send the request to medical record and forwarded the email to the department she really needed to talk. She asked again about the medical records. I then told her to go to the receptionist desk and get a paper and do a medical records request. I left a note with reception, and she did pick up the medical record request form. I assume she did because she sent an email weeks later wanting an update. I have not heard from her this month. Maybe a couple of months ago that she sent them. Review of the facility policy and procedure titled Resident Identifiable Information/Medical Records issued on 4/1/2022 read, Policy: It is the policy of this facility to maintain a medical record for each resident in accordance with applicable federal and state guidelines. Procedure . 3. Medical Records on each resident will be accurately documented; readily accessible; and systematically organized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 3 of 7 residents, Residents #12, #80, and #113, reviewed for respiratory services Findings include: 1) Review of Resident #12 medical record documented the resident was re-admitted into the facility on 5/12/2023 with diagnosis to include pneumonia, emphysema, chronic obstructive pulmonary disease, respiratory failure, diabetes, abnormal finding of lung field, hypertension, anemia. During an observation on 6/4/2023 at 11:33 AM Resident #12 was being administered oxygen via nasal cannula at 2 liters per minute. During an interview on 6/4/2023 at 11:33 AM Resident #12 stated, My oxygen is set at 3. During an observation on 6/5/23 at 11:59 AM Resident #12 was sitting in a wheelchair. Oxygen was being administered at 3 liters per minute via nasal cannula. Review of Resident #12's physician's orders did not document an order for oxygen. During an interview on 6/5/2023 at 1:48 PM Staff A, RN (Registered Nurse) stated, There are no oxygen orders for the resident [Resident #12] the oxygen order was discontinued on 5/11/2023. 2) Review of Resident #80's medical record documented the resident was admitted into the facility on 8/8/2022 with diagnosis to include hemiplegia and hemiparesis (paralysis) left non dominant side, dysphasia (difficulty swallowing), chronic obstructive pulmonary disease (difficulty breathing), respiratory failure, and acute congestive heart failure. Review of the physician order dated 10/18/2022 for Resident #80 read, Change oxygen tubing weekly and PRN [as needed] ensure to label date and time. During an observation on 6/4/2023 at 9:48 AM Resident #80 was lying in bed. Oxygen was being administered at 2 liters per minute via nasal cannula, the tubing was not labeled with the date and time. During an observation on 6/5/2023 at 8:37 AM Resident #80 was being administered oxygen at 2 liters per minute via nasal cannula. The oxygen tubing was not labeled with the date and time. 3) Review of Resident #113's medical record documented the resident was admitted on [DATE] with diagnosis to include pain syndrome, chronic obstructive pulmonary disease, heart failure, sleep apnea, morbid obesity, muscle weakness, and hypertension. Review of the physician's order dated 3/16/2024 for Resident #113 read, Change oxygen tubing weekly and PRN every night shift every Thursday. During an observation on 6/4/2023 at 10:40 AM of Resident #113 the oxygen concentrator at the bedside was administering oxygen at 2 liters per minute and was being humidified with water to Resident #113 via nasal cannula. The nasal cannula tubing and the water utilized for humidification was not labeled or dated of when the tubing was changed. During an observation on 6/5/2023 at 12:22 PM Resident #113's oxygen tubing and water utilized for humidification was not labeled or dated. During an interview on 6/5/2023 at 1:15 PM Staff C, Licensed Practical Nurse stated, [Resident #113's name] oxygen tubing is not dated. During an interview on 6/5/2023 at 1:22 PM Staff D, Medical Record stated, They are supposed to be changed [oxygen tubing] and dated on night shift. During an interview on 6/5/2023 at 02:30 PM the Director of Nursing stated, It is my expectation that physician orders are followed, oxygen tubing is changed out on Thursday nights or as needed and is dated. During an interview on 6/6/2023 at 10:22 AM the Assistant Director of Nursing/Infection Preventionist stated, It is my expectation that oxygen tubing is changed out on Thursday nights and are dated at that time. Review of the policy and procedure titled, Oxygen Administration issued 4/1/2022 read, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff but is only required to have tubing dated appropriately demonstrating that the tubing was changed.

