2. A review of Resident #19's medical record revealed an admission date of 1/21/2020 with diagnoses including a contracted right hand, need for assistance with personal care, cognitive communication disorder, other symptoms involving the musculoskeletal system, other cervical disc displacement, tremors, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. Further review of Resident #19's medical record revealed a Quarterly Minimum Date Set (MDS) assessment with a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 points, indicating moderate cognitive impairment. No behaviors were indicated, and the need for partial/moderate staff assistance with personal hygiene, transfers and bed mobility, and substantial/maximal staff assistance with transfers was documented. A review of Resident # 19's active care plan revealed the following focus areas: FOCUS: ADL self-care performance deficit related to Dementia. Goal: Resident will maintain current level of function in ADLs through the review date. Intervention: Bathing/Showering: Check nail length and trim and clean on bath schedule and as necessary. FOCUS: Resident at risk for loss of range of motion related to existing contractures of right hand. Goal: He will have no loss of skin integrity related to contractures. Interventions: Assist in keeping fingernails short and trimmed. A review of Resident #19's progress notes revealed that skin checks dated 11/1/2024 at 3:41 PM revealed: Resident skin is clear no impairment. Resident nails cleaned and trimmed. On 11/04/24 at 10:54 AM, Resident #19's right and left hands were observed and revealed fingers contracted on both hands with long fingernails and brown matter underneath. On 11/05/24 at 10:37 AM, Resident #19 was observed resting in bed. A carrot/splint was observed on his overbed table. The fingernails on his right and left hands were long with brown matter underneath. On 11/06/24 at 3:26 PM, Resident #19 was observed resting in bed. He was asked if staff had trimmed or cleaned his fingernails today and he answered, No. The fingernails on his right and left hands were long with brown matter underneath. (photographic evidence obtained) On 11/07/24 at 9:13 AM, an interview was conducted with Registered Nurse (RN) E. She stated, Nursing is responsible for nail care and nail care is performed during showers or anytime it's needed. A review of the facility's policy titaled Nail Care, Clinical services (implemented 9/1/2023), revealed: Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during ADL care and on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. Based on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain good grooming and personal hygiene for two (Residents #48 and #19) of three residents reviewed for ADL care from a total survey sample of 46 residents. The findings include: 1. A review of Resident #48's medical record revealed an admission date of 09/01/23 with diagnoses including Type 2 diabetes mellitus (T2DM), acute chronic diastolic (congestive) hear failure, muscle weakness (generalized), pleural effusion, legal blindness, end stage renal disease (ESRD), hyperthyroidism, arteriosclerotic heart disease of native coronary artery, major depressive disorder, generalized anxiety disorder, and hypertension. On 11/05/24 at 10:20 AM, an observation was made of Resident #48's fingernails which were long with brown matter underneath. (photographic evidence obtained) On 11/07/24 at 8:56 AM, an observation was made of Resident #48's fingernails which remained long with brown matter underneath. (photographic evidence obtained) A review of Resident #48's annual minimum data set (MDS) assessment, dated 08/05/24, revealed that he had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. No hallucinations or delusions were documented, no physical or verbal behavioral symptoms directed towards others, and no rejection of care or wandering behaviors were documented. An interview with the resident for daily preferences or daily activities was not documented. The resident had no impairment of the upper or lower extremities; required supervision or touching assistance with eating and oral hygiene; required substantial/maximum assistance with toileting, shower/bathing, upper and lower body dressing, and putting on/taking off footwear and personal hygiene. He required substantial/maximum assistance with mobility. He did not receive scheduled or as needed (prn) pain medications. A review of Resident #48's care plan documented a focus area for Activities of Daily Living (ADL) Performance Deficit related to activity intolerance and end-stage renal disease (ESRD). The care plan goal was to improve the current level of function in at least one of the resident's ADLs by the next review date. The care plan interventions included provision of personal hygiene and oral care. The resident required staff participation with personal hygiene and oral care. The date the intervention was created was documented as 9/13/2022. On 11/07/24 at 9:02 AM, Certified Nursing Assistant (CNA) A was interviewed and reported that she had worked at the facility for two months. She explained that she made care rounds every two hours. During care rounds, she would make a visual head-to-toe check of residents assigned to her. The visual head-to-toe check included looking at fingernail length and condition. The process for completing her rounds began with checking the resident's vital signs and providing breakfast. After breakfast, she provided ADL care, gave her assigned residents a shower, and got them ready for therapy. She explained that she was familiar with Resident #48 and his care needs. He was blind and received eye drops. She stated she had not clipped the resident's fingernails because there had been no access to nail clippers for some time. The nail clippers were usually located in the clean utility room and the person in charge of supplies said nail clippers were on backorder. She stated nails extending approximately a half a centimeter beyond the nail bed were considered too long and could be considered a scratching hazard. At 9:11 AM, CNA A was accompanied to the resident's room. She observed the resident's fingernails and reported that they were too long and looked like weapons. On 11/07/24 at 9:12 AM, Licensed Practical Nurse (LPN) B was interviewed and reported that he had worked at the facility for three months. He explained that nurses were responsible for conducting a head-to-toe skin assessment of residents once a week, which included looking at fingernail length. Residents also received a skin assessment when they received either a bed bath or shower two times per week, which included looking at fingernail length. He stated he always carried fingernail clippers in his pocket, kept a supply of clippers in a drawer at the nurses' station, and also in his personal work desk. Fingernail clippers could also be found in the clean utility room. If CNAs could not locate fingernail clippers in those areas, they could ask their nurse or go to the central supply room to obtain a pair. He also instructed CNAs to take fingernail clippers with them when they provided bed baths and showers. LPN B stated nail length that was considered as excessive was subjective. He made sure to first ask the resident of the fingernail length they preferred. Some male and female residents did not mind long fingernails. For his non-verbal residents, he ensured fingernail length was short enough to prevent them from scratching themselves. On 11/07/24 at 9:19 AM, LPN B was accompanied to Resident #48's room. He observed the length of the resident's fingernails and stated Resident #48's fingernails were excessively long. LPN B reviewed a nursing progress note dated 10/28/24 (10 days prior to this interview), which documented that a skin check was completed and the resident's nails were cleaned and clipped. LPN B stated the resident's fingernails could not have been cleaned and clipped on the documented date because the fingernails could not have grown to their present length within 10 days. On 11/07/24 at 9:24 AM, an observation was made of two pairs of fingernail clippers in a desk drawer at the east nursing station. On 11/07/24 at 9:26 AM, CNA C was interviewed and reported that she had worked at the facility for 17 years. She was responsible for stocking the main central supply room and the east and west wing clean utility rooms. She displayed five boxes of small, medium and large nail clippers in the main central supply room, each box containing 24 clippers. The main supply room also had a large plastic bag full of various sizes of fingernail clippers. She said that she stocked the clean utility rooms with various items, including fingernail clippers two or three times a week and reported that CNAs could not say that they could not clip fingernails because they did not have supplies.

