Based on interview and record review, the facility failed to make prompt efforts to resolve a grievance for one (Resident #77) of one resident reviewed for personal property (missing clothing) from a total sample of 53 residents. The findings include: On 02/13/24 at 12:54 pm, Resident #77 stated he lost his pants on two different occasions. He could not remember the exact dates, but stated it was around August 2023 and December 2023. He added that he notified the certified nursing assistant (CNA), but he could not recall the employee's name. He also notified the housekeeping director. Per the resident, the facility had not done anything about it. He stated at one time he even provided the receipt when he bought replacement pants, but the facility never reimbursed him. He stated he had already lost the new pants that he bought despite putting his name on them. He was frustrated because he liked a particular brand of pants. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/11/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact. A review of the facility's Grievance Log from August 2023 through February 2024 revealed that there were no grievances documented for Resident #77. In an interview on 02/14/24 at 10:59 am, the Housekeeping Supervisor stated when residents were admitted to the facility she introduced herself within 24 hours. If the resident chose to have their laundry done by the facility, she took the clothing to the laundry for labeling. She added that she also encouraged residents who wanted family to do their laundry to have their clothing labeled in case the clothing was inadvertently sent to the laundry. When asked how residents' clothing was sent to the laundry, she said, Residents' clothes are sent to the laundry with the linen. When it gets to the laundry, it is sorted and washed separately. Normally residents have their clothes back within 24 hours. She was asked to explain the process if she was notified that a resident had missing clothing items. She stated she checked the lost and found, and if the items could not be located, the resident was asked for the clothing receipt and social services took over from there for reimbursement of the lost items. She was asked if she was aware that Resident #77 had missing pants. She confirmed that the facility did this resident's laundry. She stated the resident reported his missing pants but she could not find them. She added that she reported this to the Social Services Director and the resident provided the receipt, but she was not sure if the resident was reimbursed. On 02/14/24 at 11:32 am, an interview was conducted with the Assistant Administrator. She stated she was stepping in for the Social Sservices Director who was on leave. She was asked to explain the facility's process for residents' personal items that went missing. She stated if the laundry department could not locate the missing items, the resident was asked to provide the receipts for reimbursement. She was asked if Resident #77 had a grievance related to missing clothing items, and she replied, I am not sure but I will check. For the grievance I am aware of, I think the daughter was reimbursed. On 02/14/24 at 3:06 pm, the Assistant Administrator stated she checked the facility's records and she could not find a formal grievance filed for Resident #77. She stated she contacted the daughter, who mentioned that she had replaced the pants and she provided the receipts. When asked to describe the grievance process, the Assistant Administrator stated the person who received the grievance should write it down, then pass the grievance to the Social Services. Social Services then assigned someone to investigate, and once resolved, got back with the resident about the resolution. She added that she had re-initiated the grievance. (Copies obtained) A review of the facility's policy and procedure titled Grievances/Complaint reports (effective 2008), revealed: The policy purpose read, To document receipt of a grievance or complaint, facility action and resolution. A grievance is defined as a concern or complaint that is unable to be immediately resolved and requires further investigation and action by facility leadership to achieve a resolution. The procedure guideline included: Responsible person: -May be initiated by any staff member upon identification of grievance or complaint. -Follow up conducted by Grievance Official, Administrator or the Director of Social Services or Designee. When: - Upon identification of a grievance /complaint. - Follow up done as soon as possible after identification. Instructions: Receipt and documentation of the grievance /Complaint. 1. Enter the date notified of the grievances/ complaint. 2. Print the name of the staff member receiving the grievance /complaint. 3. Enter a check to indicate the person (s) initiating the grievance/ compliant. 4. Print the individual's name initiating the grievance/complaint. 5. Print the phone number of the individual initiating the grievance/ complaint. 6. Document the factual description of the concern. 7. Sign as the staff member documenting the concern. Assignment of Actions 8. Identify and document the individual (s) designated to take action on the concern. 9. Enter the date assigned and the date to be resoled by 10. Note: Initial investigation and report will occur within three (3) working days , of the receipt of the grievance. .

Based on observation, medical record review, and staff interviews, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) was conducted for one (Resident #38) of two residents reviewed for PASARR completion from 53 residents in the sample. Resident #38 had psychiatric diagnoses that were not documented on the original PASARR and should have been screened for a Level II after admission to the facility. The fndings include: A review of the medical record for Resident #38 revealed an admission date of 12/13/23 and included the following diagnoses: schizophrenia and dementia with mood disorder. The current PASARR received by the facility on 12/12/23 noted no diagnoses checked under Section I, and under Section II, a diagnosis of dementia was checked no. An interview was conducted with the Assistant Administrator on 02/15/24 at 11:38 a.m. She stated she was filling in for the Social Services Director while she was on leave. She stated a PASARR was needed for admission to the facility and was reviewed and discussed in morning meetings. The PASARR was reviewed for accuracy, and if there was a diagnosis of schizophrenia, bipolar disorder and other psychiatric diagnoses, [Beneficiary and Family Centered Care Quality Improvement Organization] would be contacted online and a new PASARR would be generated. Notification would be sent if a Level II was needed. The Assistant Administrator reviewed the PASARR for Resident #38 with the resident's admission diagnoses on electronic medical record. She stated nothing was checked. The resident was diagnosed with schizophrenia and dementia, and a new PASARR should have been generated. She did not know if this happened and stated she would check the [Beneficiary and Family Centered Care Quality Improvement Organization] website. An interview was conducted with the Assistant Administrator on 02/15/24 at 1:42 p.m. She confirmed that there was no new PASARR generated for Resident #38 and she would notify the nurse to initiate a new one. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #6) of four residents reviewed for wound care, from a total sample of 53 residents, received wound care according to professional standards of practice to promote healing. The findings include: A review of the medical record revealed that Resident #6 was admitted to the facility on [DATE] with diagnoses including acute obstructive pulmonary disease with acute exacerbation, hypertension, sleep apnea, chronic pain, unspecified dementia - unspecified severity with psychotic disturbance, and depression - unspecified. On 02/13/24 at 9:50 AM, Resident #6 was observed with an undated adhesive wound care wrapping on her right forearm. On 02/14/24 at 10:05 AM, a second observation was made of Resident #6. She had the same undated adhesive wound care wrapping on her right forearm. On 02/15/24 at 10:47 AM, a third observation was made of Resident #6 with the same undated adhesive wound care wrapping on her right forearm. The resident reported she was scheduled to have wound care performed yesterday (02/14/24) and didn't receive the scheduled wound care. A review of the 01/25/24 physician's order for wound care revealed: Clean right forearm biopsy site with soap and water, apply ointment, cover bandage daily until site heals. The start date was noted as 01/25/24. A review of the resident's care plan, dated 10/19/23, revealed the following focus area: The resident has a potential for impaired skin integrity r/t impaired mobility. Date initiated 10/19/23. Revision on 10/19/23. Goal: The resident will be free from skin breakdown through the review date. Interventions: Administer/monitor effectiveness of medications as ordered. Administer treatments as ordered and monitor for effectiveness. Encourage good nutrition and hydration in order to promote healthier skin. Encourage patient to float heals whenever in bed. Identify potential causative factors and eliminate/resolve when possible. If skin breakdown occurs, treat per facility protocol and notify MD (physician), family. Keep skin clean and dry. Use lotion on dry scaly skin. Turn and reposition as needed. Weekly skin checks per facility protocol. On 02/15/24 at 11:48 AM, Registered Nurse (RN) N was interviewed. She reviewed Resident #6's electronic medical record and reported that