Based on observation and interview, the facility failed to store medications under proper temperature for 1 of 4 medication carts. Findings include: During an observation on 6/6/23 at 3:15 p.m. of the medication cart for the 300 Hall, a bag of intravenous bag of Vancomycin 1.75 GM/500 ML D5W [1.75 grams/500 milliliters dextrose 5% water] dated 6/4/23. a use by date of 6/13/23, labeled for Resident #44 was located in the bottom drawer of the medication cart. The solution was at room temperature. There was no condensation on the bag. There was no indication the bag had been refrigerated. There was no date or time on the bag indicating when the bag was removed from the refrigerator. During an interview on 6/6/23 at 3:15 p.m. Staff F stated, I gave the 8:00 a.m. dose of Vancomycin. I don't know where this bag came from. I had not noticed it in the cart until just now. Vancomycin must be refrigerated. I did not take that bag out. I don't know how long it has been in the cart. During an interview on 6/7/23 at 8:17 a.m. the Consultant Pharmacist stated, Vancomycin is always refrigerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent the possible spread of infection for 1 of 3 residents reviewed, Resident #1. Findings include: During an observation conducted on 06/04/23 at 11:10 AM, Resident #1's catheter bag was lying on the floor next to the bed without a protective barrier between it and the floor. Review of Resident #1's clinical record documented Resident #1 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis of vertebra, sacral and sacrococcygeal, sepsis, pulmonary embolism, type II diabetes mellitus, protein calorie malnutrition, and neuromuscular dysfunction of bladder. Review of Resident #1's physician orders dated 6/5/23 read, insert/maintain indwelling catheter (14 French), change indwelling catheter for leakage or blockage as needed, catheter care every shift and as needed for soiling or leakage. Review of Resident #1's care plan dated 4/24/23 read, Focus: Resident has a urinary catheter with interventions including resident has a urinary catheter in place and needs the following care: keep the drainage bag below bladder level, cover the bag for dignity, give catheter care as ordered . During an interview conducted on 06/04/23 at 11:13 AM Staff N, Licensed Practical Nurse, confirmed Resident #1's catheter bag was on the floor with no barrier between it and the floor and stated, that should not be on the floor. Review of the policy and procedure (P & P) titled, P & P Indwelling Catheters, dated 4/1/22 read, Policy: It will be the policy of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's [sic] that have the indication for use beyond 14 days. Procedure: 8. Staff will provide daily catheter care or as ordered by the physician and or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure residents were provided treatments, wound care, and services in accordance with professional standards of practice and physician orders for 4 of 8 residents, Residents #18, #274, #80, and #113. Findings include: 1) Review of Resident #18's medical record documented the resident was admitted on [DATE] with medical diagnosis to include lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), congestive heart failure (heart does not pump well), respiratory failure (difficult to breath), diabetes mellitus, chronic kidney disease, abnormalities of gait and mobility, and atrial fibrillation (irregular heartbeat). Review of the physician order dated 4/13/2023 for Resident #18's documented, Apply ace wrap to bilateral lower extremity every day shift for chronic edema. Review of Resident #18's care plan dated 3/30/2023 read, Focus: Potential for complications r/t [related to] an alteration in cardiac function. Interventions: Apply ace wraps to bilateral lower ext [extremities] in am [morning] and remove at bedtime. Review of Resident #18's Treatment Administration Record (TAR) for June 2 and 5 did not document wound care was provided. During an observation on 6/4/2023 at 11:19 Resident #18 was resting in bed, there were no ace wraps noted on the lower legs. During an interview conducted on 6/4/2023 at 11:19 AM, Resident #18 stated she never receives ace wraps on her legs. During an observation on 6/5/2023 at 9:54 AM Resident #18 was sitting in a wheelchair in the common living area. No ace wraps were noted on her lower legs. During an observation on 6/5/2023 at 12:01 PM Resident #18 was sitting in a wheelchair beside her bed. There were no ace wraps noted on her lower legs. During an interview conducted on 6/5/2023 at 1:58 PM Staff A, Registered Nurse (RN) verified Resident #18's order for ace wraps to the bilateral lower legs. Staff A, RN stated, I do not remember her ever having ace wraps on her legs, but I will check. During an interview conducted on 6/5/2023 at 2:30 PM the Director of Nursing (DON), stated, The Resident [Resident #18] needs the ace wraps on and the orders need to be followed. 