Based on observations, record reviews, interviews, and a review of facility policy, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one (Resident #72) of one resident reviewed for accident hazards out of 46 residents in the total survey sample. Medicated ointments in plastic medication cups were left at the resident's bedside. Resident #72 had not been assessed for capability of self-administering/applying medicated ointments. No self-administration assessment was found in the record or provided by the facility during the survey. No care plan was located in the record indicating that the resident was capable of safely self-administering medications/medicated ointments. The findings include: On 11/04/24 at 10:43 AM, two medication cups were observed on the resident's bedside table. (photographic evidence obtained) An interview was conducted with the resident at the time of this observation, who reported that the cups contained her medications, which were the two creams she applied to both her hands for psoriasis. She stated, The nurse brought them in here and left them over there. I usually put them on myself. On 11/05/24 at 10:28 AM, two medications cups were observed on the bedside table. (photographic evidence obtained ) An interview was conducted with the resident at the time of the observation, who confirmed that the cups contained creams she applied to her hands and they were not the same ones from the previous day. On 11/07/24 9:33 AM, two medication cups were observed on the bedside table (photographic evidence obtained) An interview was conducted with the resident at the time of the observation, who confirmed that the two cups containing medicated creams were left over from the previous day. A review of Resident #72's medical record revealed an admission date of 02/03/23 with diagoses including encephalopathy, need for assistance with personal care, other signs and symptoms involving cognitive function and awareness, and psoriasis. No Medication Self-Administration Assessment form was located in the resident's record. A review of Resident #72's Quarterly minimum data set (MDS) assessment, dated 07/23/24, revealed she had a brief interview for mental status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. She required substantial/maximal staff assistance with toileting, transfers, and personal hygiene. A review of Resident #72's active physician's orders revealed: Clobetasol Propionate External Cream 0.05%, apply to both hands topically twice daily for psoriasis of hands. Calcitrene External Ointment 0.005%, apply to both palms topically twice daily until resolved. (ordered 9/11/2024) A review of Resident #72's baseline care plan, dated 02/04/2023 (Admission), revealed in Section 3. Health Conditions, B: Level of Consciousness, 2. a. cognitively intact and b. cognitively impaired/forgetful, D. Medications, 2. Self-administer medications, a. No. A review of Resident #72's active Care Plan revealed the following focus areas: FOCUS: Cognitive-Communication deficit as evidenced by impaired safety awareness and insight (initiated 2/28/2023, revised 2/28/2023) FOCUS: Resident has an ADL (Activities of daily living) self-care performance deficit related to encephalopathy. (initiated 3/15/2024, revised 3/15/2024). No care plans were found in the record indicating that Resident #72 had been assessed and was capable of self-administering medications or medicated ointments. On 11/07/24 at 9:21 AM, an interview was conducted with Licensed Practical Nurse (LPN) D. She stated there were no residents on her unit who self-administered their medications or treatments. She was asked to explain the facility's process for allowing a resident to self-administer medications or treatments. She explained that the facility had an assessment that was completed by a nurse or the Unit Manager to determine whether or not the residents were capable of self-administering medications. She was asked if the nurse was required to observe the resident during self-administration of the medication or treatments. She replied, Yes. She was asked where the medications were stored if the resident self-administered. She stated, I need to check the policy. She was asked if the nurse was permitted to leave medications or treatments at the bedside for the resident to administer for themselves. She replied, If they have an assessment that confirmed they can self administer, but it must be care planned. On 11/07/24 at 9:38 AM, an interview was conducted with LPN B, the Unit Manager for the East unit. He stated he was familiar with Resident #72 and the condition of the skin on both her hands. He was aware that she received creams for the treatment of her hands. He stated, Yes, she has creams she gets three times daily that she puts on. He was asked if she ever refused her treatments. He replied, No. He was asked to explain the process for allowing a resident to self-administer medications or treatments. He stated, The care plan must reflect the self-administration of medications and the resident has to have a BIMS of 13 or above. That's all as far as I know. He was asked if the nurse was required to observe when the resident self-administered medications or treatments. He stated, Yes, the nurse must be there. On 11/07/24 at 12:20 PM, the completed Medication Self-Administration Assessment Form for Resident #72 was requested from the Director of Nursing (DON). It was never provided. On 11/07/24 at 2:21 PM, the DON was asked to provide any additional documentation as evidence that Resident #72 had been assessed for self-administration of medications/treatments. No further evidence was provided. A review of the facility's policy titled Resident Self-Administration of Medication, Clinical Services (implemented 9/1/2023), revealed: Policy Explanation and Compliance Guidelines: 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-administration Assessment Form, which is placed in the resident's medical record. 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into other residents' rooms or to confused roomates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider. 13. The care plan must reflect self-administration and storage arrangements for such medications. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, for one (Resident #34) of one resident reviewed for respiratory care, from a total survey sample of 46 residents. Resident #34 was not receiving oxygen at the flow rate ordered by her physician. The findings include: On 11/04/24 at 11:20 AM, Resident #34 was observed fully dressed sitting in her wheelchair inside her room wearing a nasal cannula with an oxygen tank on the back of her wheelchair. She reported receiving oxygen at a flow rate of 1.5 liters per minute (L/min) when she was in her wheelchair and 3.0 L/min when in bed and sleeping. Resident #34's oxygen concentrator located at bedside was observed to be set at 3.0 L/min. On 11/07/24 at 10:11 AM, Resident #34 was observed fully dressed in the main dining room sitting in her wheelchair wearing her nasal cannula with the portable oxygen tank located on the back of her wheelchair turned off. When the resident was asked for permission to observe her oxygen tank settings, she replied, I have not had the opportunity to turn the machine on. Resident #34 asked Activities Assistant M to turn on her oxygen. Activities Assistant M turned on the portable oxygen tank that was located at the back of the resident's wheelchair. The flow rate was set at 1.5 L/min. On 11/07/24 at 11:33 AM, Resident #34 was observed transferring herself from her wheelchair to her bed. She was not wearing her nasal cannula but her oxygen concentrator was observed in the on position with a flow rate set at 3L/min. (Photographic evidence obtained) A review of the resident's active physician's orders revealed: Oxygen at 4 L/min via Nasal Cannula, continuously, every day and night shift for oxygen management dated 9/3/24; (copy obtained) A review of Resident #34's medical record revealed an admission date of 9/3/24 with a previous admission date of 11/9/23. Her diagnoses included chronic respiratory failure with hypoxia; acute respiratory failure with hypoxia, unspecified asthma, respiratory syncytial virus (RSV - contagious virus that causes infections of the respiratory tract) as the cause of diseases classified elsewhere; dependence on supplemental oxygen; major depressive disorder, generalized anxiety disorder, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, anxiety disorder, and major depressive disorder. A review of the Quarterly minimum data set (MDS) assessment dated [DATE], revealed that the resident was assessed with shortness of breath or trouble breathing while lying flat and required oxygen therapy. A review of the active Care Plan revealed focuses and goals including oxygen therapy related to ineffective gas exchange and use of antipsychotic medication. Interventions included administration of medication as ordered, monitoring for and documenting side effects and effectiveness of medications, and oxygen as ordered. A review of the resident's Medication Administration Records (MARs) for October and November 2024 revealed that oxygen was provided as ordered by the resident's physician. (copy obtained) On 11/7/24 at 11:21 AM, Registered Nurse (RN) E reported that the facility's portable oxygen tanks could hold 10 - 15 liters of oxygen. Staff were expected to check oxygen tanks frequently. On 11/07/24 at 11:36 AM, RN E verified that Resident #34's oxygen concentrator, located at her bedside, had a flow rate set at 3L/min, and stated the oxygen concentrator should have been set at 4L/min. Nursing staff provided ongoing monitoring of the resident's oxygen therapy. Nursing was responsible for ensuring that the resident was receiving the correct oxygen flow rate per the physician's order. Correct oxygen flow rate settings were identified by checking the physician's orders. Nursing staff on the 11-7 PM shift were responsible for changing the resident's oxygen tubing. Correct flow rate settings were communicated from one nurse to another via shift change reports and reviewing orders in the computer. Resident #34 did not refuse oxygen therapy, but she would sometimes rush to leave her room and nursing then had to track her down. On 11/07/24 at 12:33 PM, the Director of Nursing (DON) confirmed that correct oxygen settings were identified by verifying the order in the computer or by calling the physician. On 11/07/24 at 1:03 PM, the DON stated nursing was responsible for changing the oxygen settings on the concentrator and on the portable oxygen tank located on the back of Resident #34's wheelchair. When asked whether anyone else could or did change the settings, the DON replied, No, nursing. A review of the facility's policy and procedure titled Oxygen Administration (implemented on 03/2024), revealed: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency . 2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists. (copy obtained) .