the order for wound care documented: Clean right forearm biopsy site with soap and water, apply ointment, cover with bandage daily until site heals with at start date of 01/25/24. She reported that the standard practice for wound care should include initialing wound care dressings by the nurse who provided wound care and then documenting the date wound care was administered. She explained that according to the resident's electronic medical record, the last time the resident received wound care was on 02/14/23 at 18:43 (6:43 PM). On 02/15/24 at 11:54 AM, RN N verified that Resident #6 had no date or initials on her wound care dressing. On 02/15/24 at 11:58 AM, the Assistant Director of Nursing (ADON) was interviewed. She explained that when wound care was provided by nursing staff, the date should be entered on the wound care dressing so staff were aware that wound care was provided. She further explained that she preferred to put her initials on the wound dressing so staff were aware of who provided the wound care. On 02/15/24 at 12:01 PM, Resident #6 showed her wound care dressing to the ADON, who verified that the wound care dressing had no date indicating the last date of wound care. The ADON removed the bandage and reported that she observed a wound approximately four to five centimeters in length and two and a half centimeters in width. On 02/15/24 at 2:22 PM, an interview with the Wound Care Nurse was conducted. She reported she had been employed at the facility for two years. Wound care rounds and rounds with the facility assigned wound care physician occurred once a week on Thursdays. During each shift, the expectation was for her to learn about new admissions who required wound care. She was not familiar with Resident #6's wound care order and reviewed the electronic medical record. She explained that according to Resident #6's electronic medical record, the order instructed nursing staff to clean the right forearm, cover with a band aid daily until site heals with a start date of 01/25/24. She further explained that the standard of practice for wound care was to date wound care dressings with the date of wound care and to initial them identifying who provided the wound care. The resident's Medication Administration Record/Treatment Administration Record (MAR/TAR) was reviewed and revealed that Resident #6 did not receive wound care treatment on 01/29/24, 02/06/24, 02/07/24, or 02/11/24. On 02/15/24 at 5:02 PM, the Wound Care Nurse was again interviewed. She reported she did not know how to review blank spaces on the MAR/TAR to research why Resident #6 did not receive wound care treatment on 01/29/24, 02/06/24, 02/07/24, or 02/11/24. She verified that wound care treatment for Resident #6 was not documented as having been provided on 01/29/24, 02/06/24, 02/07/24, or 02/11/24. She confirmed that care not documented in the electronic medical record reflected that the care was not provided. A review of the facility's Skin Integrity policy (Copyright 2008), revealed: Clinical Guideline Manual and Subject: Skin integrity documentation should address . A description of dressings and treatments. A review of Nursing.Com Wound Care - Dressing Change (1) (s) (Accessed on 02/15/24) revealed: Best standard of practice for wound care process is to time, date and initial wound care dressings. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #22) of two residents reviewed for pressure ulcers, from a total sample of 53 residents, received pressure ulcer care according to professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. The findings include: On 02/13/24 at 11:16 AM, Resident #22, was observed lying in an upright position in bed, covered by a blanket with a nasal cannula in place. When greeted, she moaned and pointed to the corner where a family member was seated. The family member introduced herself as Resident #22's daughter, and stated her mother recently returned from the hospital and should be receiving treatment for the two sores on her bottom. She said the hospital ordered wound care treatment along with frequent re-positioning, but she felt the facility was not addressing the wounds, and she feared the wounds would worsen. A review of Resident #22's record revealed her initial admission date was 2/9/2022 with a readmission on [DATE]. Her diagnoses included COVID-19, acute and chronic respiratory failure with hypoxia, and dementia. The facility's admission notice, dated 2/10/24 at 18:51 (6:51 PM), and signed by the authorized RN, revealed that the resident was alert and oriented x2 (She knew who she was and where she was, but not what time it was or what was happening to her). She was incontinent of bowel and bladder, and had two sacral pressure ulcers that were open to air with wound care orders to apply ointment and leave open to air. (Photographic evidence obtained) A review of the Admission/readmission Minimum Data Set (MDS) assessment, dated 2/11/24, revealed that Resident #22 had a left thigh (front) skin tear, a left buttock stage 2 pressure ulcer, and a right buttock stage 2 pressure ulcer. A review of the active physician's orders revealed there were no active orders for wound care treatment in place addressing Resident #22's left buttock stage 2 pressure ulcer, or right buttock stage 2 pressure ulcer. (Photographic evidence obtained) A review of the care plan addressing skin integrity and wound care, provided by RN, Regional Director of Clinical Services/Interim DON, revealed no updates or revisions had been made since 01/18/24, no mention of the left or right buttock stage 2 pressure ulcers was noted, and no baseline care plan was provided. (Photographic evidence obtained) On 2/14/24 at 10:23 AM, a second observation was made of Resident #22, who was joined by her daughter. Her daughter stated, You just missed her Certified Nursing Assistant (CNA) changing her and providing wound care. She put that cream over her sores and left them uncovered. The daughter pointed to a yellow tube of cream that was uncapped. [NAME] residue was observed on the outside of the tube located on top of Resident #22's dresser that read, Triad Hydrophilic Wound Dressing Pansement hydrophile, Coloplast 2.5 oz. (An over-the-counter zinc oxide-based wound treatment for difficult to dress sacral wounds. It can be used on wet, eroded skin, including macerated skin.) (Photographic evidence obtained) On 2/14/24 at 12:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) C, who had been assigned to Resident #22, and who confirmed that upon admission and readmission, all discharge orders should be verified, skin issues documented, and a head-to-toe assessment completed within the first 24 hours. She reported not being aware of any skin conditions for Resident #22, but after reviewing the electronic medical record, she stated the resident had two pressure wounds to the sacrum, and the physician's orders for wound treatment could be found in the MAR/TAR. She was asked to review the MAR/TAR showing the wound care orders. After her review, she confirmed there were no current active physician's orders for wound care treatment located on the MAR/TAR or in the electronic medical record. On 2/14/24 at 1:35 PM, Resident #22's wounds were observed by a registered nurse surveyor (RNS) along with LPN C. Per the RNS, the wound was approximately 5 cm x 7 cm (centimeters), with a pink-red wound base and no slough (dead tissue). (Photographic evidence obtained) On 2/15/24 at 2:20 PM, the Wound Care Nurse reported all new admissions and readmissions were discussed in the facility's morning meetings. She was then provided with a list of all the residents who triggered with new skin/wound orders that she made rounds on for treatment that day. When asked if she was familiar with Resident #22, she stated she was. She visited with her yesterday evening and confirmed that the resident did come in with a stage 2 pressure ulcer, and the admitting nurse should have obtained the order. She added that she reached out to the physician to evaluate the wound and mentioned that the measurements were approx. 11 cm x 7 cm because the physician clustered all three open areas into one. She added that treatment orders were put in place as of 2/15/24 and barrier cream was being applied for treatment. When asked if barrier cream would require a doctor's order she stated, Yes, there should be an order to apply the barrier cream. She further confirmed there were no active physician's orders in place for Resident #22 for barrier cream and stated, If the order wasn't there, that means the admitting nurse missed it. The Wound Care Nurse was asked to look at the photo of Triad Hydrophilic Wound Dressing Pansement hydrophile, Coloplast 2.5 oz. that was observed in Resident #22's room. She was then asked to identify the item. She stated the item was not barrier cream, but what appeared to be wound cream. She further confirmed that the wound cream observed in the photo would be applied by a licensed nurse, not a CNA. A review of the facility's policy on Pressure Ulcers (CCHC 0312, with a copyright year of 2016), noted on page 1, item #8: Perform wound care as per the physician's orders. A review of the facility's policy on admission Completion Check-Off List Mandatory Forms (copyright year of 2016), noted on page 1, Item #10: Skin and Wound Evaluation Completed. Page 1, Item #13: Admit/Re-Admit orders verified with MD (physician). Two nurses sign off for accuracy. On page 2, Item line #11: Treatment orders for all skin areas/wounds noted upon admission. On page 3, Item line #7: 2nd Skin Sweep Completed by Unit Manager. On page 3, Item #9: Unit Manager to review admission Orders for Accuracy. .