2) Review Resident #274's medical record documented the resident was admitted on [DATE] with medical diagnosis to include nontraumatic ischemic infraction of muscle of the left lower leg, methicillin staph aureus infection, local infection of the skin inside the Canadian tissue (a study first in Canada to characterize the incidence of skin and soft tissue infections), unspecified open wound of the left lower leg, peripheral vascular disease, and type 2 diabetes. Review of the physician order dated 6/1/2023 for Resident #274 documented, Cleanse left Achilles with ns [normal saline] apply sorbact gauze and cover with bordered drsg [dressing] Tuesdays and Fridays and prn [as needed] for Sx [signs and symptoms] wound. Cleanse left and right shin with ns [normal saline] apply Medi honey cover with bordered drsg [dressing] daily and prn [as needed] every day shift for Trauma. During an observation on 6/4/2023 at 10:10 AM Resident #274's left and right legs were wrapped in gauze and dated 5/31/2023, a Wednesday. (Photographic evidence obtained) During an interview on 6/4/2023 at 10:10 AM Resident #274 stated, They have not changed my dressing. During an observation on 6/5/2023 at 1:25 PM Resident #274's left, and right legs were wrapped in gauze dressings dated 5/31/2023. During an interview conducted on 6/5/2023 at 1:25 PM Resident #274 stated, The dressing changes have not been done. During an interview on 6/5/2023 at 1:45 PM Staff C, LPN (Licensed Practical Nurse) stated, The dressing has not been changed since 5/31/2023. During an interview on 6/5/2023 at 2:31 PM the DON stated, The dressing changes for [Resident #274's name] were not done and should not have been charted that they had been completed. 3) Review of Resident #80's medical record documented the resident was admitted [DATE] with medical diagnosis to include hemiplegia and hemiparesis (paralysis) left non dominant side, dysphasia (difficulty swallowing), chronic obstructive pulmonary disease (difficulty breathing), respiratory failure , acute congestive heart failure, cognitive social or emotional deficiency following cerebral infraction, muscle weakness, weakness, unspecified protein calorie malnutrition, major depressive disorder, hypothyroidism, gastric esophageal reflux disease. Review of the physician order dated 8/9/2022 for Resident #80 documented Multi podus boots while in bed every shift. Review of TAR for Resident #80 did not document the multi podus boots while in bed every shift was conducted on June 5, 2023. During an observation on 6/4/2023 at 9:48 AM Resident #80 was lying in bed and podus boots were not on the resident's feet. During an interview on 6/4/2023 at 9:48 AM Resident #80 stated, I don't have boots on my feet. During an observation on 6/5/2023 at 8:37 AM Resident #80 was lying in bed and podus boots were not on the resident's feet. During an observation on 6/5/2023 at 1:44 PM Resident #80 was lying in bed and podus boots were not on the resident's feet. During an interview on 6/5/2023 at 1:46 PM Staff S, RN stated, I don't remember [Resident #80's name] ever having boots on. They could be in laundry services. During an interview on 6/5/2023 at 2:31 PM the DON stated, The multi podus boots should be on resident when she is in the bed. Even if they were sent to the laundry they come back by the next day. 4) Review of Resident #113's medical record documented the resident was admitted [DATE] with medical diagnosis to include pain syndrome, COPD (chronic obstructive pulmonary disease), heart failure, hyperlipidemia, sleep apnea, morbid obesity, muscle weakness, unspecified abnormalities of gait and mobility, and hypertension. Review of the physician order dated 5/9/2023 for Resident #113 documented, Compression stockings in the morning on during the day off at night. During an observation on 6/4/2023 at 10:40 AM Resident #113 was sitting in a recliner with her legs prompted up; there were no compression stockings on her legs. During an observation on 6/5/2023 at 12:22 AM Resident #113 was sitting in a recliner at bed side with her feet prompted up. Compression stockings were not on the resident's legs. During an interview on 6/5/2023 at 12:22 AM Resident stated I never wear the compression socks they are in the cabinet, but no one assists me to put them on. I can't reach down there and do it myself. I've not had my compression stockings on. During an interview conducted on 6/5/2023 at 1:15 PM Staff C, LPN, confirmed Resident #113 was not wearing compression stockings and should be. During an interview on 6/5/2023 at 2:30 PM the DON stated, The resident needs her compression stocking on. Review of the policy and procedure titled, Wound Care issued 4/1/2022 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. 6.Wound care procedures and treatments should be performed according to physician orders. 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. 8. Preventative measures such as barrier creams, can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots and use of positioning devices.