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen. The facility failed to 1) Date mark open packages of croutons and tea bags, 2) Clean grease build-up inside and around the door area of the convection oven, 3) Clean grease and food substances from the inside door area and oven floor, 4) Clean grease and food debris from the oven tray, 5) Clean food debris stuck on and around the safety guard of the mixer, 6) Clean food debris stuck on the meat slicer, 7) Clean one of two microwaves located in the east unit nourishment room, 8) Clean the ice machine dispenser tray located in the west unit nourishment room, and 9) Address condensation build-up in the walk-in freezer. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 11/04/24 at 9:40 AM. During the tour, no date markings were observed on one open package of croutons or one open package of tea bags located on the rack in the dry storage room. Condensation build-up was observed in the walk-in freezer and water leaks were observed on the floor coming from the walk-in freezer. Observation of the open package of croutons and tea bags, water on the floor around the walk-in freezer area, and condensation build-up in the walk-in freezer were made again on 11/05/24 at 8:51 AM. (photographic evidence obtained) A follow-up tour of the kitchen was conducted on 11/06/24 at 10:45 AM. During the tour, the convection oven next to the oven was covered with food grime and grease build-up. The inside oven door area and oven floor next to the convection oven were covered with grease and food substances. The oven tray was filled with grease and dried food debris. The mixer located across from the meat slicer had food debris stuck on and around the safety guard. Food debris was stuck on the meat slicer. The inside top area of the microwave, located in the east unit nourishment room, was filled with food debris, and the west unit nourishment room's ice machine's dispenser tray was covered with a white substance. (photographic evidence obtained) On 11/7/24 at 1:23 PM, another observation was made of the open package of croutons and tea bags in the dry storage room, condensation build-up in the walk-in freezer, the convection oven remained covered with food grime and grease build-up, and the inside oven door area and oven floor were covered with grease and food substances. The oven tray was filled with grease and dried food debris, and the mixer located across from the meat slicer had food debris stuck on and around the safety guard. (photographic evidence obtained) On 11/07/24 at 12:10 PM, Dietary Aide J reported that dietary aides and cooks were responsible for stocking the dry storeroom. The facility's policy around date marking food was to date and discard after three days. Cooks were responsible for cleaning kitchen and food service equipment daily or after each use. Dietary aides were responsible for cleaning the microwaves and ice machines in the nourishment rooms. On 11/07/24 at 12:19 PM, [NAME] K reported that the dietary aides were responsible for stocking dry foods in the dry storage room, and the cooks were responsible for stocking frozen and produce foods. The facility's policy around date marking food was to add the open date, use by date, and discard after three days. Cooks were responsible for cleaning the meat slicer and mixer. [NAME] K stated the menu had not required kitchen staff to use the mixer. Kitchen equipment was cleaned each Wednesday. Dietary aides were responsible for cleaning the microwaves and ice machines in the nourishment rooms. When asked to explain the condensation build-up in the freezer, [NAME] K replied, It was reported to the Certified Dietary Manager (CDM). The freezer shields would get stuck and the door will open itself if you're not paying attention. On 11/07/24 at 12:51 PM, Maintenance Director L reported that Maintenance requests were received from staff verbally and through the computer. He added verbal requests to the computer. He was aware of the condensation build-up in the walk-in freezer. He said the gasket was replaced twice and Maintenance was currently monitoring. He reported the freezer issue to the vendor on 10/29/24 via a verbal conversation. The vendor stated they would stop by the next day. There was no documented evidence of the request for service. There had been no follow-up with the vendor since 10/29/24. A review of the facility's policy and procedure titled Food Safety Requirements (undated), revealed: Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handing process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: . b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms . e. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food . 3ci. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation . iv. Labeling, dating, and monitoring refrigerated foods, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. keeping foods covered or in tight containers . 8e. Cleaning and sanitizing the internal components of the ice machine according to manufacturer's guidelines. (copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 5/24/2024): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-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 observation, interviews, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, by failing to provide dermatology consults as ordered for one (Resident #4) of four sampled residents. The findings include: On 8/26/2024 at 11:44 am, Resident #4 was observed in her room with several areas of blotches (dark red in color) and scaly skin on the palm of her left hand. A blue plastic glove was covering her right hand. When questioned about her hands, Resident #4 stated, she had an unknown skin condition which affected both her hands. She stated that it was present upon her admission into the facility. She was getting a topical cream for it; however, she hadn't received it in some time. She did not know if it had been discontinued nor did she know the proper diagnosis. Resident #4 explained that the facility nurses had advised her that she needed to see a dermatologist, but she had not seen one yet. The condition was painful, and she wore the glove on her right hand to keep it moisturized. With the resident's permission the glove was removed. Multiple blotches (dark red in color), dry peeling, scaly skin and an open area to the palm of the resident's right hand were observed, along with redness and peeling to several of the fingers on her right hand. (Photographic evidence obtained) Review of Resident #4's medical record revealed an admission date of 2/3/2023. Her diagnoses included encephalopathy; acute respiratory failure with hypoxia; unspecified atrial fibrillation (Afib); other symptoms & signs involving cognitive functions and dependence on supplemental oxygen. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 13 out of 15 possible points, indicating intact cognition for Resident #4. Review of the clinical skin assessment revealed Resident #4 was at risk for developing pressure ulcers however; no pressure ulcers were present. Treatments included: applications of ointments/medications other than to feet. Review of the resident's physician orders included: dermatology consult dated 4/15/2024, dermatology consult for reddened dry flaky skin to bilateral palms 8/25/2023, and weekly skin checks. Review of the most recent care plan revised on 8/15/2024 included: FOCUS At risk for alteration in skin integrity related to decreased mobility, GOAL The resident will have no alteration in skin integrity; INTERVENTION Preventative skin care with turning and positioning, pericare, lotions and other interventions as ordered. FOCUS The resident has potential for pressure ulcer development related to impaired mobility, impaired cognition, GOAL The resident will have intact skin, free of redness, blisters or discoloration b/through review date INTERVENTION Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Monitor nutritional status. Serve diet as ordered, monitor intake and record. (Photographic evidence obtained) On 8/26/2024 at 4:30 pm, an interview was conducted with Employee A, Registered Nurse (RN) who was familiar with Resident #4. She referred to her as a nice lady. She stated the resident had dermatitis to her hands and that she received an ointment for it. She stated the resident was waiting to see the dermatologist and added it was not getting any better. The resident wore gloves on her hands because they peel. When asked if the resident had seen a dermatologist at the facility, she stated, she was not sure if/when the resident had seen the dermatologist. She explained that a third-party dermatologist comes to the facility once a month to see residents and that Resident #4 had been referred to the provider. On 8/26/2024 at 4:49 pm, a follow up interview was conducted with Employee A, RN. She stated that she was not able to locate any dermatology visit notes for Resident #4. She confirmed there were orders for a dermatology consult on 8/25/2023 and also 4/15/2024. When asked about the resident's medication orders, she confirmed that Resident #4 had orders for, Clotrimazole antifungal cream 1%; Tacrolimus 0.1% external ointment and at one point in the past she received Prednisone. Employee A, RN, stated the orders had all ended. On 8/26/2024 at 5:21 pm, Employee A, RN returned with some orders for Resident #4. She confirmed the topical creams were only for a scheduled amount of time and not a standing order. She again confirmed they were not able to locate any of records of a dermatology visit for the resident. During an interview on 8/26/2024 at 5:24 pm with the Director of Nursing (DON), he stated he was not familiar with Resident #4. He confirmed that there was a third-party dermatologist who provided services to residents. He stated the last time the dermatologist was in the facility was on 8/20/2024. He reviewed the orders for Resident #4 and stated she had an order for a dermatology consult on 8/25/2023. He confirmed the resident was not seen on the 8/20/2024 visit nor was he able to locate any documentation that she was ever seen by a dermatologist. He stated the Social Service Director (SSD) typically adds the residents to the list for third party services and he would consult with the SSD regarding Resident #4. On 8/26/2024 at 6:12 pm, an interview was conducted with the Administrator and DON. They stated after consulting with the SSD they were unable to locate any documentation indicating Resident #4 had been seen by the dermatologist as ordered while she resided in the facility. .

Based on observations, interview, record review, and facility policy and procedure review, the facility failed to ensure the privacy and confidentiality of protected health information (PHI) for 15 of 15 residents receiving skilled therapy services, by posting a list of residents on the counter top of the East and [NAME] wing nurses' station, visible to other residents and guests. The findings include: On 09/19/2023 at 10:00 am, an observation of the nurse's station on the East Wing revealed a list of fifteen (15) resident names receiving therapy with their appointment times, wing, room, type, duration, and therapy provider taped down to the top of the counter. This information could be seen by residents and guests who were observed passing along the hallway. (Photographic evidence obtained) On 09/19/2023 at 10:23 AM, an observation of the nurse's station on the [NAME] Wing revealed a list of fifteen (15) resident names receiving therapy with their appointment times, wing, room, type, duration, and therapy provider taped down to the top of the counter. This information could be seen by residents and guests passing by the nurses' station. (Photographic evidence obtained) During a second observation of the East Wing nursing station on 09/19/2023 at 1:00 PM, the resident therapy list was still taped to the counter. During a second observation of the [NAME] Wing nursing station on 09/19/2023 at 1:05 PM, the resident therapy list was still taped to the counter. Further review of the resident daily therapy schedule sheets posted on the counter top of the East and [NAME] Wing nurses' station revealed the following statement at the bottom of the documents: This document contains Protected Health Information (PHI) and therefore must be disposed of properly. Confidential (Photographic evidence obtained) In an interview with the Director of Rehabilitation on 09/19/2023 at 2:03 PM, she stated that the lists of residents and their appointments times were posted at the nurses' stations for the Certified Nursing Assistants (CNAs) so they would know who to get up first in the mornings and who to keep up after lunch, etc. She said that she has worked at this facility for five months and they have been posting the lists on the top counter of the nurse's station since she's been here. She acknowledged it was a confidentiality breach of PHI for each of the residents listed on the form. A review of the facility's policy and procedure Residents Rights Guidelines for All Nursing Procedures (Revised October 2010), revealed: Purpose: To provide general guidelines for resident rights while caring for residents. Preparation: 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: e. Confidentiality of protected health information. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to maintain and implement an infection prevention control program to provide a safe, sanitary and comfortable environment. The facility staff failed to ensure the proper use of protective equipment (PPE) in transmission base precaution (TBP)/COVID-19 isolation room for three (Residents #3, #7, and #6) of four sampled residents; and the facility failed to ensure all staff used proper hand hygiene in a TBP room/COVID-19 isolation room (rooms [ROOM NUMBERS]). Failure to adhere to infection control and prevention protocol increase the risk of transmitting communicable diseases and infection. The findings include: During a tour of the facility on 09/19/2023 at 12:30 PM, room [ROOM NUMBER] was observed to have a sign posted for droplet precautions and isolation instructing staff to cover their eyes, nose and mouth completely. (Photographic evidence obtained) The storage cart for PPE next to the room door in the hallway had no gowns or eye protection stored in the cart. Observations of the PPE carts outside TBP rooms #202, #204, and #210 revealed there were no gowns. PPE was requested of a Certified Nursing Assistant (CNA), Employee L working in hallway. The CNA returned with one blue gown and no other PPE. She did not fill the storage carts with more PPE. During an interview with Resident #3 in her room on 09/19/2023 at 12:33 PM, she confirmed that she was in isolation for COVID-19. She expressed understanding of the need to remain in isolation. During this time, Employee L entered the room with no gown, gloves or eye protection on. She was wearing a facemask. Resident #3's roommate, Resident #7, asked Employee L to purchase a soda for her. Resident #7 handed Employee L two dollars. Employee L told Resident #7 she would and left the room. She returned to the room at 12:35 PM with a soda and a quarter and told Resident #7 it was her change. Employee L did not don PPE prior to entering the room for the second time. She went over to the B-bed side of the room and asked Resident #7 and Resident #3 if they needed anything. When asked about the garbage can for doffing the PPE gown, Employee L stated, Oh don't get me started. She stated that the facility sometimes does not provide the appropriate PPE or garbage receptacles for the contaminated PPE. When asked where the paper towels were for hand washing, she stated, See what I mean? She left the isolation room and went down the hall to get paper towels for this surveyor. She returned with a handful of towels and handed them to this surveyor. She did not fill the towel dispenser in the isolation room. She did not wash her hands prior to leaving the isolation room. On 09/19/2023 at 12:45 PM, Employee N, CNA was observed in room [ROOM NUMBER]. The room had signage posted that it was an isolation room. A cart with PPE was located outside the room in the hallway. Employee N had donned a gown, gloves and mask. He was stripping the A-bed (Resident #5's) and bagging up the dirty linens. He had three bags of dirty linens tied up on the floor near the door. The resident was not in the room. The resident's roommate was in the room on the B-bed side seated in his wheelchair. The CNA doffed the gown and gloves into the garbage can and tied up the garbage bag. He removed the garbage bag and picked up the three bags of dirty linens and walked out of the room. He explained that he was taking the soiled linen to the laundry room and the garbage to the soiled utility room. He takes the soiled linen directly to the laundry room because it is so close to that unit. He opened the door to the soiled utility room and threw the bag of garbage into a large bin full of garbage bags. He let the door go closed on its own and walked down to the laundry department door. He pushed the door open with his bare hand and went inside. He threw the three bags of soiled linens into a large linen cart. He then went back to the door and opened it with his bare hand and went out of the laundry room into the hallway. He did not wash or sanitize his hands at any point. He went down the hall and started talking to a male resident in the hallway. During an interview with Employee N on 09/19/2023 at 12:53 PM, he confirmed room [ROOM NUMBER] was an isolation room. He stated he is supposed to wash his hands before he leaves the isolation room. He confirmed that he had not done so. He asked if it would be okay to wash his hands in the laundry department. When asked if he could have washed his hands in the residents' bathroom in room [ROOM NUMBER], he stated, yes and that is what he should have done. On 09/19/2023 at 2:20 PM, Employee M, CNA, was observed entering room [ROOM NUMBER] without donning a gown, gloves, face shield or goggles. She was wearing a facemask. The room had signage posted on the PPE cart in the hallway. The signage was for droplet precautions and isolation instructing the staff to cover their eyes, nose and mouth completely. She exited the room at 2:21 PM. She went down the hall to the nurse's station and returned to the room at 2:22 PM. She entered the room a second time without donning a gown, gloves or eye protection. During an interview with Employee M on 09/19/2023 at 2:23 PM, she stated she did not think room [ROOM NUMBER] was still an isolation room. She confirmed the signage was still on the PPE cart outside the room. During an interview with Employee J, Registered Nurse (RN) on 09/19/2023 at 2:23 PM, she went to her computer and looked up the physician's orders for Resident #6 in room [ROOM NUMBER]. She confirmed the resident had a physician's order for isolation with an end date of 09/22/2023. She confirmed the resident was on droplet precautions for COVID-19. She went to the room and posted the signage on the door frame at eye level. During an interview with the Director of Nursing (DON)/Infection Control Preventionist 09/19/2023 at 1:24 PM, she was informed of the infection control breaches observed during the survey. She stated that Employee L should have donned PPE prior to entering room [ROOM NUMBER] because it was an isolation room. She confirmed the two residents in that room are positive for COVID-19. She should have washed her hands prior to leaving the room both times. She confirmed that Employee N should have washed his hands prior to leaving room [ROOM NUMBER]. She confirmed that room [ROOM NUMBER] is an isolation room. Resident #6 in room [ROOM NUMBER] is positive for COVID-19. She confirmed that Employee M should have donned PPE prior to entering the room both times. Review of the clinical record for Resident #3 revealed a physician's order for droplet isolation times 10 days every day and night shift dated 09/12/2023 with an end date of 09/22/2023 (Copy obtained). Review of the clinical record for Resident #7 revealed a physician's order for droplet isolation times 10 days every day and night shift dated 09/12/2023 with an end date of 09/22/2023.(Copy obtained) Review of the clinical record for Resident #5 revealed a physician's order for contact precautions every day and night shift for Extended-spectrum beta-lactamases (ESBL) foot wound dated 09/7/2023 with no end date. (Copy obtained) Review of the clinical record for Resident #6 revealed a physician's order for droplet isolation times 10 days every day and night shift dated 09/12/2023 with an end date of 09/22/2023. (Copy obtained) A review of the facility's policy and procedure titled Isolation-Categories of Transmission-Based Precautions (Revised January 2022) revealed: Policy Statement: 1. Standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Contact Precautions: 1. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 2. Examples of infections requiring Contact Precautions include, but are not limited to: a. Infections with multi-drug resistant organisms. 4. Gloves and Handwashing: b. While caring for resident, change gloves after having contact with infective material. c. Remove gloves before leaving room and perform hand hygiene. Droplet Precautions: 1. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). (Copy obtained) A review of the facility's policy and procedure titled Handwashing/Hand Hygiene revealed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 3. Hand hygiene products and supplies (towels, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 7. Use of alcohol-based hand rub containing at least 62% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after coming into direct contact with residents; f. before donning sterile gloves; k. after contact handling contaminated equipment; l. after contact with objects in the immediate vicinity of the resident; m. after removing gloves; n. before and after entering isolation precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: c. when in contact with a resident, or the equipment or environment of a resident who is on contact precautions. Procedure: Equipment and Supplies 1. The following equipment and supplies are necessary for hand hygiene: d. paper towels; e. trash can. Applying and Removing Gloves. 5. Perform hand hygiene. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy and procedure review, the facility failed to administer intravenous (IV) medication Ceftriaxone Sodium (antibiotic used to treat certain infections) as ordered and in accordance with professional standards of practice for one (Resident #1) of three residents sampled for IV administration from a total sample of 7 residents. The findings include: A record review for Resident #1 revealed she was admitted on [DATE] with diagnoses of encephalopathy and cellulitis of the left lower limb. A review of the 5-day Medicare Minimum Data Set (MDS) assessment, dated 2/4/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating cognitively intact. Resident required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and was able to eat independently. The MDS also indicated that Resident #1 had an infection of the foot and had IV medications while not a resident. On 2/5/2023, Resident #1 was discharged to the hospital per family request. A review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008 Form) dated 2/2/2023 indicated that Resident #1's reason for transfer was rehabilitation and IV antibiotics. (Photographic evidence obtained) A review of the physician's order dated 2/3/2023 revealed: Ceftriaxone sodium intravenous solution reconstituted 1GM. Use 1 gram intravenously in the afternoon for infection until 2/9/2023. (Photographic evidence obtained) Resident #1's medical records did not contain intravenous access orders and/or IV site care orders. A review of the February 2023 electronic medication administration record (eMAR) revealed Ceftriaxone sodium intravenous solution reconstituted 1 gram was scheduled to be administered daily at 5:00 PM, however on 2/2/2023 the signature box used to indicate the medication was administered was marked with X. There was no explanation of what X meant. On 2/3/2023 and 2/4/2023, both signature boxes had nurses' initials in them with 9 which refers to: Other/See Progress Notes. There were no progress notes located that mentioned medication administration on those days. Review of Resident #1's care plan dated 2/3/2023 indicated she had functional mobility deficit as evidenced by impaired bed mobility, transfer, and ambulation secondary to recent condition of left lower extremity (LLE) cellulitis (a common and potentially serious bacterial skin infection). Review of the hospital doctors' discharge progress notes dated 2/3/2023 revealed recommendations to continue ceftriaxone and clindamycin (antibiotics). (Photographic evidence obtained) Review of wound care nurse progress notes dated 2/3/2023 showed that Resident #1 had head to toe skin assessment. LLE noted hot to touch, with fluid filled blisters, ruptured blisters, and scattered open areas with [NAME] noted to wound bed. Skin impairment extended from left inner thigh, down to ankle. Area noted with a large amount of serous drainage. Review of the nursing progress note dated 2/5/2023 revealed Residents' #1 family came to nursing station complaining that no IV antibiotics were administered. The family has been speaking with unit manager regarding antibiotics, Resident #1 did have a PICC line (peripherally inserted central catheter). Family was reporting decline in mental status, increased lethargy, and confusion. They requested Resident #1 to be sent out to the hospital. Placed call to advanced registered nursing practitioner on call, 911 called and have taken patient out. On 3/23/2023 at 3:23 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She looked at Residents' #1 chart and stated she was only Residents' #1 nurse for a couple of hours. She could not remember if Resident #1 had a PICC line. She stated that relatives were in Residents' #1 room and complained that she had not been changed, and they were not happy with the services. The family wanted Resident #1 to be sent to the hospital. LPN A called the doctor and received an order to send Resident #1 to ER. When LPN A was questioned why the Ceftriaxone IV medication was not administered, she stated they didn't have it available. However, Ceftriaxone could be in the Cubex emergency supply. LPN A checked the Cubex to see if Ceftriaxone IV medication was currently in stock, which revealed it was listed under the inventory. On 3/23/2023 at 3:38 PM, an interview was conducted with Registered Nurse (RN) Supervisor B. When asked if he admitted Resident #1 and why the resident's IV medication was not given to her, he replied, I don't remember. When I admit someone, I usually go through a lot of information. I do not remember if resident had an IV. He had no idea why it was not given. RN Supervisor B looked in Resident #1's chart and confirmed that IV medication was not given. Then he said, Now I remember, I admitted her, she came in late at night. All I did was look at her legs and did not even see a PICC line. During an interview with the Director of Nursing (DON) on 03/23/2023 at 4:00 PM, she was asked what the facility did about Resident #1 not receiving her IV antibiotic treatment. The DON stated, Nothing. She confirmed that the facility did not initiate any corrective measures after they realized the resident did not receive her IV antibiotics. She mentioned that she was on sick leave and not at the facility during that time. When she returned, she was made aware of the problems the family had with the facility. One of their complaints was that Resident #1 had not received the IV medications. The DON confirmed that a Performance Improvement Plan (PIP) was not initiated, and the Quality Assurance and Performance Improvement (QAPI) committee was not looking at this issue. On 03/23/2023 at 5:00 PM, a telephone interview was conducted with the Regional Nurse Consultant (RNC). She stated, she was made aware of the concerns by the family that Resident #1 did not receive her IV medications. She stated a male nurse put an order in as for house stock, so the Pharmacy could not see it from their end. She stated she started a Performance Improvement Plan (PIP) and re-educated the nurses involved with Resident's #1 care. The doctor was also notified. She stated she started to audit the clinical records. The facility did not provide any evidence of doctor's notification and a PIP regarding this concern. The RNC explained they had experienced some transitional changes in the facility. A review of the facility's policy and procedure titled, Administering Medications (effective 2001 and revised December 2012) read: 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. (Photographic evidence obtained) A review of the facility's policy and procedure titled, Antibiotic Stewardship (effective 2001 and revised December 2016) read: 5. When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. (Photographic evidence obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to reasonable accommodate the needs for four (Residents #4, #5, #6, and #7) of five residents reviewed for call light access, out of a total sample of 7 residents. Failure to have the call light within reach puts the resident at risk of potential negative health outcomes. The findings include: 1. During an observation of room [ROOM NUMBER] on 03/23/2023 at 11:01 AM, Resident #4 was lying in his bed with his eyes open. The resident did not respond when spoken to. The call light was on the floor out of reach. (Photographic evidence obtained) Review of Resident #4's care plan dated 01/20/2023 for fall risk revealed an intervention to have call light within reach at all times. 2. Also in room [ROOM NUMBER], Resident #5 was observed lying in his bed with his eyes shut. His call light was on the nightstand wrapped around a cowboy hat and hanging off the opposite side of the nightstand out of reach of the resident. (Photographic evidence obtained) Review of Resident #5's care plan dated 02/11/2023 for fall risk revealed an intervention to have call light within reach at all times. During an interview with Employee D, Licensed Practical Nurse (LPN) on 03/23/2023 at 11:11 AM at the East Wing nurse's station, she stated Resident #4 does not talk often, however he will sometimes say two words here and there. Resident #5 will talk to her. She thought both were capable of using their call bell. 3. During an observation of room [ROOM NUMBER] on 03/23/2023 at 11:25 AM, Resident #6 was observed lying in bed watching television. His call light was on the floor behind the nightstand. He was asked if he uses his call bell. He stated, he uses it sometimes. He was informed that it was coiled up behind his nightstand. He stated, Obviously I don't. When asked if he wanted it, he stated, Yes. (Photographic evidence obtained) Review of Resident #6's care plan dated 03/01/2023 for fall risk revealed an intervention to have call light within reach at all times. 4. During an observation of room [ROOM NUMBER]-C on 03/23/2023 at 1:29 PM, Resident #7 was seated in his wheelchair at the foot of his bed. The call light was draped over the light fixture above the head of his bed approximately 6 feet away from him. (Photographic evidence obtained) He was shaking slightly and stated he could not reach his call light. Review of Resident # 7's care plan dated 02/06/2023 for fall risk revealed an intervention to have call light within reach at all times as an intervention. During a second observation of room [ROOM NUMBER] on 03/23/2023 at 4:28 PM, Resident #4's call light was not accessible. It was found on the floor in the same place it was during the first observation. Resident #5's call light was clipped to his bedding and was now in reach. During a second observation of room [ROOM NUMBER] on 03/23/2023 at 4:30 PM, Resident #6's call light was still coiled up on the floor behind his nightstand. It was not accessible. Resident #6 stated he still did not have it and he wanted it. During a second observation of room [ROOM NUMBER] on 03/23/2023 at 4:35 PM, Resident #7's call light was still draped over the light fixture at the head of the bed. During an interview with Employee F, LPN on 03/23/2023 at 4:36 PM, he was asked to look at the call light in room [ROOM NUMBER]-C for Resident #7. He saw the light hanging over the light above the bed and stated, It should not be up there. He took the light down and stretched it across the length of the bed and clipped it to the bedding. He asked the resident to turn on his call light so he could determine if the resident could reach it. The resident refused and stated he did not need it. He would just yell if he needed help. The nurse explained why the resident needed to have it. The resident then reached over the footboard of the bed and turned the call light on. The nurse explained that Resident #7 has tremors, but he understands how to use the call light and he can do it. He just does not like to. He confirmed the resident could not yell loud enough to be heard from down the hallway. The nurse was asked to look at the call lights in room [ROOM NUMBER]. He went into room [ROOM NUMBER] and the Unit Manager, Employee E, followed him into the room. She picked up the call light next to the A-bed and stated, This should not be here. She then clipped it to the bedding of Resident #4 and asked the resident to hold the call bell cushion and squeeze it. The resident did so, and the light came on. She shut it off and confirmed that he could use it. She was asked to look at the call light in room [ROOM NUMBER] B-bed. When she entered the room, Resident #6 was awake, and she asked him where his call light was. He stated he did not know, he thought it was on the floor. She looked behind the nightstand next to his bed and saw it. She confirmed that he could not reach it. She retrieved the light from behind the nightstand and clipped it to the bedding on the resident's bed. He thanked her. She stated, Of course, you need to have it! He agreed with her. A review of the facility's policy and procedure titled, Answering the Call Light read: Purpose. The purpose of this procedure is to respond to the residents' requests and needs. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that one (Resident #2) of 12 sampled residents received treatment in accordance with professional standards of practice, based on the comprehensive assessment of the resident. Clinical staff failed to complete dressing changes as ordered. The findings include: On 2/23/2023 at 11:30 AM, Resident #2 was observed in bed with both of his lower legs wrapped with bandages over white gauze. There were no dates on the bandages. Resident #2 stated that staff did not come into his room very often and when they did, they only stayed for a minute. He explained that he did not get out of bed and blamed his current bedbound state on his leg wounds, which haven't been dressed in a week. A review of Resident #2's medical record revealed he was admitted on [DATE]. His diagnoses included lymphedema (swelling caused by a blockage in the lymphatic system) and type 2 diabetes mellitus. A review of the 5-day minimum data set (MDS) assessment, dated 1/09/2023, revealed a brief interview for mental status (BIMS) score of 15 out of 15 points, indicating Resident #2 was cognitively intact and able to make decisions about his care. A review of the active physician's orders revealed an order dated 9/21/2022 to cleanse the RLE (right lower extremity) with NSS (normal saline solution), pat dry, apply Zinc to the dry areas and wrap with gauze, [than] ace bandage 3 times a week and PRN (as needed). There was another identical physician's order dated 9/21/2022 for the left leg; Cleanse LLE (left lower extremity) with NSS normal saline solution, pat dry, apply Zinc to the dry areas and wrap with gauze [than] ace bandage 3 times a week and PRN. Directions for the order were for every day shift every Monday, Wednesday, and Friday for wound care. (Photographic evidence was obtained) A review of Resident #2's treatment administration record (TAR) for January and February 2023 found the same orders were reflected on the TARs. The TARs had been set up so that signature boxes for the days treatment was to be withheld were crossed off with an X; this left the signature boxes for the days dressings were to be changed blank. The days dressing changes were to be performed in January were the 2nd, 4th, 6th, 9th, 11th, 13th, 16th, 18th, 20th, 23rd, 25th, 27th, and 30th. The only day the dressing change was signed off as provided was January 4th. All remaining boxes were blank. (Photographic evidence was obtained) In February 2023, the days the dressing changes were scheduled for the 1st, 3rd, 6th, 8th, 10th, 13th, 15th, 17th, 20th, 22nd, 24th and the 27th. The only days the dressings were signed as provided were the 13th and the 20th. (Photographic evidence was obtained) An interview was conducted with the Unit Manager (UM) on 2/23/2023 at 3:15 PM. When asked about the dressing changes for Resident #2, she pulled up the order in the electronic medical records. After reviewing it, she confirmed it was scheduled for every 3 days. She explained that wound care does the scheduled dressing changes and if they become soiled or soaked, the floor nurse does the PRN change. However, she said she would call wound care to be sure. On 2/23/2023 at 3:50 PM, the UM clarified that wound care was not doing the dressing changes. It was supposed to be the floor nurses and she confirmed they were not doing it as ordered.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #47) of 35 sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, specifically, failure to apply physician-ordered, medicated cream/ointment to an ongoing rash. The findings include: On 12/19/22 at 11:50 a.m., Resident #47 was observed lying in bed, awake. She was scratching at her upper chest and both upper extremities. Her upper chest and both upper extremities were observed with a patchy, red rash. The rash was comprised of small red circles, some raised slightly and some flat. Some areas were observed open with scratch marks and some were intact. The resident stated the rash was related to nerves from her last roommate. She stated, It gets itchy and I think I'm supposed to have some kind of antibiotic cream but no one has put it on. On 12/20/22 at 9:15 a.m., Resident #47 was observed lying in bed, awake. She was scratching at her upper chest and both upper extremities. Her upper chest and both upper extremities were observed with a patchy red rash. The upper chest rash area was observed with pin point spots of blood. The resident stated, I scratched at it. I couldn't help it. It's so itchy. I wish they'd give me something for it. She was asked if she had let staff know that the rash is itchy. She stated, Yes, I let them know but I guess they don't have anything for me. On 12/21/22 at 8:20 a.m., Resident #47 was observed lying in bed, awake. She was scratching at the rash on her upper chest. Both upper extremities remained red with the rash as well. She was asked if she had let staff know her rash had been bothering her since at least yesterday. She stated, Yes, but no one does anything. She was asked if any staff member had applied ointment or cream to her rash or provided any care for the rash. She stated no. On 12/21/22 at 2:53 p.m., Registered Nurse (RN) A was asked if she was aware of the rash that Resident #47 had on her upper arms and chest. She replied, Yes, I know she has a rash. She's had that since I first came here in November (2022). It's chronic. I don't recall what it is but she gets a cream for it. RN A then asked Licensed Practical Nurse (LPN) D, the nurse caring for Resident #47, if she knew about the rash. LPN D stated, Yeah, she gets hydrocortisone cream for that. LPN D was asked how often the cream was applied. She stated, it's just prn (as needed). She was asked if the resident had received any cream today. She replied, No, she didn't ask for it. She just asked for a pain pill and I gave her that. On 12/21/22 at 3:00 p.m., in an interview with Certified Nursing Assistant (CNA) B, she was asked if she was caring for Resident #47. She stated, Not today, but I have occasionally in the past, and I help other CNAs with her care. She was asked if the resident had ever complained to her about a rash on her arms and upper chest being itchy. She stated, Yes, she has. She was asked what she did when the resident complained that she was itchy. She stated, I go tell my nurse. On 12/21/22 at 3:05 p.m., in an interview with CNA C, she was asked if she was caring for Resident #47 today. She stated yes. She was asked if she usually had Resident #47 on her assignment. She stated yes. She was asked if Resident #47 had complained to her about a rash on her forearms and upper chest being itchy. She stated yes. She was asked how often the resident voiced this complaint. She stated, Well, I don't know about the days I'm not here, but every day I work, she tells me she's itchy. She was asked what she did when the resident told her she was itchy. She stated, I go tell my nurse. She was asked if she told her nurse today. She stated yes. She was asked which nurse she told. She said [LPN D]. She was asked if the nurse went to see the resident after she told her about the resident's complaint. She replied, I don't know. On 12/22/22 at 8:50 a.m., Resident #47 was observed lying in bed, awake, and scratching her upper chest. Her upper chest and both forearms were observed with a red rash. The rash was comprised of small, red, raised and open spots covering the top of each forearm and her upper chest. She was asked if she told staff her rash was itchy since yesterday. She stated, Yes I told them and they don't do anything. It's itching like crazy. She was asked if any staff applied lotion to her rash since yesterday. She stated, No, no one has at all. On 12/22/22 at 9:05 a.m., LPN D was asked if she was caring for Resident #47 today. She stated yes. She was asked if the resident had complained of her rash being itchy today. She stated, No, I haven't heard that. I haven't been in to see her yet today. She was asked to open the treatment cart and see if there was any hydrocortisone cream for Resident #47. She opened the cart and this cream was not in the cart for the resident. The nurse stated, She must have run out. I'll reorder it from the pharmacy. We have two treatment carts on the unit, it could be in that (the other) cart. On 12/22/22 at 9:07 a.m., RN E was asked if she had a treatment cart on her wing. She stated yes. She was asked how many treatment carts the facility had. She stated two. She was asked if she could open the treatment cart on her wing to check if there was Hydrocortisone cream for Resident #47 in the cart. She opened the cart and the cream was not found in the cart. She stated, I know she had it. I'm the one who ordered it for her to begin with for the rash on her arms, but I haven't cared for her in maybe over a month now, so I haven't seen her in that time. RN E was asked where she would sign out the treatment when it was administered. She stated, On the treatment sheet. That's where it's signed out when it's used because it's an as needed order. She was asked if signing the treatment out was an expectation when the treatment was provided. She stated yes. On 12/22/22 at 10:59 a.m., in an interview with the Director of Nursing (DON), she was asked what the expectation was when a treatment was provided to a resident. She stated, It should be signed out on the treatment sheet. She was asked if a treatment was not signed out, where would it be documented if it was provided. She stated, In a progress note, but it should also be initialed on the treatment sheet if it was done. In a medical record review for Resident #47, it was revealed that the resident had an MDS (Minimum Data Set) quarterly assessment completed on 11/23/22. The assessment revealed a BIMS (brief interview for mental status) score of 13 out of 15 possible points, indicating that that resident was cognitively intact. The same assessment further revealed an assessment of behaviors which revealed that the resident did not exhibit any behaviors for rejection of care. A review of the care plan for Resident #47 revealed a focus identified on 5/12/17 (with most recent revision on 5/19/21) that stated, The resident is at risk for alteration in skin integrity related to limited mobility, obesity, diabetes, incontinence, and refusal to get out of bed. The goal stated, Decrease/minimize skin breakdown risks. The interventions stated, Body audits for skin observations (revised 8/5/21). Observe skin condition with ADL (activities of daily living) care daily; report abnormalities (revised 6/19/19), provide preventative skin care routinely and PRN. A review of current physician's orders for Resident #47 revealed: 9/23/21: Hydrocortisone cream 1%: apply to right forearm and upper back topically every 8 hours as needed for itching. A review of the eTAR (electronic treatment administration record) for Resident #47 for the past three months revealed an order for hydrocortisone 1%: Apply to right forearm and upper back topically every 8 hours as needed for itching. The eTAR was not signed by nursing to indicate this medication had been administered on any date. A review of all progress notes (11/1/22 through 12/22/22) did not reveal any treatment had been provided for rash, nor was there any documentation concerning a rash. A review of weekly skin checks provided by the DON revealed: 12/20/22: rash on arms and chest 12/13/22: no new wound/injury 12/6/22: pt with itchy/rash on both forearms- under current treatment. The DON provided weekly nurse skin checks for Resident #47 for 12/6/22 and 12/20/22. On 12/22/22 at 11:15 a.m., in an interview with the DON, she stated, December 6th shows they noted a rash and it's being treated. She was asked if there was documentation that any treatment was provided for the rash. She replied no. A review of the facility's policy titled Administering Medications (revised 12/2012) read: Policy Statement: Medications shall be administered in a safe and timely manner and as prescribed. 21. Topical medications used in treatments must be recorded on the residents' treatment record (TAR). .

Based on observations, medical record review, staff interviews, and facility policy review, the facility failed to ensure a medication error rate of 5% or less. There were four errors and 33 opportunities for error, resulting in an error rate of 12.12% and involving two errors for Resident #50, one error for Resident #69, and one error for Resident #28. The findings include: On 12/21/22 at 4:20 p.m., Licensed Practical Nurse (LPN) F was observed preparing medications for Resident #50. One of the tablets (Bumex 2 mg (milligrams) was observed to fall onto the medication cart when popped out of the blister pack. LPN F was observed picking up the tablet with an ungloved hand and placing it in the medication cup with another tablet (Coreg 25 mg). LPN F was observed picking up the medication cup and then proceeded to walk toward the resident's room. He was stopped and asked if he was going to give the medication he had dropped and picked up with his ungloved hand to the resident. He stated, Yes, the cart is clean. If I dropped the pill on the floor, I would throw it away and get a new one. He was advised at that time that the medication cart and his ungloved hands were not considered clean. He then proceeded to pop two new pills for the resident from the blister pack. LPN F was then observed leaving the pills he wasn't going to administer to the resident on top of the cart in a medication cup. He walked into the resident's room. The medication cart was out of his sight for six minutes while he administered the medications. Upon returning to his medication cart, he saw the pills he had left out and threw them in the trash. He was asked if he should leave medications out on top of the medication cart and out of his sight. He stated, No, that's why I just threw them away when I saw I left them there. On 12/21/22 at 4:30 p.m., LPN F was observed preparing medications for Resident #28. LPN F entered the resident's room and handed him the medication cup with the pills in it. LPN F was asked if he had checked the resident's blood pressure for the ordered parameters before administering the medication. He stated, Hold on and left the room. He left the resident holding the medication cup, with three pills in the cup, unattended. He returned 90 seconds later and stated, His blood pressure is 119/69, and he instructed the resident to take the pills in the cup. On 12/21/22 at 4:50 p.m., LPN G was observed preparing medications for Resident #69 to be administered via gastric tube (feeding tube). These medications included Vitamin C 500 mg, give one tablet via gastric tube, and Ferrous Sulfate liquid 325mg/5ml (milligrams per milliliter), give 5 ml via gastric tube. LPN G was observed bringing separated medications in two medication cups into the resident's room and setting them on the bedside table. She then stated, Oh, I need my stethoscope, and left the room. She was observed leaving the two medications (Vitamin C and ferrous sulfate) unattended and out of her sight on the resident's bedside table. She was asked if she usually left medications unattended when she left a resident's room. She replied, Well, the med cart has to be plugged in and it won't reach to this room. She was asked about leaving the Vitamin C and Ferrous Sulfate on the resident's bedside table unattended while she went to go get her stethoscope. She stated, Oh, well generally I wouldn't do that. I guess I should have taken them with with me when I went to get my stethoscope. A review of the facility's policy titled Administering Medications (revised 12/2012) read: Policy Statement: Medications shall be administered in a safe and timely manner and as prescribed. 16. No medications are kept on top of cart. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and medical record review, it was determined that the facility failed to ensure one of 33 sampled residents (Resident #59) received treatment and care in accordance with professional standards of practice for her skin rash and itching. The findings include: On 5/16/2021 at 3:10 pm, Resident #59 was observed in her room, rubbing under her chin and her arms. She voiced a complaint of constant itching. She stated staff tell her it is anxiety, but she doesn't think it is anxiety. A tube of Cortisone 10 cream which was observed to be almost empty was seen next to her bed. She lifted her shirt several times and it appeared red under her shirt area. She stated it itched on her arms, neck, and chest. On 05/18/21 at 8:30 AM, Resident #59 was observed sitting up in bed. She was lightly scratching her bilateral upper arms, not causing any scratches to appear. No rash was observed on her arms. She was asked if her skin was itchy. She replied, Yes, my arms, my chest, my back and my abdomen. Not my legs. She was asked if staff was aware and she stated, Yes, they know. They've looked at it and prescribed some medicine and cream for it. On 05/18/21 at 10:15 AM, Employee F she was asked if she had seen Resident #59's rash. She stated, Yes, I was asked to see her last week for that. It's not really a wound, so I wasn't planning on seeing her again, but if it's still going on, she may need a derm (dermatology) consult. I know we did prescribe an ointment. I'll check in and see how's she is doing. On 05/18/21 at 1:30 PM, Employee A was confirmed that she was caring for Resident #59 today. She stated that she know the resident well and was aware of her itchy rash. She replied Yes, she's getting a cream for that 3 times a day. A review of progress notes for Resident #59 shows an entry on 5/5/2021 by her primary physician's nurse practitioner at 9:15 am which stated: Patient is a [AGE] year old Caucasian female that presents today with mildly worsening itching and puritis to her arms and chest in March with an underlying diagnosis of acute rash. The patient was started on Prednisone for a few days and Calamine lotion for the itching and she has not used it for over a month. The next note in relation to Resident #59's rash was on 5/11/2021 as a wound progress note. The note stated, Chief complaint- Initial wound care, consult requested by (primary physician). Patient presents today with c/o (complaints of) pruritic to the upper extremities and chest. Diagnosis 1: Rash. Diagnosis 1 plan- start Triamcinolone 0.1% cream to bilateral upper extremities, axilla and chest BID (twice a day) for itching. A review of the resident's hard copy medical record revealed an order written on 5/11/2021 which stated, Triamcinolone 0.1% cream to chest and bilat upper extremities/axilla for itching. A review of the resident's electronic medical record showed an order entered on 5/11/2021 at 14:30 which stated: Triamcinolone 0.1% cream Apply to BUE/axilla and chest topically as needed for itching. Give TID (three times a day) PRN (as needed). A review of the resident's electronic Treatment Administration Record shows this order added on 5/11/2021. The record did not show the cream was administered on any date in May 2021. On 05/19/21 at 1:50 PM, the treatment cart was observed with Employee E, RN. There was one tube of Triamcinolone Acetonide Cream which was in a baggie and had a pharmacy label with Resident #59's name and instructions which matched the current order. Inspection of the tube showed it had been opened, but it appeared to almost full with a minimum amount of cream missing from the tube. The nurse was asked if she had ever applied this cream to Resident #59. She stated, No, I don't think I have. On 05/19/21 at 2:00 PM Resident #59 was observed lying in her bed with her head elevated. She was scratching both arms. When asked how her rash was feeling today she stated, It's terrible. Nobody is putting any cream on it; I have to do it myself. An empty tube of cortisone 10 1% cream was observed on her bedside table. She confirmed she had been applying it to herself and stated, Yes, and my brother brought me two more tubes. A small, brown paper bag was observed on her table which she then opened to show two more tubes of Cortisone 10 1% cream. Employee G was in the room at that time and asked if Resident #59 has ever told her that she is itchy. She stated, Yes, I tell the nurse and she puts cream on her. Employee E then entered the room was asked if she knew Resident #59 had her own Cortisone 10 1% cream that she was applying herself. She stated, That's new, we're not sure where that came from. A review of Resident #59's current orders on 05/20/21 at 8:36 AM did not include a consult ordered for dermatology. Current orders did not show an order for Cortisone 10 1% cream, nor an order for self-administration of this or any medication. The facility policy and procedure for self administration of medication (11/2017) was reviewed. The purpose of the policy stated, To provide guidance for patients wishing to self-administer medications. Review of the medical record/chart for Resident #59 did not reveal that she was evaluated for self-administration of medications. A review of the facility policy and procedure for Medication and Treatment Administration Guidelines (7/2006, updated 3/2018) stated: PRN medications require an outcome evaluation after administration. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure that residents with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections (UTI) for one resident (Resident #63) out of 3 residents with a Foley catheter in a total sample of 33 residents. The findings include: During the initial tour on 05/16/21 at 02:33 PM, Resident #63 was observed lying on the bed. The Foley catheter tubing had cloudy drainage. Another observation on 5/17/21 at 9:00 AM, revealed the resident lying on the bed facing the door. The catheter bag was in a privacy bag, but cloudy drainage was flowing through the tubing. Record review indicated that Resident #63 was admitted to the facility on [DATE]. Diagnoses included pneumonia, disease of stomach and duodenum, encounter for surgical aftercare following surgery on the digestive system, obstructive reflux uropathy, methicillin resistant staphylococcus aureus (MRSA), history of malignant neoplasm of prostate, and retention of urine. Resident #63 had physician orders for Foley 16fr /10ml for prostate cancer and urinary retention, complete blood count and complete metabolic panel for hematuria, lidocaine (anorectal cream 5%) apply to the tip of the penis every shift for pain and change Foley catheter every 30 days. Review of the care plan revealed that the resident had a UTI with intervention to monitor/report to physician for signs and symptoms of UTI such as: urgency, malaise. foul smelling urine, dysuria (pain on urination), hematuria(blood in urine), fever, cloudy urine, and behavior changes . The care plan also included the resident's use of indwelling urinary catheter needed due to urinary retention and history of prostate cancer with interventions to change urinary collection bag as needed and change catheter per physician order. Review of the laboratory test for urine culture dated 4/27/21 indicated the resident was positive for pseudomonas aeruginosa (bacteria). Review of the electronic treatment record (TAR) revealed catheter change was not completed per orders and there was no documentation for catheter care. On 05/19/21 at 10:08 AM, the Assistant Director of Nursing (ADON) stated that the resident was not admitted with a Foley catheter, but due to retention an order was obtained for the indwelling catheter. She added that for residents with a Foley catheter, staff are supposed to complete catheter care and document in the TAR. When asked about Resident #63's catheter care, she confirmed that there was no documentation for catheter care. She also confirmed that the order for catheter change was not completed on 5/14/21. The ADON continued to state that resident had just completed antibiotic prescription due to UTI. In an interview on 05/19/21 at 11:48 AM , Employee C , Certified Nursing Assistant (CNA) stated that care is provided every shift by the CNAs and the nurses are supposed to check. When asked if she had received any training on catheter care she stated that none was provided at this facility. On 05/19/21 at 02:21 PM, the Director of Nursing (DON) was asked the expectation for Foley catheter care. She stated that the facility protocol was for staff to clean the catheter with soap and water every shift. She confirmed that residents with Foley catheter orders were not updated in the TAR; therefore it was not clear if care was provided. She also confirmed that the catheter for Resident #63 was not changed per physician order. Review of the policy and procedure titled catheter care: indwelling catheter revealed the following: Suggested documentation : Care provided in POC including task completion. Create a new alert in POC creating a custom alert if required for unusual observation. Care provided in progress notes including reaction to procedure, color and amount of urine, and usual observation and/or complaint and subsequent interventions including communications with the medical practitioner as clinically indicated. .

Based on record reviews and interviews, the facility failed to ensure Pharmacist recommendations of gradual dose reductions were reviewed and acted upon by the resident's physician in a timely manner for one of five residents (Resident #54) reviewed for unnecessary medications from a sample of 33 residents. The findings include: During a record review of Resident #54's chart, the physician orders showed he was ordered Paxil for depression and Seroquel for a psychotic disorder. Resident #54's electronic record contained an assessment titled Medication Regimen Review dated 08/03/2020 which contained pharmacy recommendations for the Paxil. The Pharmacist recommended a change from 20 mg to 10 mg at that time. The associated progress note contained the same information, but neither included information that these recommendations were sent to a physician for review. A paper note from the resident's psychiatric APRN showed that on 09/01/2020, Resident #54 was on 25 mg of Seroquel twice a day and 20 mg of Paxil once a day. Page 3 of this note stated he was on a trial dose reduction of both medications. The note from 09/28/2020 had the same information on the resident's dose and gradual dose reduction (GDR) status. (Photographic evidence obtained) No notes were presented past September 2020. All the notes presented contained language the resident was undergoing a trial GDR, but a review of the physician orders negated this comment. Review of the physician orders in the electronic medical record confirmed the Paxil was changed from 20 mg to 10 mg on 5/18/2021. Prior to this adjustment, he was on 20 mg of Paxil since 02/14/2020. His current Seroquel dose of 25 mg twice a day was ordered 04/07/2020. (Photographic evidence obtained) On 5/19/2021 at 10:01 am Employee A, LPN, stated the resident's Paxil was just adjusted on 05/18/2021 from 20 mg to 10 mg, and the Seroquel (25 mg) was given twice a day since 04/07/2020. During a review of the Medication Regimen Review (MRR) binder for the facility, there was also a recommendation made for Resident #54 dated 01/21/2021 which requested the Paxil be reduced to 10 mg from 20 mg as a trial gradual dose reduction (GDR). Handwritten on this recommendation from the Pharmacist was a marking to accept the GDR, signed and dated 4/21/21 by the resident's physician. (Photographic evidence obtained ) There were no additional paper recommendations in the MRR book which were signed by residents' physicians; this was previously explained by the Director of Nursing (DON) at 9:38 AM on 5/19/2021, who explained the previous DON did not maintain these records. She explained she was going to have the Pharmacist email her his recommendation letters which were missing from the MRR book. These emails were presented and upon further review, none of the recommendations contained signature and acceptance/rejection of the Pharmacist's recommendation since they were just emailed and printed off during the survey. The unacknowledged paper MRRs were for a span of May 2020 to November 2020. Review of the hard chart for Resident #54 kept at the nurse's station showed no more additional pharmacy recommendation letters for the Paxil. The emailed MRRs from the Pharmacist were reviewed and a hard copy of a recommended GDR for the Seroquel was issued to the facility on 7/20/2020. It did not contain a signature or any indication the physician reviewed this recommendation and accepted or rejected it. (Photographic evidence obtained) There was no information in the progress notes of the electronic record to indicate a physician reviewed the recommendation. During an interview with the DON at 8:21 AM on 5/20/2021, she confirmed Resident #54 received 20 mg of Paxil from February 2020 to May 2021. She again confirmed they could not locate any MRR recommendations which were signed off by a physician from May to December 2020 and only had the print outs which were emailed to her this week, which did not show a physician was given the recommendation to review. At 11:35 AM on 5/20/2021, she confirmed the notes from the visiting psych APRN did not match what was actually being given to Resident #54 and he was not actually undergoing a GDR as the note read. A follow up interview was conducted with the DON on 5/20/21 at 12:38 PM. She reviewed the last year's worth of notes from Resident #54's visiting physician and confirmed he did not address the pharmacist's recommendations within the progress notes either. Upon review of the visit notes from May 2020 to present, there was no indication the physician addressed the GDR recommendations within his own progress notes. (Photographic evidence obtained Review of the policy contained within the MRR book showed the following process for GDR recommendations (dated 2018): The Consultant Pharmacists perform MRR for patients and will generate recommendations with the overall goal of promoting positive outcomes and minimizing adverse consequences. To ensure MRR recommendations are addressed timely, the DON or designee reviews the MRR and contacts the attending physician to review and obtain orders as warranted. The DON or designee documents on the MRR and in the patient's clinical record the physician's orders and forwards the completed MRR to the DON within 30 days of the review. The attending physician documents the review and any resulting actions or orders on the MRR. New orders may be generated on physician orders. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Gradual Dose Reduction (GDR) recommendation was enacted in a timely manner for one of five residents reviewed for unnecessary medications (Resident #54) from a sample of 33 residents. The findings include: Record review for Resident #54 revealed physician orders for Paxil for depression and Seroquel for a psychotic disorder. On 5/19/2021 at 10:01 am Employee A, LPN, stated his Paxil was just adjusted on 5/18/2021 from 20 mg to 10 mg. Review of the physician orders in the electronic medical record confirmed the Paxil was changed from 20 mg to 10 mg on 5/18/2021. Until this change, he had been on Paxil 20mg since 02/14/2020. (Photographic evidence obtained) During a review of the assessment dated [DATE] within the electronic record titled Medication Regimen Review (MRR) for Resident #54, the Pharmacist recommended the Paxil be reduced to 10 mg (from 20 mg) as a trial gradual dose reduction (GDR). The facility also had paper recommendation forms on this MRR, and there was a handwritten marking to accept the GDR, signed and dated 4/21/21 by Resident #54's physician. (Photographic evidence obtained) There were no additional paper recommendations in the MRR book which were signed by residents' physicians. This was previously explained by the Director of Nursing (DON) at 9:38 AM on 5/19/2021, who indicated the previous DON did not maintain these records. She explained she was going to have the Pharmacist email her his recommendation letters which the facility had been unable to locate. During an interview with the DON at 8:21 AM on 5/20/2021, she confirmed Resident #54 received 20 mg of Paxil from February 2020 to May 2021. The paper MRR was reviewed and she confirmed the excessive length of time it took the physician to sign off on the review (3 months), and that the resident only started getting the reduced dose this week, 4 months after the GDR recommendation and 1 month after the physician signed off on it. .

Based on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure Schedule II-V medications were stored in a separately locked compartment, permitting only authorized personnel to have access. The findings include: On May 20, 2021 at 10:00 am, Employee E was asked to show the medication room where their Omni Cell Automated Medication Dispensing System (AMDS) was located. Employee E asked Employee D to show the surveyor where the AMDS was kept. Both Employees D and E escorted the surveyor to a room across from the Med-Bridge nurses station area which had a sign next to the door that said Doctors Lounge. The door to this room was open. It was observed that the door handle had a 5 digit push lock system. It was observed that the door latch was taped down with paper surgical tape in such a fashion that the latch would not engage with the door frame if closed. The AMDS was observed inside this room. Employee D was asked if this door was always kept open. She replied, To be honest, I've never seen this door closed, unless a doctor is in here dictating. Both Employees D and E were asked if they knew the code to the 5 digit push lock system on the door. They both replied no, they did not know the code to gain access to that door lock system. Employee D was asked if the AMDS contained narcotic medications. She stated Yes. The machine contains all the IV supplies and medications we might need for a new admission, or for if a doctor wrote a new order, so we can get the medication started right away, while we are waiting for the pharmacy to deliver the medications ordered. Or if we run out of something that was ordered, but we are still waiting for the delivery, we can access those meds in the machine. Review of the Omni Cell AMDS contents list found 14 different schedule II-V medications listed. A review of facility policy/procedure titled 5.3 Storage and Expirations of Medications, Biologicals, syringes and Needles (effective date 12/1/07, revised 5/10/10, 1/1/13, and 10/31/16) states: 3. General Storage Procedures: 3.1 Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device. 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. A review the facility policy and procedure titled Medication and Treatment Administration Guidelines (7/2002, revised 3/2018) states: Medication Storage and Security: - Controlled substances are securely stored using a double lock system (medication cart, medication room, refrigerator, controlled substance lock box, and/or separately keyed controlled substance drawer in medication cart) - Only licensed nursing staff have key access to medication storage area. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that two of 33 sampled residents, Residents #187 and #73, who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The findings include: 1. On 5/17/2021 at 1:44 pm, Resident #187 was observed in her room with nasal cannula present and an oxygen concentrator administering oxygen at .5 liters per minute. On 5/18/2021 at 10:45 am, Resident #187 was observed in her room sitting in a wheelchair with nasal cannula present. The the oxygen concentrator was administering oxygen at 1 liter per minute. Record review for Resident # 187 revealed that she was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus; dysphagia; unspecified dementia without behavioral disturbance; acute respiratory failure with hypoxia; essential hypertension; anxiety disorder; arteriosclerotic heart disease of native coronary artery; other nonspecific finding abnormal finding of lung field; and major depressive disorder. Physician orders included Oxygen at 3 liters per minute via nasal cannula every shift. Per the admissions Minimum Data Set completed on 5/10/2021, Resident #187 required limited assistance with personal hygiene and extensive assistance with eating, toilet use, bed mobility, transfers and dressing. She required oxygen while residing in the facility. Review of the care plan, dated 5/4/2021 revealed: Focus: the resident has altered respiratory status related to respiratory failure with hypoxia; Goal: the resident will have no shortness of breath; Intervention includes: provide Oxygen as ordered. Per nurses progress notes, on 5/5/2021 a new order was received for oxygen at 3 liters per minute via nasal cannula. During an interview on 5/18/2021 at 10:45 am with Employee D, a Licensed Practical Nurse (LPN) Supervisor, she stated that she was familiar with Resident #187. She confirmed that Resident #187 had an order for Oxygen via nasal cannula at 3 liters per minute. She stated that the nurses are responsible for oxygen care which included patient positioning, ensuring the proper placement of the nasal cannula and the accuracy of the settings based on the orders each shift. 2. During an interview with Resident #73 on 5/16/2021 at 4:25 PM, the oxygen tubing with nasal cannula was observed on the floor unbagged and not in use. The resident placed the cannula on and turned on the concentrator during the interview. It was observed to be set at 3.5 liters per minute (lpm). (Photographic evidence obtained) During a second observation on 5/18/2021 at 8:30 AM, Resident #73 was using her oxygen at 3 lpm. She stated she didn't know her order and guessed it was between 2 and 3 lpm. (Photographic evidence obtained) Record review of Resident #73's orders showed she was ordered oxygen at 2 lpm via nasal cannula every shift for COPD, written at admission on [DATE]. On 5/17/2021 it was rewritten for 2 lpm as needed, for saturations below 92%. (Photographic evidence obtained) A note authored in the electronic chart for Resident #73, dated 4/23/2021, also explained she was to use oxygen at 2 lpm. On 05/05/2021 a note stated, Patient is alert and responsive able to make needs known. On Oxygen at 3 LPM via nasal cannula. Employee B, LPN, confirmed at 10:46 AM on 5/18/2021 that Resident #73's oxygen order was for 2 lpm. During a third observation at 10:49 AM on 5/18/ 2021, Resident #73's nurse, Employee B, was present and confirmed she was using her oxygen at 3 lpm. .