Based on observations, record review, staff interviews, and a review of the policy and procedure for Oxygen Therapy, the facility failed to ensure oxygen was administered at the physician-ordered flow rate for two (Residents #29 and #129) of six residents reviewed for oxygen use, from a total sample of 53 residents. The findings include: 1. An observation was made of Resident #29 in her room on 2/12/14 at 11:00 a.m. She was observed with oxygen infusing via a concentrator through a nasal cannula. She reported her oxygen flow rate should have been set at 3 liters per minute (LPM). Her oxygen concentrator was observed with a flow rate set at 2.5 LPM. A medical record review for Resident #29 revealed an admission date of 1/22/24 with the following diagnoses: chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and atrial fibrillation. A 1/23/24 physician's order noted oxygen at 2 LPM as needed (PRN) for oxygen saturations of less than 92% for COPD. The care plan, updated on 1/23/24, noted: Resident has altered respiratory status/difficulty breathing related to COPD and sleep apnea. Interventions included to elevate the head of the bed, and administer oxygen as ordered. On 2/12/24 at 2:00 p.m., an observation was made of the resident in her room using oxygen and the concentrator was set at 3 LPM. On 2/13/24 at 9:30 a.m., an observation was made of the resident in her room using oxygen and the oxygen flow rate was set at 2.5 LPM. On 2/14/24 at 9:20 a.m., an observation was made of the resident in her room using oxygen in bed, which was set at a flow rate of 3 LPM. A review of the February 2024 Medication Administration Record (MAR), noted oxygen at 2 LPM via nasal cannula PRN for oxygen saturations of less than 92%. Vital signs were documented with oxygen saturations at 94% or above on all days except 2/1/24, when her saturation was documented at 84%. An interview was conducted with Licensed Practical Nurse (LPN) A on 2/14/24 at 1:38 p.m. She reviewed the oxygen order for Resident #29 and reported the oxygen was to be set at 2 LPM PRN. She was not aware that the resident is wearing the oxygen constantly. She confirmed the order was as needed (PRN) with parameters for oxygen saturations. LPN A walked into the resident's room and confirmed that the oxygen was set at 3 LPM. She changed the oxygen to 2 LPM and confirmed the resident was using the oxygen. 2. An observation and interview was conducted with Resident #129 on 2/12/24 at 12:52 p.m., which noted the resident sitting up in bed with the head of the bed elevated and oxygen infusing at 2.5 LPM via nasal cannula. The resident reported being on 2 LPM of oxygen. A medical record review was conducted which noted an admission date of 11/20/23 with a diagnosis of COPD. The physician's orders were reviewed, which noted continuous oxygen at 3 LPM via nasal cannula on 11/22/23. The MAR was reviewed, which noted continuous oxygen at 3 LPM, dated 11/22/23. The current care plan, updated on 11/22/23, noted: Resident has altered respiratory status related to COPD. Interventions included to administer medications and respiratory therapy as ordered. An observation was made of the resident in her room on 2/13/24 at 9:25 a.m. Her oxygen flow rate was set at 2.5 LPM. An observation was made on 2/14/24 at 9:39 a.m. The resident was sitting up in bed with oxygen infusing at 2.5 LPM. An observation was made on 2/14/24 at 1:15 p.m. The resident was sitting up in a wheelchair with an oxygen canister attached to the back of it. The oxygen canister was set at 2 LPM. An interview was conducted with LPN B on 2/14/24 at 1:26 p.m. She reviewed the resident's physician's order for oxygen and reported it was ordered for 3 LPM. LPN B walked into the resident's room and confirmed the resident had an oxygen canister on the back of her wheelchair with a flow rate set at 2 LPM. The resident wanted her oxygen saturation taken and asked when the oxygen order was changed to 3 LPM. The resident removed her oxygen while the LPN was retrieving the pulse oximeter. The LPN took the resident's oxygen saturation which was 87%. The resident applied the oxygen cannula and the LPN changed the oxygen to 3 LPM. The oxygen saturation went to 95%. A review of the facility's policy for Oxygen Therapy (2019) revealed under Purpose, a statement that oxygen must be prescribed by an appropriate clinician and administered by appropriate clinical staff. Under procedure .5, a statement to check the oxygen prescription, administer according to prescription, and use the appropriate delivery device was in place. .

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less. There were six errors out of 26 opportunities for error, resulting in an error rate of 23% and involving two (Residents #123 and #166) of three residents observed for medication administration. Failure to administer medications appropriately as ordered could result in side effects leading to harm to the residents. The findings include: During a medication administration observation on 2/14/24 at 8:52 a.m., Licensed Practical Nurse (LPN) A was observed preparing medication for Resident #123. She obtained Potassium Chloride (KCL), 20 miliequivalent (meq) tablet and Rytary extended release (ER) 48.75 -195 milligrams (mg) capsule (A combination of carbidopa and levodopa used to treat symptoms of Parkinson's disease). She crushed each medication separately and mixed with applesauce. She did not crush the KCL she mixed in apple sauce. She opened the Rytary capsule and poured the powder in applesauce. She then proceeded to the resident's room and administered the medication to the resident . In an interview on 2/14/24 at 9:10 a.m., LPN A was asked why she did not crush the KCL. She stated Resident #123 took the medication crushed but the the label for KCL indicated do not crush. She was then asked about the Rytary capsule. She said, That's the medication label noted do not crush, but the capsule cannot be crushed, it can be opened and that's why I opened it. She was asked why she did not administer the Lidoderm patch, Omega 3 or Vitamin D. She stated the medications were not in the cart and she would have to get them from central supply. She added that she also had to wait for the resident to finish breakfast so she could apply the Lidoderm patch. On 2/14/24 at 9:35 a.m., Registered Nurse (RN) L was observed preparing medication for Resident #166. She obtained a blister pack of Gabapentin 100 mg (milligrams) and popped one tablet into the medication cup. She then obtained Breo Elipta Inhalation aerosol powder breath activated 100-25 mcg (micrograms). RN L confirmed that there was only one 100 mg gabapentin pill. (Photographic copy of the blister pack obtained) She then proceeded to the resident's room and administered the medication. The resident was not offered water to rinse her mouth after the inhaler treatment. A review of the Breo Ellipta medication package insert revealed instructions to use water to rinse/gargle and spit after dose to prevent yeast infection (candidiasis/thrush). (Copy obtained) A review of the medication label revealed Gabapentin 100 mg, give 2 tablets once a day. A review of the physician's order, dated 1/17/24, revealed Gabapentin 400 mg, give one tablet three times a day. (Copy obtained) In an interview on 2/14/24 at 9:45 a.m., RN L stated Resident #166 had two blister packs of Gabapentin (400 mg and 100 mg). She stated she was confused and chose the wrong dosage. A follow-up interview was conducted with LPN A on 2/14/24 at 10:17 a.m. She confirmed that she had still not given the medication (Lidocaine patch, Omega 3 and Vitamin D) to Resident #123. She added that she was to obtain medications from central supply. During an interview on 2/14/24 at 10:20 a.m., LPN N/Unit Manager said, If the medications are not available in the cart, the nurse should stop and check to see if the medication is in the Pyxis. If it is not available, she should notify the physician and also contact the pharmacy to check when the medication was ordered. For the over-the-counter (OTC) medication, the facility has stock in the medication room and central supply. LPN N was made aware that Resident #123 had not received all of his medication (Lidoderm patch, Omega 3, and Vitamin D). She stated they should be on the cart because she had just restocked all of the medication carts. She proceeded to the medication cart that LPN A was assigned to. She opened the top drawer, obtained the medication fish oil, vitamin D and a Lidocaine patch, and placed the medication on top of the cart. She educated LPN A about medications' generic names. Upon review of Resident #123, LPN A confirmed that she had already checked the medications as having been administered before administering them. A review of the active physician's orders for Resident #123, revealed Cholecalciferol, 1000 units, give one tablet by mouth one time a day. Omega 3 capsule, 1000 mg one time a day for nutritional support. Lidoderm Patch 5 %, apply to lower back topically one time a day. Another follow-up interview was conducted on 2/14/24 at 10:20 a.m. with RN L, who was asked if she had completed medication administration. She replied, I still have around ten residents to give medications to. She was asked when medications were due and she replied, They were due at 9:00 a.m. She added that medications could be administered up to an hour before or an hour after they were scheduled. She confirmed that she was running behind schedule because it was her first time working on the unit. She was then asked what she would do now that she was behind schedule. She said, I will continue to pass them. I was assigned 28 residents and I have to pass to all of them. The nurse was not familiar with the facility's process for late medication administration. A review of the computer screen revealed that 16 residents had not yet received their medication. During an interview with the RN Regional Director of Clinical Services (RDCS)/Interim Director of Nursing (DON) on 2/14/24 at 1:38 p.m., she was informed of the concerns identified during medication administration. She stated additional education would be initiated. A review of the facility's policy and procedure titled Medication Pass Guideline (2008), revealed the Purpose read, To safely and accurately administer medications according to physicians' orders and patient needs. The procedure was outlined as follows: 2 .Read transcribed physicians' orders on MAR, patient name, medication name, dosage, route and interval ordered. - remove medication from the cart - compare MAR with medication label for accuracy 3. If medication is new for the resident, or the medication is unfamiliar or physician order is questioned -read original physician order -compare original physician order with MAR for accuracy -verify allergy status -contact physician for clarification as needed 4. Read special medication instructions Tablet and Capsule - Do not crush medication when contraindicated in a cautionary statement on MAR, if appears on pharmacy list of non-crushable or without a physician's order. 