Based on observations, interviews, and policy review, the facility failed to ensure stored food is labeled and dated, thawed according to professional standards, and that food is distributed in a safe manner. Findings Include: During a walk-through tour of the kitchen on 6/04/23 at 09:16 AM with the morning cook, an observation was made in the walk-in cooler in the kitchen of a large pan of what appeared to be diced chicken; the food item was not labeled identifying the content or dated and a quart size container with what appeared to be gravy or sauce that was not labeled identifying the contents or dated. An interview was conducted with the morning cook on 6/04/2023 at 9:20 AM. The cook stated, That is a large pan of chicken, and the quart container was breakfast gravy, and both items should have had a label and date. An observation was made on 6/04/23 at 9:25 AM of four 5# (pound) rolls of raw ground beef being thawed in a prep sink of 12 of standing water. An interview was conducted with the Dietary Manager (DM) on 06/04/2023 at 10:00 AM regarding thawing of frozen foods. The DM stated, Foods should always be thawed under running water. Review of a document provided, with no date, titled Food Preparation read, 5. The Dining Services Director/Cook(s) is responsible to ensure that proper practice is utilized in thawing frozen foods. Completely submerged under cold water that is running fast enough to agitate and float off loose ice particles. An observation of the food carts being transported to seven various hallways for delivery was conducted on 6/04/23 at 12:30 PM. Observations of the tray delivery showed food trays included pork loin, seasoned potatoes, buttered zucchini, roll, and a dessert of a piece of chocolate cream pie. An observation was made of the food trays being removed from the food cart located at one end of each hallway, drinks being added from a drink cart and then being transported by a staff member down the hall and delivered to the resident rooms. An observation was made of the trays without any covering or lid on the dessert on all the room trays that were being delivered throughout the entire length of each hallway. An interview was conducted with the DM on 06/04/2023 regarding covering food items during transport. The DM confirmed all drinks and food should be covered during transporting to the residents' rooms and not be delivered uncovered in the hallways. Review of a document provided, dated October 2019, and titled Meal Distribution read, 3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered.

Based on record review and interview, the facility failed to ensure residents' medical records were complete and accurately documented for 7 of 12 residents, Residents #44, #54, #18, #274, #80, #85, and #113. Findings Include: 1) Review of the Health Status Note dated 5/16/23 at 11:09 PM [eINTERACT form] for Resident #54 read, At approximately 2200 [10:00 PM] this writer was notified by the CNA [Certified Nursing Assistant] that resident was not responding. On arrival to the residents room resident was noted laying on the bed with eyes closed and mouth breathing. Resident was not wearing her O2 [oxygen] as ordered. Pulse ox noted to be 76. B/P [blood pressure] noted to be 179/78 with HR [heart rate] at 104. Or [sic] at 5L [liters] via non-rebreather mask was applied O2 noted to increase to 91%. Resident remained unresponsive. Accu check was performed and noted to be 25. Glucagon injection administered and 911 called. Resident transported to [Hospital's name] for further eval. Review of Resident #54's Nursing Home to Hospital Transfer Form dated 5/16/2023 at 11:17 PM read, Key Clinical Information. Reason(s) for transfer: Other -- planned surgery. During an interview on 6/5/23 at 3:50 p.m., the Director of Nursing (DON) stated, The eINTERACT form was not filled out correctly on the 16th. The form populates information from previous forms, and it looks like that information is from a previous form. This was not a planned hospitalization. I would expect the nurse completing the form, to provide the correct information on the form prior to transfer. 2) Review of the physician's order for Resident #44 dated 5/30/23 read, Anasept Antimicrobial External Gel 0.057%. Apply to buttocks and sacrum topically every day shift for wound. Review of the Treatment Administration Record (TAR) for Resident #44 did not document wound care on 6/3/23 or 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Anasept Antimicrobial External Gel 0.057%. Apply to coccyx R & L [right and left] buttocks topically every day shift for wound. Review of TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/22/23, 5/24/23, 5/26/23, and 5/29/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse coccyx wound with ns [normal saline], skin prep periwound, apply moistened gauze with Anasept gel cover with bordered drsg [dressing] daily and prn [as needed] every day for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse left buttock wound with ns, skin prep periwound, apply moistened gauze with Anasept gel cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse left lat [lateral] foot wound with ns, skin prep periwound apply medihoney on ca [calcium] alaginate, cover with bordered drsg daily, and prn every day for wound. Review of the TAR Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right buttock wound with ns skin prep periwound, apply moistened gauze with Anasept gel cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right heel wound with ns, skin prep periwound, apply medihoney on ca alginate cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right inner thigh wound with ns, skin prep periwound, apply medihoney on ca alginate cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right lat calf wound with ns, skin prep periwound apply medihoney on ca alginate cover with bordered drsg daily and prn every day for wound care. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right lat foot wound with ns, skin prep periwound apply medihoney on ca alginate cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. 3) Review of the physician's order for Resident #18 dated 4/13/2023 documented, Apply ace wrap to bilateral lower extremity every day shift for chronic edema. Dated 4/13/2023, Cleanse wound with wound cleanser, pat dry, apply calcium alginate, and cover with dry dressing every day shift. Review of Resident #18's TAR did not document wound care on 4/7/23, 4/9/23, 4/13/23, 4/14/23, 4/16/23, 5/3/23, 5/10/23, 5/17/23, 5/19/23, 5/23/23, 5/27/23, 6/2/23 and 6/5/23. 4) Review of the physician's order dated 6/1/2023 for Resident #274 documented, Cleanse left Achilles with ns, apply sorbact gauze and cover with bordered drsg Tuesdays and Fridays and prn as needed for Sx [signs and symptoms] wound. Cleanse left and right shin with ns apply Medi honey cover with bordered drsg daily and prn every day shift for trauma. Cleanse left heel wound with ns, apply medi honey on calcium alginate cover with bordered drsg daily and prn as needed for wound. Review of Resident #274's TAR did not document wound care for the left Achilles on 5/19/23, 5/23/23, and 5/27/2023 and did not document wound care to the left heel and left shin wounds on 5/18/23, 5/19/23, 5/20/23, 5/21/23, 5/22/23, 5/23/23, 5/24/23, 5/25/23, 5/26/23, and 6/2/23. 5) Review of the physician's order dated 4/21/2023 for Resident #85 documented, Nystatin triamcinolone cream 100000-0.1 unit gram %, apply to left palm topically two times a day for dermatitis for 14 days start. Dated 5/24/2023 Eucerin Eczema Relief External Cream 2% colloidal oatmeal, apply to left palm topically three times a day for eczema for 30 days. Review of the TAR for Resident #85 did not document wound care of the Nystatin triamcinolone cream on 4/24/23, 4/25/23, 4/28/23, 4/29/23, 4/30/23, 5/1/23 and 5/2/23 at 5:00 PM, and on 4/29/23 at 9:00 AM. Review of the TAR did not document wound care of Eucerin Eczema Relief External Cream 2% colloidal oatmeal on 5/27/23 at 9:00 AM, 1:00 PM, and 9:00 PM, and on 6/2/23 at 9:00 PM. 6) Review of the physician's order for Resident #80 dated 8/9/2022 read, Multi podus boots while in bed every shift. Review of the TAR for Resident #80 did not document care and treatment for the multi use podus boots on 4/2/23, 4/8/23, 4/14/23, 4/28/23 night shift, 4/8/23, 4/15/23, 4/27/23 day shift, 4/23/23 evening shift, 5/3/23, 5/11/23, 5/16/23, 5/27/23, 5/31/23, 6/2/23, 6/5/23, 6/6/23 day shift, 6/5/23, and 6/6/23 evening shift. 7) Review of the physician's order for Resident #113 dated 5/9/2023 read, Compression stockings in the morning on during the day off at night. Review of the TAR for Resident #113 did not document care and treatment for compression stockings on 5/20/23, 5/25/23, 5/27/23 and 6/1/23. During an interview on 6/6/23 at 9:45 a. m. Staff J, LPN Wound Care Nurse stated, If it was a weekend or holiday, I may not have been here to do it. We know if it wasn't documented, it isn't done. But, when I come back on Mondays or after being gone, the dressings have been changed. The dressings were always labeled and I'm sure they were done because I check the date on the actual dressing. It is a documentation problem. The care was given. There is a way for them to chart it even if it is done later. But they didn't do that. Maybe they got busy, but it wasn't charted. Review of policy and procedure titled, P & P Charting and Documentation dated 4/1/22 read, Policy: It is the policy of this facility that services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as needed. Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #69's records revealed the resident was admitted on [DATE] with diagnoses to include chronic kidney disease, cellulitis of right lower limb, diabetes mellitus, severe protein calorie malnutrition, congestive heart failure, lymphedema, and dementia. During an interview on 1/18/2022 at 9:34 AM, Resident #69 stated, The swelling in my legs gets worse during the day and this has been occurring for a long time. My legs get a dressing sometimes by the nurses. On 1/18/2022 at 9:34 AM, both legs of Resident #69 were observed to be swollen and red. The left leg had oozing of clear fluid on the resident's skin, with no dressing covering the leg. On 1/19/2022 at 8:34 AM, both legs of Resident #69 were observed to be red and swollen, and the lower left leg had oozing clear fluids, with no dressing on the leg. Review of the physician orders dated 12/1/2021 read, LLE [Left Lower Extremity): Cleanse skin tear with NSS/ wound cleanser, apply Bactroban ointment to wound bed, wrap bilateral lower extremities with unna boots from knee-to-toes, cover with tubigrip twice weekly and additionally as needed. During an interview on 1/20/2022 at 2:59 PM, Staff G, LPN, stated that Resident #69's dressings were changed daily if she could find the time to do them. She verified that the dressing was not on the resident. During an interview on 1/21/2022 at 11:14 AM, the DON stated that nursing staff on the assigned units should complete the wound care as ordered. Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care for wounds in accordance with professional standards of practice for 2 of 4 residents reviewed for skin conditions, Residents #69 and #113, in a total sample of 54 residents. Findings: 1. Review of Resident #113's records revealed the resident was admitted on [DATE] with diagnoses to include left hip fracture, diabetes mellitus and hypertension (high blood pressure). During an interview on 1/19/2022 at 10:00 AM, Resident #113 stated, I haven't had my dressing changed since I saw the wound care doctor the other day. On 1/19/2022 at 10:10 AM, observation of Resident #113's coccyx dressing showed a large pink border dressing on the resident's coccyx with the outer edges curling up from the skin and a large amount of serous drainage noted on the dressing. The dressing was not dated. Review of the PRN (as needed) skin check dated 12/28/2021 read, Site 31: Right buttock abrasion, redness, skin tear, no infection. Review of Wound Evaluation dated 12/28/2021 read, Wound Description. Site: 32) Left buttock. Type: Skin Tear. Length: N/A [Not Applicable]. Width: N/A, Depth: N/A. Stage: II [A partial thickness loss of skin on the buttocks]. Review of [NAME] Initial Wound Evaluation and Management Summary dated 1/14/2022 read, Focused Wound Exam (Site 1): Stage 2 Pressure Wound Sacrum Partial Thickness. Wound size (L [Length] x W [Width] x D [Depth]): 6 x 3 x 0.1 cm [centimeters]. Dressing Treatment Plan: Primary Dressing(s). Foam silicon bdr and faced apply three times per week for 30 days. Review of the physician orders found no orders for wound care entered on 1/14/2022 when the wound care consult was completed. Review of the physician orders dated 1/18/2022 read, Order Summary: Clean left buttocks with NSS [Normal Saline Solution], pat dry. Cover with dry dressing once daily; as needed until wound consult. Review of Treatment Administration Record revealed no dressing changes documented from 12/28/2021 through 1/20/2022. During an interview on 1/20/2022 at 10:15 AM, Staff H, Licensed Practical Nurse (LPN) stated, I really don't know what his dressing orders are. I know he has a wound on his coccyx. I don't know when the wound care doctor saw him. We should do dressings as they are ordered by the doctor. There is no date on his dressing. I would have to look up when it was changed. During an interview on 1/21/2022 at 9:10 AM, the DON stated, I expect staff to complete physician orders for care for wounds. It looks like the wound dressing wasn't done. I'm not sure why the wound care order didn't get ordered. It is a standard to complete doctor's orders and follow recommendations. During an interview on 1/21/2022 at 10:50 AM, the Medical Doctor (MD) stated, I did recommend dressing changes when I completed his initial consult on 1/14/2022. I made wound care recommendations on that day, and I was not aware that they were not followed. I expect that when I make recommendations for wound care, they are followed. I assessed his wound today and feel that he may have an underlying infectious process brewing. His wound has deteriorated to unstageable from a stage 2 when I saw it on the 14th. I have added antibiotics and Bactroban ointment to his wound care and increased his dressing changes to twice a day. I was not aware that he was not getting his dressing changed according to my recommendations. I have added an air mattress also. Review of the facility policy and procedure titled Wound Care, with an approval date of 1/6/2022, read, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care received such care consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care, Resident #63, in a total sample of 54 residents. Findings: Review of Resident #63's records revealed the resident was admitted with diagnoses to include rhabdomyolysis (breakdown of skeletal muscle), history of pulmonary embolism (a blood clot in the lung), asthma, and bell's palsy (weakness or paralysis of the muscles in the face). During an observation on 1/18/2022 at 11:00 AM, Resident #63's respiratory pattern and speech were labored, and the resident required breathing periods between words. An oxygen concentrator was sitting in the corner of the room, not in use. An oxygen tank was sitting on the floor at the end of the resident's bed. The oxygen tank regulator read empty and was not in use. During an interview on 1/18/2022 at 11:00 AM, Resident #63 stated, I was given an oxygen concentrator that began to make noise and not work properly, so it was turned off and I was given an oxygen tank. The oxygen tank is empty, and the staff have not brought me a new one yet. I have told the nurse, when she brings my medications, and the aides, when they come in, that the oxygen tank is empty. I am supposed to always have oxygen but have not had it for two days. I get very short of breath when I try to move around too much. Review of Resident #63's physician orders dated 7/1/2021 read, Oxygen at two liters/minute via NC [Nasal Canula] every shift. On 1/18/2022 at 12:50 PM, Resident #63 was observed sitting up in bed with no oxygen in use. An oxygen concentrator was sitting in the corner of her room, not in use. An oxygen tank was sitting on the floor at the foot of the bed, with the oxygen regulator reading empty. During an interview on 1/18/2022 at 12:50 PM, Staff A, Licensed Practical Nurse (LPN), stated Resident #63 had an order for continuous oxygen, and the resident should have oxygen always running at two liters/minute via nasal cannula. Staff A verified the resident was not currently receiving oxygen. Staff A stated, [Resident #63's name] told me that the oxygen concentrator provided to her does not work and her oxygen tank is empty. I don't know how long she has gone without oxygen. During an interview on 1/18/2022 at 1:05 PM, the Director of Nursing (DON) stated it was her expectation that the nursing staff would follow all physician orders. She further stated if a resident was ordered to receive oxygen by her physician, that resident should receive the oxygen as ordered. Review of the facility policy and procedure titled, Oxygen Administration, with an approval date of 1/6/2022 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, and included the expiration date when applicable, in 6 of 7 medication carts. Findings: On 1/18/2022 at 9:05 AM, the surveyor observed Medication Cart #1 with Staff A, Licensed Practical Nurse (LPN), and found one opened bottle of Humalog insulin with an opened date of 11/29/2021, one opened bottle of Levemir insulin with an opened date of 11/29/2021, one opened Levemir insulin pen with no opened or expiration dates, one opened Aspart insulin pen with an opened date of 12/13/2021, one opened Levemir pen with an opened date of 12/2/2021, one opened Lantus insulin with an opened date of 12/5/2021, one opened Lantus insulin with an opened date of 12/10/2021, four opened Basaglar insulin pens with no opened or expiration dates, one opened Lantus insulin pen with no opened or expiration dates, one opened bottle of Polymyxin-trimethoprim eye drops with no opened or expiration dates, one opened Admelog Insulin pen with no opened or expiration dates, one opened bottle of Tobramycin eye drops with no opened or expiration dates, and two opened bottles of artificial tears with no opened or expiration dates. During an interview on 1/18/2022 at 9:15 AM, Staff A, LPN, stated, Insulin is only good for 30 days and the insulins are expired and should not be on the cart. All eye drops and insulin should be labeled with the date they are opened and date they expire, and these are not labeled at all. On 1/18/2022 at 9:20 AM, the surveyor observed Medication Cart #2 with Staff B, LPN, and found two opened Lantus insulins with no opened or expiration dates, one Novolog insulin with an opened date of 12/8/2021 and an expiration date of 1/7/2022, one opened Glargine insulin with no opened or expiration dates, one opened Aspart insulin with no opened or expiration dates, one opened Humalog insulin with no opened or expiration dates, one opened bottle of Latanoprost eye drops with an opened date of 12/9/2021 and pharmacy instructions to discard 42 days after opening, three opened bottles of Brimonidine eye drops with no opened or expiration dates, and one bottle of Dorzolamide 2% eye drops with an opened date of 9/4/2021. During an interview on 1/18/2022 at 9:30 AM, Staff B, LPN, stated, These insulins and eye drops are expired. Insulin is only good for 30 days and the eye drops are expired. All eye drops and insulin should have a label when they are opened or when they expire. I don't know why these expired medications are in the cart. On 1/18/2022 at 9:35 AM, the surveyor observed Medication Cart #3 with Staff F, LPN, and found three opened Aspart insulin pens with no opened or expiration dates, one opened Victoza pen with no opened or expiration dates, two opened Glargine insulin pens with no opened or expiration dates, one open Humulin R insulin with no opened or expiration dates, one opened Humulin N insulin with no opened or expiration dates, one opened bottle of Dorzolamide/Timolol eye drops with an opened date of 12/13/2021 and pharmacy instructions to discard 28 days after opening, one opened bottle of Moxifloxacin eye drops with no opened or expiration dates, one opened bottle of Brimonidine eye drops with an opened date of 12/13/2021 and pharmacy instructions to discard after 28 days, and one opened bottle of Latanoprost eye drops with no opened or expiration dates. During an interview on 1/18/2022 at 9:45 AM, Staff F, LPN, stated, These insulins and eye drops should be labeled when they are opened and when they expire, and they aren't. Most insulin is only good for one month and eye drops