7 . Administration of medications; -Administer medication in accordance with the frequency prescribed by the physician. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 2/13/24 at 1:57 p.m,, Diclofenac cream for Resident #77 was observed on his activity table in his room. In an interview on 2/13/24 at 2:00 p.m., Resident #77 stated he was supposed to apply the cream on his wrist four times a day, but he did not remember to apply it. He said he used it when he remembered. (Photographic evidence obtained) A record review indicated that Resident #77 was admitted to the facility on [DATE] with a diagnosis of acute on chronic systolic congestive heart failure. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/11/23, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact. A review of Resident #77's physician's order dated 10/16/23, revealed Diclofenac Sodium gel 1%, apply to both wrists topically two times a day for arthritis pain. Another observation was made of the resident's room on 2/14/24 at 9:00 a.m. and the medication was still at bedside. During an interview with LPN A on 2/14/24 at 10:17 a.m., she confirmed that the medication was at bedside and stated that it should be in the medication cart. Based on observations and staff interviews, the facility failed to ensure medications were stored in locked medication carts for three (Residents #16, #22, and #77) of 53 residents in the total sample. Pain creams and other creams were found in residents' rooms, which could lead to overdosing or harm to other residents. The findings include: 1. An observation was made of Resident #16 in her room on 2/12/24 at 11:57 a.m. She was sitting up in bed with a neck brace on and Voltaren, Triamincolone, and Bacitracin were sitting on her dresser at bedside. The resident reported using her Voltaren for arthritis pain. She was asked about the other creams but did not respond. An observation was made of Resident #16's room on 2/13/24 at 9:30 a.m. The resident was not in the room. Voltaren and Triamincolone were observed at bedside. An observation was made of Resident #16 on 2/14/24 at 9:20 a.m. in her room. She reported not using Triamincoline. She said it came from the hospital. She used Voltaren before therapy and at bedtime. Voltaren and Triamicolone were observed at bedside in a drawer. A review of Resident #16's medical record noted an admission date of 9/16/22 with a re-entry date of 1/18/24 and a diagnosis of Osteoarthritis of first carpometacarpal joint (thumb). The active physician's orders were reviewed, which noted to apply Voltaren gel 1% one application transdermally three times a day for pain, apply 2 grams (gm) to thumb for pain. A review of the current Medication Administration Record (MAR) noted nurses signing out the application of the Voltaren. There was no order for the Triamincolone. An interview was conducted with Licensed Practical Nurse (LPN) B on 2/14/24 at 1:26 p.m. She reported the resident had Voltaren ordered for her thumb pain. She reviewed the order which indicated the medication was to be used three times a day and apply 2 gms to the resident's thumb. She stated the resident wanted it applied to her hip and leg, but there was no physician's order, and the physician would have to be notified to obtain an order for the hip and leg applications. The LPN entered the resident's room and explained to the resident the medication (Voltaren) was on the medication cart, and the medications needed to be locked in the cart. The Voltaren was being applied by the nurses. She asked the resident if she could remove the medications, and the resident became upset, stating, You are going to do what you want, just take it. LPN B took the creams and locked them in the medication cart. An interview was conducted with the Administrator on 2/15/24 at 10:43 a.m. He stated upon admission medications were reviewed with the residents/families and they were made aware that mwdications could not be brought in or left in the resident room. The Welcome Committee also addressed this when meeting with the resident. Residents liked to order things online and receive medications that way. The facility was trying to have residents open packages in front of them to prevent this, but some would not agree to do that. Angel rounds were utilized for opportunities and not meeting the practice. Angel rounds were conducted daily during the week and turned in on Fridays. If there was an issue, it was brought to the Director of Nursing immediately. He was apprised of the creams left in Resident #16's room and he acknowledged receiving the information. He also stated a new improvement plan was started on 2/12/24 recognizing no medications or prescription creams should be left at the bedside of residents. 2. On 02/13/24 at 11:16 AM, Resident #22 was observed lying in an upright position in bed, covered in a blanket, with a nasal cannula in place. When greeted, she moaned and pointed to the corner where a family member was seated. The family member introduced herself as Resident #22's daughter, and reported her mother recently returned from the hospital, and should be receiving treatment for the two sores on her bottom. She said the hospital ordered wound care treatment, along with frequent re-positioning, but felt the facility wasn't addressing the wounds, and feared the wounds would get worse. A review of Resident #22's record revealed her initial admission date was 2/9/2022 and she was readmitted on [DATE]. The facility's admission notice dated 2/10/2024 at 18:51 signed by the authorized Registered Nurse (RN), revealed she was alert and oriented x2, incontinent of bowel and bladder, and had two sacral pressure ulcers that were open to air with wound care orders to apply ointment and leave open to air. (photo evidence obtained) On 2/14/2024 at 10:23 AM, a second observation was made of Resident #22, who was joined by her daughter. Her daughter stated you just missed her Certified Nursing Assistant (C.N.A.) changing her and providing wound care. She put that cream over her sores and left them uncovered. The daughter pointed to a yellow tube of cream that was uncapped, white residue observed on the outside of the tube located on top of Resident #22's personal dresser that read Triad Hydrophilic Wound Dressing Pansement hydrophile, Coloplast 2.5 oz. (Photographic evidence obtained)

Based on record reviews, interviews, and a review of the Medication Pass Guideline Policy and Procedure, the facility failed to ensure to maintain complete, accurately documented medical records for one (Resident #50) of 53 sampled residents for blood pressure medication with parameters. Documenting the blood pressures before administration ensures nurses are following the physician's orders and not administering medication if the resident's blood pressure is too low. The findings include: On 2/14/24 at 9:45 a.m., Resident #50 was observed in her room sitting up in bed. She reported she had a sore throat this morning. She reported receiving her medications this morning. A medical record review was conducted for the resident which noted an admission date of 1/20/22 with diagnoses including dementia and hypertension. The active physician's orders were reviewed, which noted Lisinopril 2.5 milligrams (mg) every day for blood pressure and Metoprolol extended release 25 mg daily, hold if systolic blood pressure is below 110. The February 2024 Medication Administration Record (MAR) was reviewed, which noted Lisinopril and Metoprolol were being administered daily with no blood pressures documented. A physician's order dated 6/18/23, noted blood pressures to be taken weekly which was also noted on the February 2024 MAR. An interview was conducted with Licensed Practical Nurse (LPN) C at 3:55 p.m. on 2/14/24. The LPN reviewed the MAR and reported the resident had two blood pressure medications with parameters (Lisinopril and Metoprolol) and whoever put them in did not add space to write in blood pressures. She reported taking residents' blood pressures before administering the medications. When she was asked where she documented those blood pressures, she replied that she documented that information under Vital Signs in the electronic record. An interview was conducted with the Registered Nurse (RN)/Assistant Director of Nursing (ADON) at 1:33 p.m. on 2/15/24. The ADON was asked about inputting orders for medications such as Digoxin (apical pulse needed), and blood pressure medications with parameters. He stated a batch order could be pulled up in the electronic medical record. The nurse would click on the medication and it would give the dosage, parameters, etc. Blood pressures were attached to blood pressure medications with parameters and should be documented on the MAR. The RN reviewed the MAR for Resident #50. The ADON reported the orders were not input correctly, and blood pressures would be taken before administering the medications. He confirmed the blood pressures were not being documented on the MAR or under Vital Signs consistently. He stated, It is not clear whether the blood pressures were taken since it is not documented. A review of the facility's policy and procedure for Medication Pass Guideline, noted to safely and accurately prepare and administer medication according to the physician's order and patient needs. Under procedure 5. it was noted to obtain vital signs if applicable and record results on the MAR. .

Based on the kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to document temperatures and sanitation, and clean and maintain kitchen foodservice equipment to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility. The facility failed to maintain temperature logs for the 3-compartment sink and maintain the kitchen oven in a clean and sanitized condition. Food safety and sanitation is important in health care settings serving nursing home residents. Kitchen equipment shall be maintained and kept free of food residue and other debris to avoid a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted on 2/12/24 at 10:55 AM. During the tour, there was no temperature log sheet maintained for the 3-compartment sink. During the initial tour on 2/12/24 at 11:05 AM, [NAME] G reported that he washed, rinsed, and sanitized dishes in the 3-compartment sink and there was no sheet to document temperatures. He confirmed that he had not documented temperatures and sanitation after washing dishes in the 3-compartment sink. During the initial tour of the kitchen on 2/12/24 at 11:10 AM, the Certified Dietary Manager (CDM) was asked to provide the temperature log for the 3-compartment sink. The CDM initially stated staff mostly used the dish machine and had not used the 3-compartment sink, but later provided a blank temperature log dated 9/2023. The CDM later confirmed there were no 3-compartment sink temperature logs for the past 6 months. (Photographic evidence obtained) A follow-up kitchen tour was conducted on 2/14/24 at 12:15 PM. Two ovens had food residue, a white powdery substance, and grease deposits on the floor below the rack and on and around the doors. The bottom convection was covered with food debris and grease build-up on and around the inside oven door. The mixer, located next to the prep table, with clear plastic covering, had food debris stuck on and around the safety guard. The same observations of the two ovens were made again on 2/15/24 at 1:40 PM. (Photographic evidence obtained) An interview was conducted on 2/15/24 at 1:45 PM with [NAME] H. She reported the cook was responsible for documenting temperatures and sanitation for the 3-compartment sink. The cook or any staff that use equipment outside of the cook area was responsible for cleaning after each use or as needed. When asked how often the ovens and mixer were cleaned, she replied, It varies depending on its use. The oven was cleaned yesterday. Before that day, it had been a while since it was last cleaned. An interview was conducted on 2/15/24 at 1:54 PM with [NAME] I, who reported the cook was responsible for documenting 3-compartment sink temperatures daily after breakfast, lunch, and dinner. He also stated the cook was responsible for cleaning the oven. Other kitchen equipment was cleaned after each use or weekly if not used and kept covered with plastic. A second interview was conducted on 2/15/24 at 1:57 PM with the CDM. She reported the cooks or any kitchen staff were responsible for cleaning the kitchen and food service equipment. Ovens were cleaned weekly by the cook and mixers were cleaned as needed. She stated, I just created job flows for all the positions. When asked who was responsible for documenting temperatures and sanitation for the 3-compartment sink, she confirmed it was the cook. When asked what the requirement for documenting temperatures for the 3-compartment sink was, the CDM stated staff had not used the 3-compartment sink due to the CDM cleaning and organizing the dish area. They had not really started using the sink because there were no stoppers. The stoppers were received about one month ago, but the staff used the 3-compartment sink mainly to soak pans. An interview was conducted on 2/15/24 at 2:05 PM with Dietary Aide K. She reported the cook cleaned the oven. The mixer was cleaned by whoever used it last or weekly if not used. When asked how often the oven was cleaned, she replied, weekly. When asked what the requirement for documenting the 3-compartment sink temperatures was, Dietary Aide K was not sure of the requirement for documenting the 3-compartment sink. She stated it was the cook's responsibility. When asked how often the 3-compartment sink was utilized, she confirmed it was used daily, three times a day and as needed. Whoever washed dishes was responsible for documenting the temperature and sanitation. A review of the facility's policy and procedure titled HACCP Tips for Food Safety (dated 2015) revealed: Staff to be educated and supervised on HACCP information and procedures. Procedure #8. Dishwashing: Be sure the wash and rinse temperatures are appropriate for your dish machine. Document temperatures regularly on a temperature log. Policy and Procedure entitled Sanitation - Overview dated 2015 revealed: Standards established by the U.S. Public Health Service FDA Food Code are followed regarding safe food handling techniques and food temperatures. Procedure #18. Clean and sanitize food-contact surfaces and equipment: before and after every use, at least every 4 hours during continual use. 19. Maintain clean and sanitary kitchen facilities and equipment by following cleaning instructions procedures. (Copy Obtained) Reference: 2022 Food Code, United States Food and Drug Administration. Chapter 4, Page 127 and 165. https://www.fda.gov (Accessed on 2/20/24). Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and a review of resident records, the facility failed to provide medication and treatments as ordered and in accordance with professional standards of practice for one (Resident #121) of one resident who reported problems receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample. The findings include: An observation of and an interview with Resident #121 was conducted on 03/22/22 at 10:24 AM. During the interview, she commented that by this time of day, her legs should already be wrapped. They were still not wrapped. She explained that staff were supposed to wrap her legs daily with ace bandages, however, some days it was after 4:00 PM or 5:00 PM by the time they finally applied the wraps. Some days, the staff did not apply them at all. Resident #121 added that her doctor recently prescribed her some nasal spray, but she still had not received it. It was intended for her wheezing and coughing. An observation at this time found no ace bandage wraps on either of Resident #121's lower legs, which were both edematous (swollen due to a buildup of fluid). Resident #121 was observed on 03/22/22 at 1:43 PM and again at 4:21 PM, and the ace wraps had still not been applied. During an observation and interview with Resident #121 on 03/23/22 at 10:08 AM, she had ace bandage wraps to both of her legs below the knees. She reported that Agency Certified Nursing Assistant (CNA) N wrapped her legs this morning before she got out of bed. She had gone to therapy this morning and the bandages were now loose. When asked if the wraps had been applied yesterday (3/23/22) after the 4:21 PM observation, she said, No. A record review for Resident #121 found she was readmitted to the facility on [DATE]. The 5-day minimum data set (MDS) assessment, dated 02/27/22, indicated Resident #121 had a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact. She required limited to extensive assistance with activities of daily living (ADLs) and used a walker and wheelchair as mobility aids. Her diagnoses included asthma/COPD (chronic obstructive pulmonary disease, or lung disease that blocks air flow making breathing difficult), myocardial infarction (heart attack), and atherosclerotic heart disease of the native coronary artery without angina pectoralis (hardening of the arteries that supply blood to the heart). She received diuretic medications (used to remove excess fluid from the body) on seven days over the assessment look-back period. Resident #121 was care planned on 01/11/22 for her altered cardiovascular status related to diagnoses of coronary artery disease (CAD) and hypertension with a goal to be free from complications from cardiac problems through the next review. Interventions included, but were not limited to, medications as ordered and monitor for/document any edema (swelling). (Copies obtained) Resident #121 had a physician's order dated 03/01/22 that instructed clinical staff to apply ace wrap knee highs (ace bandages applied to the lower legs up to knee level in order to provide gently pressure and reduce swelling); On in the AM (morning), remove in the PM (evening). She also had a physician's order for Ipratropium Bromide Solution 0.3% (a medication used to open up the airways in the lungs), two sprays in both nostrils twice a day for rhinorrhea (excessive drainage from the nose/nasal passages). The order was written on 3/14/22 (8 days ago), but said it was still Pending Confirmation instead of Active. (Copies obtained) A review of the electronic medication administration record (eMAR) found the Ipratropium nasal spray was scheduled to be administered daily at 9:00 AM and 6:00 PM, however, between 03/14/22 (the day the order was written) and 03/21/22, the signature boxes used to indicate the medication was administered were all marked with Xs. There was no explanation of what X meant. On 03/22/22, both signature boxes had nurses' initials in them, indicating the spray was administered at 9:00 AM and 6:00 PM. A review of the electronic treatment administration record (eTAR) found Resident #121's ace wraps had been signed off as applied on 3/22/22, despite multiple observations and an interview with the resident verifying that they had not been put on. (Copies obtained) An interview was conducted with Agency CNA N on 03/23/22 at 10:12 AM. She explained that Resident #121's legs swelled a lot if not wrapped. An interview was conducted with Licensed Practical Nurse (LPN) O on 03/23/22 at 3:09 PM. She confirmed that Resident #121 had edema and received ace wraps to her legs each morning. The wraps were removed at night, and this was to be done every day. LPN O reported staff encouraged Resident #121 to keep her feet elevated, but the resident stayed out of her bed all day and late into the night. LPN O was asked why Resident #121's nasal spray was still pending confirmation a week after it was ordered. She explained that Sometimes the physicians write an order, but the electronic medication ordering system does not allow the facility nurses to confirm the order. She speculated that perhaps that was why the order was pending for that long. LPN N said Resident #121's nasal spray just came in, but she had not received it yet. Photographic evidence of the Ipratropium spray was obtained on 03/23/22. The medication label said it was filled by the pharmacy on 03/22/22, eight days after it was ordered. A handwritten note indicated the spray was not opened until 03/23/22. The Director of Nursing (DON) was interviewed on 03/24/22 at 2:41 PM and was advised that Resident #121's ace wraps were being signed off by nursing as having been applied when they had not been applied. She had no explanation and acknowledged the findings. She said she would speak with the nurses. .

Based on observations, interviews, and record reviews, the facility failed to ensure that psychotropic medications were used to treat a specific, diagnosed condition and failed to ensure as-needed (PRN) anti-anxiety medications were limited to a use of 14 days for one (Resident #57) of five residents reviewed for unnecessary medications. The findings include: A review of Resident #57's medical record revealed an admission date of 1/14/22. She received hospice services for end-of-life care related to her primary medical diagnosis of Alzheimer's disease. Secondary diagnoses included dementia, major depressive disorder, and anxiety. A review of the resident's physician's orders revealed the following medication orders: An order dated 2/18/22 for Seroquel (antipsychotic medication) 25 milligrams(mg) to be given twice daily for behavior management. An order dated 2/18/22 for Seroquel 50 mg to be given by mouth at bedtime for behavior management. An order dated 1/25/22 for Depakote (anticonvulsant medication)125 mg to be given two times a day for a diagnosis of anxiety. An order dated 1/16/22 for Ativan (sedative medication) 0.5 mg to be given by mouth every 12 hours as needed (PRN) for a diagnosis of agitation. On 3/21/22 at 12:27 p.m., Resident #57 was observed walking out of her room into the hallway. She was wearing pajamas and was barefoot. A staff member in the hallway approached the resident and hurriedly redirected the resident back into her room while stating, Where are you going? When Resident#57 attempted to reply, the staff member interrupted the resident and stated, You have to put some shoes on. Let's go. Resident #57 did not display any other behaviors. On 3/21/22 at 12:35 p.m., an interview was conducted with Resident #57's assigned Licensed Practical Nurse. The nurse identified Resident #57 as having dementia and wandering behaviors. The nurse stated she was not aware of any other behaviors aside from wandering. She added that the resident had been relocated to the top floor of the facility due to her wandering. On 3/21/22 at approximately 12:47 p.m., Resident #57 was observed sitting in a chair in her room. Her lunch tray was positioned in front of her on the over-bed table. The room lights were off and the window blinds were closed. The room was dark and Resident #57 was not eating. A review of the nursing progress notes revealed an entry dated 1/16/22 at 1:25 p.m. which indicated the resident was wandering in the hallway barefoot with only a brief and a shirt on. The resident stated she was looking for the restroom. She removed her brief and threw it on the floor. The hospice nurse visited and gave new orders for Haldol (antipsychotic medication) 1 mg to be given every twelve hours and Ativan 0.5 mg to be given every twelve hours as needed. A review of the hospice provider's documentation revealed a handwritten order dated 1/16/22 for Ativan 0.5 mg to be given by mouth every 12 hours as needed for agitation. A pharmacy recommendation for Resident #57, dated 2/27/22, indicated, This resident has an order to receive Seroquel for behavior management. Per FDA (Food and Drug Administration) guidelines, the only approved indications for this agent are the treatment of manifestations of psychotic disorders, the short-term treatment of schizophrenia, the treatment of acute manic episodes associated with bipolar disorder, and the treatment of bipolar depression. Seroquel is not approved for aggression, Alzheimer's disease, anger management, anxiety, attention-deficit/hyperactivity disorder, bipolar maintenance, dementia, depression, mood disorder, post-traumatic stress disorder, or sleeplessness. A second pharmacy recommendation dated 2/27/22 indicated, Previous recommendation to discontinue PRN [as needed] use of Ativan was not completely addressed by MD [physician], and thus no duration for treatment was given . A psychiatric provider note dated 2/4/2022 was reviewed. The note indicated Resident #57 was receiving Depakote for management of mood and behavior. A review of Resident #57's Medication Administration Record (MAR) for March 2022, revealed documented administration of PRN Ativan on 3/11/2022, 3/12/2022, 3/17/2022 and 3/23/2022. A review of Resident #57's Behavior Monitoring Records for March 2022, revealed one instance of a documented behavior identified as continuous crying/vocalizations. The documented attempted interventions were redirection, providing a rest period, and administration of medication. A review of Resident #57's care flow records for March 2022, revealed one documented episode of difficulty sleeping. There were no documented behaviors for the remainder of the month. According to the Mayo Clinic (Accessed 3/24/2022 at 4:15 p.m.) at https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/description/drg-20066912), Seroquel is an antipsychotic medication that works in the brain to treat bipolar disorder and schizophrenia. This medicine should not be used to treat behavioral problems in older adult patients who have dementia or Alzheimer's disease. According to the Mayo Clinic (Accessed 3/24/2022 at 4:20 p.m.) at https://www.mayoclinic.org/drugs-supplements/valproic-acid-oral-route/description/drg-20072931), Depakote is used to treat the manic phase of bipolar disorder and certain types of seizures. According to the Mayo Clinic (Accessed 3/24/2022 at 4:24 p.m.) at https://www.mayoclinic.org/drugs-supplements/lorazepam-oral-route/description/drg-20072296), Ativan is a medication used to treat anxiety disorders and is used for short-term relief of the symptoms of anxiety. According to the Alzheimer's Foundation (Accessed 3/24/2022 at 5:15 p.m.) at https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior), individuals with dementia should use antipsychotic medications only if behavioral symptoms are due to mania or psychosis, the symptoms present a danger to the person or others, or the person is experiencing inconsolable or persistent distress, a significant decline in function, or substantial difficult receiving needed care. Antipsychotic medications should not be used to sedate or restrain persons with dementia. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and a review of resident records and facility policies, the facility failed to accurately document resident medication and treatment records for one (Resident #121) of one resident who reported problems with receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample. The findings include: An observation of and an interview with Resident #121 was conducted on 03/22/22 at 10:24 AM. During the interview, she commented that by this time of day, her legs should already be wrapped. They were still not wrapped. She explained that staff were supposed to wrap her legs daily with ace bandages, however, some days it was after 4:00 PM or 5:00 PM by the time they finally applied the wraps. Some days, the staff did not apply them at all. Resident #121 added that her doctor recently prescribed her some nasal spray, but she still had not received it. It was intended for her wheezing and coughing. An observation at this time found no ace bandage wraps on either of Resident #121's lower legs, which were both edematous (swollen due to a buildup of fluid). Resident #121 was observed on 03/22/22 at 1:43 PM and again at 4:21 PM, and the ace wraps had still not been applied. During an observation and interview with Resident #121 on 03/23/22 at 10:08 AM, she had ace bandage wraps to both of her legs below the knees. She reported that Agency Certified Nursing Assistant (CNA) N wrapped her legs this morning before she got out of bed. She had gone to therapy this morning and the bandages were now loose. When asked if the wraps had been applied yesterday (3/23/22) after the 4:21 PM observation, she said, No. A record review for Resident #121 found she was readmitted to the facility on [DATE]. The 5-day minimum data set (MDS) assessment, dated 02/27/22, indicated Resident #121 had a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact. Resident #121 had a physician's order dated 03/01/22 that instructed clinical staff to apply ace wrap knee highs (ace bandages applied to the lower legs up to knee level in order to provide gently pressure and reduce swelling); On in the AM (morning), remove in the PM (evening). She also had a physician's order for Ipratropium Bromide Solution 0.3% (a medication used to open up the airways in the lungs), two sprays in both nostrils twice a day for rhinorrhea (excessive drainage from the nose/nasal passages). The order was written on 3/14/22 (8 days ago), but said it was still Pending Confirmation instead of Active. (Copies obtained) A review of the electronic medication administration record (eMAR) found the Ipratropium nasal spray was scheduled to be administered daily at 9:00 AM and 6:00 PM, however, between 03/14/22 (the day the order was written) and 03/21/22, the signature boxes used to indicate the medication was administered were all marked with Xs. There was no explanation of what X meant. On 03/22/22, both signature boxes had nurses' initials in them, indicating the spray was administered at 9:00 AM and 6:00 PM. A review of the electronic treatment administration record (eTAR) found Resident #121's ace wraps had been signed off as applied on 3/22/22, despite multiple observations and an interview with the resident verifying that they had not been put on. (Copies obtained) An interview was conducted with Licensed Practical Nurse (LPN) O on 03/23/22 at 3:09 PM. She confirmed that Resident #121 had edema and received ace wraps to her legs each morning. The wraps were removed at night, and this was to be done every day. LPN O was asked why Resident #121's nasal spray was still pending confirmation a week after it was ordered. She explained that Sometimes the physicians write an order, but the electronic medication ordering system does not allow the facility nurses to confirm the order. She speculated that perhaps that was why the order was pending for that long. LPN N said Resident #121's nasal spray just came in, but she had not received it yet. Photographic evidence of the Ipratropium spray was obtained on 03/23/22. The medication label said it was filled by the pharmacy on 03/22/22, eight days after it was ordered. A handwritten note indicated the spray was not opened until 03/23/22. LPN P was interviewed on 03/24/22 at 9:29 AM. She stated if a medication was not available at the time of administration, she would go to the electronic medication dispenser to see whether the medication was available. If not, she would call the physician and mark the eMAR (electronic medication administration record) Other and note the medication was not available. The Director of Nursing (DON) was interviewed on 03/24/22 at 2:41 PM and was advised that Resident #121's ace wraps were being signed off by nursing as having been applied when they had not been applied. She was also told of the two doses of nasal spray that were signed as having been administered before the medication had been delivered to the facility. The DON explained there was a code on the eMAR and eTAR (electronic treatment administration record) for nurses to document Other if a medication was not available for administration. The nurses just received training on that. She had no explanation for why nurses were documenting that medication and treatments were being provided when they were not. She said she would speak with the nurses. A review of the Clinical Guidelines Manual Medication Pass Guidelines, CCHC 0115 Copyright 2008, revealed: Purpose: To safely and accurately prepare and administer medication according to physicians' orders and patient needs. Document: -Medication administered -Resident refusal of medication and reason, contact physician for guidance. (Copy obtained) .

Based on observation, dietary staff interview, facility document review, and facility policy and procedure review, the facility failed to store, prepare, and serve food under sanitary conditions when the dietary staff failed to wash hands between glove changes and change gloves when contaminated, as required. Food was stored in the walk-in cooler and walk-in freezer uncovered and not date marked. Food was kept beyond the allowed use by date. Baking sheets were wet nesting. Cutting boards were deeply grooved and in need of replacement. Handwashing sinks had no signage posted to indicate the sink was for handwashing only. The handwashing sink in the dish room was blocked by a mop bucket, broom, and dustpan. Food was observed on the floor of the freezer. Paper products to be used by residents were stored on the floor in the nutrition room. Hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a food safety hazard and a potential source of pathogen exposure for residents. The findings include: On 03/21/22 at 9:54 AM, Dish Room Aide D was observed putting insulated domes that had been washed and were still wet on a rack to air dry. He then went back to the dirty side of the dish room and started rinsing the dirty dishes and loading them into the dish machine. He then went to the clean side of the dish room and stacked the clean glasses on a pan. He did not change his gloves or wash his hands. He continued to go back and forth between the dirty and clean side without changing his gloves or washing his hands. At 10:14 AM, he changed his gloves but did not wash his hands. On 03/21/22 during the 9:54 AM kitchen observation, large stainless steel baking pans were observed to be wet and stacked on top of each other, not able to air dry on a rack near the dish room. Four large cutting boards were worn and deeply grooved. The handwashing sinks had no signage posted to indicate the sink was for handwashing only, and that staff must wash their hands. The milk cooler had no internal thermometer. Inside one milk crate was observed one quart-size carton of whipping cream that had not been opened and was dated 03/19/22. (Photographic evidence obtained) The Certified Dietary Manager (CDM) stated, I don't know why he left that in here. He was just here. Speaking in reference to the milk delivery man. On 03/21/22 at 10:20 AM, the walk-in cooler was observed with a large ham that was on a tray with plastic wrap covering it. There was no date mark. The CDM stated she thought a dietary aide had opened the package and sliced off a piece last Friday (03/18/2022). (Photographic evidence obtained) Cheese sandwiches were observed prepared and stacked in a large stainless steel pan with plastic wrap covering part of the pan. The sandwiches were not date marked. (Photographic evidence obtained) Eleven quarts of scrambled egg mix were on a tray on a bottom shelf. The date mark on the cartons was 03/07/22. (Photographic evidence obtained) The CDM confirmed they were out of date and needed to be discarded. Sliced cheese wrapped in plastic wrap was observed stacked on a large pan. The opened packages were not date marked. (Photographic evidence obtained) A cardboard box with cucumbers had one cucumber wrapped in plastic wrap with no date mark. (Photographic evidence obtained) A plastic re-sealable bag with sliced corned beef was dated 03/11/22. (Photographic evidence obtained) A pan of baked fish sitting on a shelf was observed to be uncovered. (Photographic evidence obtained) Two pans were observed covered with aluminum foil with no date marks. (Photographic evidence obtained) A plastic container was observed with lettuce in it. It was not covered or date marked. (Photographic evidence obtained) The CDM stated the expectation was that the dietary staff would cover the food and date mark it in the cooling units. On 03/21/22 at 10:42 AM, the walk-in freezer was observed with frozen beef patties uncovered in a box. (Photographic evidence obtained) Frozen plant-based chicken strips were observed uncovered in the freezer.(Photographic evidence obtained) There were two packages of unidentified frozen food observed on the floor of the freezer. (Photographic evidence obtained) During a second tour of the kitchen on 03/23/22 at 11:16 AM, observed in the walk-in cooler was the same plastic re-sealable bag with sliced corned beef that was dated 03/11/22. (Photographic evidence obtained) Observed in the walk-in freezer was the box of frozen beef patties still open and uncovered. An open box of frozen zucchini sticks was observed. (Photographic evidence obtained) The handwashing sink was still blocked by the mop bucket, broom and dust pan. There was still no signage at the sink. (Photographic evidence obtained) Observed wet nesting of baking sheets and pans. (Photographic evidence obtained) Dietary Staff C was observed preparing the lunch meal in the main kitchen on 03/23/22 from 11:50 AM until 12:25 PM. At 12:04 PM, he was observed wearing a pair of disposable gloves and was cooking the vegetables and meat patties. He touched the handle on the walk-in cooler, returned to the preparation area and continued to prepare the meal. He did not change his gloves. At 12:15 PM he changed gloves but did not wash his hands in between. He touched the handles of the oven and utensils used for the preparation of the meal. He moved food pans from the preparation area to the steam table, using a pair of oven mitts, touching the surfaces of the steam table. He doffed the oven mitts and donned new disposable gloves without washing his hands. On 03/23/22 at 12:35 PM, the Bistro kitchen and nutrition room on the second floor of the facility were toured. Paper products were stored on the floor in the nutrition room. (Photographic evidence obtained) On 03/23/22 from 12:35 PM until 12:50 PM, Housekeeping Staff Q and Social Services Staff R were working in the Bistro kitchen during the lunch food service and were observed donning and doffing disposable gloves without washing their hands in between. Social Services Staff R was preparing sandwiches on a panini press. She touched the utensils to make the sandwiches and kitchen equipment with her gloved hands and then touched the ready to eat sandwiches with her contaminated gloves. The hand sink for employees to wash their hands was located in the nutrition room next to the Bistro kitchen. During an interview with Dietary Staff C on 03/24/22 at 8:25 AM, he was asked if he was supposed to change his gloves when they became contaminated and wash his hands prior to donning new gloves. He replied Yes. Did I not do that? When he was informed that he was observed on 03/23/22 during the lunch meal service not changing gloves as needed and not washing his hands prior to donning new gloves, he stated, Oh, I'm sorry. I was a little nervous. During a 03/24/22 interview with the CDM at 8:35 AM, she stated she was not aware that her staff were changing gloves without washing their hands. She agreed that the food in the cooler and freezer was not covered. She stated the staff were running in there in a hurry, grabbing what they needed and then not covering it again. She confirmed that she did not have enough room in the kitchen to air dry the dishes. A review of the Food Storage Chart For Safety and Quality, used by the facility for date marking and shelf time, revealed prepared meat products should be kept only three days wrapped in the refrigerator. (Copy obtained) A review of the staff training dated 03/09/22, entitled Food Handling and Food Safety, Glove Usage, revealed Dietary Staff Q and Social Services Staff R received the training. A review of the staff training dated 02/17/22, entitled Storage of Foods Food Safety and Leftovers, revealed Dietary Staff C received the training. A review of the facility policy and procedure for Food Storage Overview revealed: Purpose: Food is stored by methods designed to prevent contamination. 3. Food items should be stored on shelves. 4. Containers are to be labeled. 11. Food is stored a minimum of 6 inches above the floor. 12. Leftover food is stored in covered containers or wrapped securely. Each item is securely labeled and dated before being refrigerated. Leftover food is used within 2 days or discarded. 14. e. Foods are to be covered, labeled, and dated including month, day, and year. A review of the facility policy and procedure for Glove Use revealed: Wash hands thoroughly before and after wearing or changing gloves. .

Based on a review of the Facility Assessment, CMS (Centers for Medicare and Medicaid Services) form 672 (Census and Condition of Residents), and interviews with staff, the facility failed to update the Facility Assessment on an annual basis in order to assess the population's acuity level and determine what resources were needed to provide care for its residents during not only day-to-day operations, but during an emergency. The facility also failed to employ the input of facility staff members including the Medical Director, Director of Nursing, any member of the governing body, residents or their representatives. This had the potential to affect all 124 residents in the facility. Without a comprehensive assessment of the residents' diagnoses, conditions and needs, the facility was not able to determine staff competencies required to provide appropriate care, nor the environment or equipment needed to perform such care. The findings include: A review of CMS form 672, Census and Condition of Residents, found there were 124 residents in the building at the time of the survey. Some of the current population's special care needs included, but were not limited to: 7 indwelling catheters, 3 bedfast residents, 10 residents with contractures, 14 residents with pressure ulcers, 6 residents with depression, 7 residents with dementia, 9 residents receiving hospice services, 4 residents on dialysis, 3 residents requiring ostomy care, 55 residents receiving psychotropic medications, 34 residents requiring injections, 6 residents receiving tube feedings, 65 residents requiring rehabilitative services, and 4 residents with significant weight loss. The Director of Nursing (DON) signed the CMS 672 on 3/21/22. (Copy obtained) A review of the Facility Assessment (FA), dated 2022, found there were two people involved in completing the assessment; the Administrator and the Compliance Officer. The FA was updated in 3/2020, 10/2020, 1/15/2021 and 1/2022, and the Quality Assurance and Performance Improvement (QAPI) committee reviewed the FA on those same dates. The Resident Profile section reported there were 146 licensed beds. It also asked for the following information: -Average daily census. -Average weekday admissions in 2021. -Average weekend admissions in 2021. -Average weekday discharges in 2021. -Average weekend discharges in 2021. Each section's response noted, Fluctuations due to Covid-19. The section titled Common Diagnoses/Conditions, provided general examples falling under each condition, however, the Acuity section of the FA asked for the following data based on resident needs: -Rehabilitation Plus Extensive Services. -Rehabilitation. -Extensive Services. -Special Care High. -Special Care Low -Clinically Complex. -Behavioral Symptoms and Cognitive Performance. -Reduced Physical Function. All fields asking for the number/average range of residents was left blank. The Special Treatments and Conditions section asked for data on the following resident needs: -Cancer treatments (chemotherapy and radiation), respiratory treatments (oxygen therapy, suctioning, trachesostomy care, ventilator/respirator or BIPAP/CPAP machines). -Mental health services (behavioral health needs, substance abuse disorders). -Other services (Intravenous medications, injections, dialysis, ostomy care, hospice, respite care, isolation or quarantine for active infection diseases and advanced wound care needs). All of the corresponding fields asking for the typical number of residents with these needs were blank. The Assistance with Activities of Daily Living - Currently In-house section asked how many in-house residents required assistance with dressing, bathing, transfers, eating, toileting, mobility or other care needs. All fields were left blank. Section 3, Facility Resources Needed, revealed the facility staffing patterns were based on an average of 125 residents, however, this pattern was considered without first identifying the above resident-specific information. The final Risk Assessment section of the FA, the SWOT (Strengths, Weaknesses, Opportunities and Threats) Analysis was left blank for all 4 sections. (Copy obtained) An interview was conducted with the Administrator on 03/24/22 at 5:43 PM. He was asked where the updates to the 2022 FA were, since there was no assessment of the acuity levels of his resident population. He stated the facility's needs changed last year. After serving all COVID-19-positive residents, the census went to zero then built back up. He had no other explanation as to why residents' needs had not been assessed since initial licensure. He was asked if he had considered that initially, because there were primarily COVID-19-positive residents in the building, and each of those residents had conditions and special treatment needs other than COVID-19. He admitted he had not included that information in the assessment. The Administrator acknowledged after the facility zeroed out on the census, then rebuilt, the new residents' needs were also never assessed in order to determine proper staffing and other resources required to meet those needs. The Administrator was reminded that the FA was driven by census and acuity levels of the residents and without that information, it was not possible to accurately assess facility resources required. He acknowledged the requirement. The Administrator also confirmed that only he and the Compliance Officer were involved in the FA completion. He was not aware additional team members should be involved in its development in order to comprehensively assess needs and plan for meeting those needs. The Administrator stated he would review the FA requirements again. .