should have been reordered when they expired. Both of the eye drops that are labeled have expired and shouldn't be on the cart. On 1/18/2022 at 9:50 AM, the surveyor observed Medication Cart #4 with Staff E, LPN, and found two opened bottles of Artificial tears with no resident identifiers and no opened or expiration dates, two opened bottles of Latanoprost eye drops with no opened or expiration dates, one opened bottle of Dorzolamide eye drops with an opened date of 12/3/2021 and pharmacy instructions to discard after 28 days, one opened bottle of Dorzolamide eye drops with no opened or expiration dates, two opened bottles of Brimonidine eye drops with no opened or expiration dates, one opened bottle of Polymyxin trimethoprim eye drops with no opened or expiration dates, one opened bottle of Lantus insulin with an opened date of 12/20/2021 and pharmacy instructions to discard after 28 days, one opened Glargine insulin pen with no opened or expiration dates, one Humalog insulin pen with no opened or expiration dates, one opened bottle of NovoLog insulin with an opened date of 11/22/2021, one Levemir insulin with an opened date of 11/21/2021, one opened Humulin R insulin with an opened date of 12/3/2021 and pharmacy instructions to discard after 28 days, one opened Humulin R insulin with no opened or expiration dates, one Lantus insulin pen with no opened or expiration dates, and one opened Levemir insulin pen with an opened date of 12/2/2021 and pharmacy instructions to discard after 42 days. During an interview on 1/18/2022 at 10:00 AM, Staff E, LPN, stated, Insulin is only good for 28 or 42 days and should be labeled when it is opened and discarded and reordered when needed. All insulin and eye drops should be labeled when they are opened. I'm not sure how long eye drops are good for. On 1/18/2022 at 10:05 AM, the surveyor observed Medication Cart #5 with Staff C, LPN, and found two opened bottles of Latanoprost eye drops with no opened or expiration dates, and one opened Lantus pen with no opened or expiration dates. During an interview on 1/18/2022 at 10:10 AM, Staff C, LPN, stated, All insulin and eye drops should be dated when they are opened, and these are not. On 1/18/2022 at 10:15 AM, the surveyor observed Medication Cart #6 with Staff D, LPN, and found two Basalagar insulin pens with no opened or expiration dates, one Novolog insulin with an opened date of 12/10/2021, one Novolog insulin with an opened date of 12/16/2021, one Admelog insulin with an opened date of 12/19/2021, and one opened bottle of Pred Forte eye drops with an expiration date of 12/4/2021 on the packaging. During an interview on 1/18/2022 at 10:20 AM, Staff D, LPN, stated, I'm not sure why they didn't label the insulins. All the insulins are expired and should be thrown out. All insulin and eye drops should have the dates on them. Review of the facility policy and procedure titled, Storage of Medication, with an approval date of 1/6/2022 read, Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 5. Discontinued, outdated, or deteriorated drugs and biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure food was stored, distributed and served in accordance with professional standards for food service. Findings: 1. During the initial tour of the kitchen on 1/18/2022 beginning at 9:20 AM, an observation of the walk-in freezer showed an opened and unlabeled bag of English style battered cod exposed to the air sitting in a box on a shelf, an opened and unlabeled bag of frozen meat on an open wire shelf, and an opened and unlabeled box of frozen hash brown patties exposed to the air. During an interview on 1/18/2022 at 9:35 AM, the Kitchen Manager stated the frozen fish bag should have been sealed, the hash brown patties should have been closed in a bag, and both in addition to the bag of frozen meat should have been labeled with identification of product and an opened date. Review of the facility policy and procedure titled, Food Storage: Cold, dated October 2019 and reviewed on 1/6/2022, read, Policy Statement: It is the center policy to insure all Time/ Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code . Action Steps . 5. The Dining Services Director/ [NAME] insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. 2. On 1/18/2022 at 1:01 PM, an observation of the meal trays being distributed on the 500 Hall showed the cornbread portions on trays in the cart were uncovered. The trays were being removed from the cart and carried down the hall to the resident rooms (Photographic evidence obtained). During an interview on 1/18/2022 at 1:06 PM, the Kitchen Manager stated that all food items should be covered when being delivered to the resident rooms. Review of the facility policy and procedure titled, Meal Distribution, dated October 2019 and reviewed on 1/6/2022 read, Policy Statement: It is the center policy that meals are transported to the dining locations in a manner that insures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner . Action Steps . 3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered.