Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secure manner. Findings include: During an observation on 12/9/2024 at 9:30 AM, there was one bottle of Spring Valley Cinnamon Dietary Support Supplement on Resident #5's bedside table. During an interview on 12/9/2024 at 9:30 AM, Resident #5 stated, I take that for my diabetes. I have permission to have that. During an observation on 12/9/2024 at 9:35 AM, there was one clear plastic cup containing 3 round white tablets on Resident #6's bedside table. During an interview on 12/9/2024 at 9:35 AM, Resident #6 stated, It's my sodium pills and I'm not taking those. They get stuck when I try to swallow them, so I'm not taking them. The cup is from the night before. I just didn't take them. During an interview on 12/9/2024 at 1:15 PM, the Assistant Director of Nursing (ADON) stated, There are never to be medications left at bedside. I expect them [staff] to stand with the resident until they have taken all of their medications. If they [residents] wish to have meds at bedside, then an assessment needs to be conducted to see if it's appropriate, then it would be care planned and we would obtain a lockbox for the resident to have. Review of Resident #5's medical records revealed no order for Cinnamon supplements and no care plan focus to have medication at bedside. Review of the facility policy and procedure titled Medication Administration issued on 4/1/2022 showed it read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 3. Medications should be administered in a timely manner and in accordance with the physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During an observation on 11/3/2024 at 8:40 AM, Resident #19's nebulizer mouthpiece and tubing was uncovered on the table in her room. Review of Resident #19's physician order dated 8/23/2024 read, Albuterol Sulfate Inhalation Nebulization Solution 2.5 mg/3 ml. 2.5 mg inhale orally via nebulizer every 6 hours as needed for wheezing or shortness of breath. During an interview on 11/5/2024 at 8:45 AM, the Regional Registered Nurse confirmed Resident #19's nebulizer mouthpiece and tubing were improperly stored. Review of the facility policy and procedure titled Respiratory Care with the last review date of 1/23/2024, read, Policy: It is the policy of this facility to provide respiratory care and safe oxygen administration to meet the needs of the residents. Procedure: 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration, nebulizer treatments, inhalers, trach care, chest tube/PleurX care, BiPap, CPAP or medication administration . 10. Oxygen, trach and nebulizer tubing is changed weekly and dated as verification that the tubing was changed. Tubing change may be recorded in the clinical record but is not required. Tubing should be store appropriately when not in use. Based on observation, record review, and interview, the facility failed to ensure residents received appropriate respiratory care for 3 of 4 residents reviewed for respiratory care, Residents #21, #19, and #36. Findings include: 1) During an observation on 11/3/2024 at 10:20 AM, Resident #21's nebulizer mask was stored on the resident's bedside table next to a soiled cushion (photographic evidence obtained). During and observation on 11/4/2024 at 10:45 AM, Resident #21's nebulizer mask was on the resident's bedside table open to air next to a soiled cushion. During and observation on 11/5/2024 at 12:08 PM, Resident #21's nebulizer mask was laying on the resident's bedside table open to air next to a soiled cushion. Review of Resident #21's admission record showed the resident was initially admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease, chronic pulmonary edema, dependence on supplemental oxygen, chronic diastolic (congestive) heart failure, and chronic pulmonary embolism. Review of Resident #21's physician order dated 6/5/2023, read, Albuterol Sulfate Nebulization Solution (2.5 mg/ 3ml) [2.5 milligram/3 milliliter] 0.083%. 3 ml inhale via nebulizer four times a day for shortness of breath related to chronic obstructive pulmonary disease. During an interview on 11/5/2024 at 12:30 PM, Staff A, Licensed Practical Nurse (LPN), stated, The mask should be stored in a clean bag. During an interview on 11/5/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) stated that her expectation was to have the staff properly store masks in the plastic bags. 2) During an observation on 11/3/2024 at 10:00 AM, Resident #36 was receiving oxygen via nasal cannula at 3.5 liters per minute (photographic evidence obtained). During an observation on 11/4/2024 at 10:40 AM, Resident #36 was receiving oxygen via nasal cannula at 3.5 liters per minute. Review of Resident #36's admission record showed the resident was admitted on [DATE] with diagnosis to include congestive heart failure, and presence of aortocoronary bypass graft. Review of Resident #36's physician order dated 4/11/2024 read, Oxygen at 2 liters/minute Via -NC [nasal cannula] with no humidification. During an interview on 11/5/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) stated, [Resident #36' name] should be set at what the physician orders are. [Resident #36's name] order reads O2 [oxygen] at 2 liters.

Based on observation, interview, and record review, the facility failed to ensure food was stored properly and kitchen equipment were kept in a safe and sanitary manner in the main kitchen and 3 of 3 nourishment rooms. Findings include: During an observation on 11/3/2024 beginning at 9:24 AM while conducting the initial tour of the kitchen, there were white substance buildup on the exterior of the ice machine, one package of pork that was wrapped in foil that was gapped open, shredded cheese wrapped in plastic wrap that was not sealed, one undated and unlabeled plastic container of red sauce, one undated container of pancakes in the reach-in refrigerator. The exterior surface of the oven was discolored and splattered with black and brown substances. There was a black substance caked on the gas stove top grates. During an interview on 11/4/2024 at 8:42 AM, the Certified Dietary Manager confirmed there were undated and unlabeled food items in the reach-in refrigerator. She confirmed the ice machine, oven and gas stove top needed cleaning. During an observation on 11/4/2024 at 8:48 AM with the Regional Certified Dietary Manager, the ceiling above the dishwasher was cracked, flaking and missing paint. There was paint missing from both sides of the overhead light in front of the dishwasher. During an interview on 11/4/2024 at 8:48 AM, the Regional Certified Dietary Manager confirmed there was missing, flaking and cracked ceiling paint over the dishwasher that needed repair. During an observation on 11/4/2024 beginning at 8:52 AM, there were one undated and unlabeled blue lunch bag that contained bottled water, juice packets, and one undated and unlabeled plastic container of food in the East Nourishment Room refrigerator. During an interview on 11/4/2024 beginning at 8:52 AM, the Regional Certified Dietary Manager confirmed foods and beverages stored in the nourishment room refrigerators should be labeled and dated. During an observation in on 11/4/2024 beginning at 8:58 AM, there were one undated and unlabeled 32-ounce thermos of liquid in the refrigerator, and one 64-ounce plastic container of peanut butter with an unsecured lid and one undated and unlabeled 16-ounce cup of liquid in the cabinet in the [NAME] Nourishment Room. During an interview on 11/4/2024 beginning at 8:52 AM, the Regional Certified Dietary Manager confirmed foods and beverages stored in the nourishment room refrigerators should be labeled, sealed and dated. During an observation on 11/4/2024 beginning at 9:04 AM in the South Nourishment Room, there were one undated tray of cookies, and three thawed supplements stored in the refrigerator with no thawed-on date noted on the containers. The cartons of the supplements contained directions that the product should be used within 14 days of thawing. Review of the facility policy and procedure titled Food Delivery and Storage with the last review date of 1/23/2024 read, Policy: It will be the policy of this facility that foods shall be received and stored in a manner that complies with safe food handling practices. Procedure: 1. Dietary/Food Services, or other designated staff, will maintain clean food storage areas at all times . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated. Review of the facility policy and procedure titled Foods Brought in From the Outside with the last review date of 1/23/2024 read, Policy: It will be the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and beverages brought to residents by family and other visitors . Procedure . 4) Food Receiving and Storage a) Upon receiving food and beverages products brought in for residents nursing staff will complete the following . ii) Inspect containers for tight fitting lids, iii) Wrapped items will be inspected to assure the wrapping seals tightly, iv) Label containers with food item name and date received . 6) Any item noted without a label and/or date will be discarded . 9) Leftover trays and/or meals will not be kept on the unit. They will be returned to the Food Services Department and disposed - for example: (Resident at an outside appointment such as a follow up and or dialysis and the like).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 3 of 7 residents reviewed, Residents #13, #35, and #78. Finding include: 1. During an observation on 7/31/2023 at 12:00 PM, Resident #13 was sitting in her room, with oxygen being administered via nasal cannula. During an observation on 8/1/2023 at 9:00 AM, Resident #13 was sitting in her wheelchair, with oxygen being administered via nasal cannula. Review of Resident #13's MDS 5-day Significant Change in Status assessment dated [DATE] reads, Section O. O0100. Special Treatments, Procedures and Programs . C. Oxygen. 1. While NOT a Resident: No, 2. While a Resident: No. Review of Resident #13's physician order dated 5/4/2023 reads, Monitor O2 [oxygen] sats [saturation] as needed for SOB [Shortness of Breath]/Respiratory Distress . Monitor O2 sats every shift for O2 monitoring. Review of Resident #13's physician order dated 5/5/2023 reads, May apply O2 @ [at] 2 LPM [liters per minute] via nasal cannula as needed to maintain sats above 92% as needed for monitoring O2 sats > or = 92%. Review of Resident #13's Weights and Vitas Summary reads, 05/09/2023, 20:00 [8:00 PM] 95% (Oxygen via Nasal Cannula), 05/08/2023, 18:04 [6:04 PM] 90% (Oxygen via Nasal Cannula), 05/07/2023, 18:11 [6:11 PM] 95% (Oxygen via Nasal Cannula), 05/06/2023, 19:34 [7:34 PM] 98% (Oxygen via Nasal Cannula), 05/06/2023, 15:49 [3:49 PM] 98% (Oxygen via Nasal Cannula), 05/06/2023, 13:35 [1:35 PM] 98% (Oxygen via Nasal Cannula), 05/05/2023, 22:33 [10:33 PM] 98% (Oxygen via Nasal Cannula), 05/05/2023, 15:43 [3:43 PM] 95% (Oxygen via Nasal Cannula), 05/04/2023 at 22:33 [10:33 PM] 97% (Oxygen via Nasal Cannula). During an interview on 8/2/2023 at 7:52 AM, the MDS Coordinator stated, [Resident #13' name] MDS dated [DATE] is marked no for oxygen, but she did have oxygen administered. It needs to be corrected. 2. During an observation on 7/31/2023 at 10:27 AM, Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. During an observation on 8/2/2023 at 6:05 AM with Staff K, Registered Nurse (RN), Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Review of Resident #35's physician order dated 7/27/2023 reads, Continuous O2 at 2 L/MIN via NC [Nasal Cannula] every shift. Review of Resident #35's Quarterly MDS dated [DATE] reads, Section O. O0100. Special Treatments, Procedures and Programs . C. Oxygen . 2. While a Resident: No. Review of Resident #35's Weights and Vitals Summary reads, 05/23/2023, 17:11 [5:11 PM] 94% (Oxygen via Nasal Cannula), 05/21/2023, 17:37 [5:37 PM] 98% (Oxygen via Nasal Cannula). During an interview on 8/2/203 at 7:58 AM, the MDS Coordinator stated, [Resident #35's name] has so many things going on with her. She sure did use oxygen. 3. Review of Resident #78's records revealed the resident was admitted to the facility on [DATE] with diagnoses including lobar pneumonia, pyuria, cardia murmur, congestive heart failure and chronic kidney disease. Resident #78 was discharged home with family on 7/7/2023. Review of Resident #78's MDS Assessment Discharge Return Not Anticipated dated 7/7/2023 reads, Section A. Identification Information . A2100. Discharge Status: 03. Acute hospital. Review of Resident #78's Social Services Progress Note dated 7/7/2023 reads, Pt [Patient] given d/c [discharge] instructions/ med list, verbalized understanding all. all meds sent with pt. discharged approx. [approximately] 12 noon . Discharge Planning- [Resident #78's name] has requested to discharge today at noon with her daughter . During an interview on 8/1/2023 at 2:00 PM, the MDS Coordinator confirmed that Resident #78's was discharged home with her daughter, but the discharge MDS showed the resident was discharged to a hospital. During an interview on 8/2/2023 at 10:30 AM, the Director of Nursing stated, Yes, [Resident #78's name] discharged home with her family. Her MDS shows she discharged to the hospital. Review of the facility policy and procedure titled MDS Assessments with the last review date of 1/17/2023 reads, Procedures: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was diagnosed with a serious mental illness was referred for level II Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents reviewed, Resident #49. Findings include: Review of Resident #49's admission records showed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive communication deficit, dementia, major depressive disorder, anxiety disorder, and schizophrenia (onset date of 9/18/2022). Review of Resident #49's records revealed no referral for Level II PASRR screening when the resident received the diagnosis of schizophrenia. During an interview on 8/2/2023 at 10:00 AM, the Director of Nursing stated, We did not conduct a new Level I screen when [Resident #49's Name] was officially diagnosed with schizophrenia. Review of the facility policy and procedures titled P&P Role of Admissions and Social Services in PASRR last reviewed on 1/17/2023 reads, Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services . Procedure . IV. Resident Review . 2. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition who experience a significant change.

Based on interview and record review, the facility failed to ensure a resident who was admitted with a diagnosis of a serious mental received a referral to the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination for 1 of 3 residents reviewed, Resident #39. Findings include: Review of Resident #39's admission record revealed the resident was admitted most recently to the facility on 6/3/2022 with diagnoses including cerebral atherosclerosis, psychotic disorder with delusions, unspecified psychosis not due to a substance or known physiological, general anxiety disorder, mood disorders, major depressive disorder, neurocognitive disorder with Lewy bodies and encounter for palliative care. Review of Resident #39's level II Preadmission Screening and Resident Review (PASRR) dated 6/3/2022 reads, Section IV: PASRR Screen Completion . Individual may not be admitted to an Nursing Facility. Use this form and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of [Check on of the following]: X Serious Mental Illness and Intellectual Disability. During an interview on 8/2/2023 at 10:00 AM, the Director of Nursing (DON) stated, We did not send out a referral for a level II screening for [Resident #39's Name]. It should have been referred out. Review of the facility policy and procedure titled P&P Role of Admissions and Social Services in PASRR) last reviewed on 1/17/2023 reads, Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services . Procedure: I. Preadmission Screening . 3. If the result of the PASRR (Level 1) screening indicates that serious mental illness (SMI) and/or intellectual disability (ID) or related condition appears to exist (positive Level I screen) and the individual does not meet a Provisional or Hospital Discharge Exemption, the individual will be referred to KEPRO [Keystone Peer Review Organization] for a Level II screening prior to the individual being accepted for SNF [Skilled Nursing Facility] admission.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for 1 of 5 residents reviewed for nutrition, Resident #30, and failed to develop a person-centered care plan for 1 of 4 residents reviewed for respiratory services, Resident #13. Findings include: 1. During an observation on 7/31/2023 at 12:10 PM, Resident #30 was eating independently in her room. The meal tray had a plate with green beans and pasta on the same plate, rice pudding in a bowl and a cup of coffee. During an observation on 8/1/2023 at 8:13 AM, Resident #30 was eating independently in her room. The meal tray contained scrambled eggs and toast on the same plate and a bowl of oatmeal. During an observation on 8/1/2023 at 11:59 AM, Resident #30 was eating in the restorative dining room area. The plate contained macaroni and cheese, chopped meat, spinach, and a roll. All items were together on the same plate (Photographic evidence obtained). Review of Resident #30's care plan with revision date of 4/4/2022 reads, Focus: [Resident #30's name] has an alteration in visual function AEB [As Evidenced By]: dx [diagnosis] of glaucoma, is legally blind, is only able to see shapes, lights. Assist with meals as needed . Interventions: Per [Resident #30's name] request, her food will be put in separate bowls for easier self-feeding. During an interview on 8/2/2023 at 7:57 AM, the Registered Nurse Assessment Coordinator stated, [Resident #30's name] food should come in separate bowls. During an interview on 8/2/2023 at 1:27 PM, the Director of Nursing stated, [Resident #30's name] food should have come in separate containers as mentioned in the care plan. We had been talking about this with staff. 2. During an observation on 7/31/2023 at 12:00 PM, Resident #13 was sitting in her room, with oxygen being administered via nasal cannula. During an observation on 8/1/2023 at 9:00 AM, Resident #13 was sitting in her wheelchair, with oxygen being administered via nasal cannula. Review of Resident #13's physician order dated 5/4/2023 reads, Monitor O2 [oxygen] sats [saturation] as needed for SOB [Shortness of Breath]/Respiratory Distress . Monitor O2 sats every shift for O2 monitoring. Review of Resident #13's physician order dated 5/5/2023 reads, May apply O2 @ [at] 2 LPM [liters per minute] via nasal cannula as needed to maintain sats above 92% as needed for monitoring O2 sats > or = 92%. Review of Resident #13's care plan revealed no focus for respiratory care or oxygen use. During an interview on 8/2/2023 at 7:49 AM, the Registered Nurse Assessment Coordinator stated, I see under cardiac functions to monitor O2 [oxygen] sats. I do not see [Resident #13's name] care plan for respiratory or oxygen concerns. I will add it. During an interview on 8/3/2023 at 8:54 AM, the Director of Nursing stated, I have been made aware that [Resident #13's name] did not have a respiratory/oxygen care plan developed. There should have been one. Review of the facility policy and procedure titled Oxygen Administration last reviewed on 1/17/2023 reads, Procedure . 9. The use of oxygen should be reflected in the resident's plan of care. Review of the facility policy and procedure titled Care plans, Comprehensive Person-Centered last reviewed on 1/17/2023 reads, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure that residents received care in accordance with professional standards of practice for medication administration for 1 of 7 residents reviewed, Resident #180. Finding include: During an observation of medication administration for Resident #180 on 8/2/2023 at 8:26 AM, Staff L, Registered Nurse (RN), pulled Depakote Delayed Release 250 mg (milligram) blister pack out of the medication cart and verified the order and medication on hand. Staff L placed one tablet in a clear plastic sleeve, crushed the medication, and placed the crushed medication into a plastic medication cup. Staff L proceeded to prepare Citalopram Hydrobromide 10 mg and Metoprolol 25 mg, crushed the medications individually and placed them in separate medication cups. Staff L stated to review how many milliliters of water each medication should be mixed with. When asked to review Depakote delayed release medication order one more time, Staff L stated, It says delayed release. We should not be crushing this medication, but that is what the order reads. I guess I can ask my DON [Director of Nursing] for clarification. Staff L walked to the DON's office. The DON was not available in her office. Staff L returned to the unit and asked Staff E, License Practical Nurse (LPN), about the medication. Staff E stated a delayed release medication could not be administered via gastric tube and would contact the doctor for clarifications. Review of Resident #180's physician order dated 7/27/2023 reads, Depakote Oral Tablet Delayed Release 250 mg, give 3 tablet enterally three times a day for mood disorder. Review of Resident #180's physician order dated 7/26/2023 reads, Nothing by mouth diet, nothing by mouth texture, nothing by mouth consistency, for nutrition. Review of Resident #180's Medication Administration Record (MAR) for July 2023 revealed staff initials for administration of Depakote Oral Tablet Delayed Release 250 mg on 7/27/2023, 7/28/2023, 7/29/2023, 7/30/2023, 7/31/2023 at 9:00 AM, 1:00 PM and 5:00 PM Review of Resident #180's MAR for August 2023 reads revealed staff initials for administration of Depakote Oral Tablet Delayed Release 250 mg on 8/1/2023 at 9:00 AM, 1:00 PM and 5:00 PM. During an interview on 8/2/2023 at 10:43 AM, the Attending Physician A stated, Depakote delayed release should not be crushed. I was not notified prior to today that the order was incorrect. The medication should not be crushed because it is supposed to be released along some time. What will happen is that the resident will have a higher dose in a short period of time, but it will wear out in a short period of time. The facility will need to check levels. I have an order in place for the levels to be checked this upcoming Monday to make sure of the resident's therapeutic level. I do not see any potential harm since it takes time to build a steady level. It will not be immediately. I would not have a devastating consequence. The medication is not for seizures, but due to behavior. During an interview on 8/2/2023 at 11:04 AM, Staff E, LPN, stated, If I gave it, I probably gave it as ordered. Delayed release medication should not be usually crushed. I had not realized the medication was extended release until today when you and [Staff L's name] approached me. I kind of float all over the building and it is hard for me to keep up. When I am going to administer medication, I read the order and double check the route and dose. I missed that. I crushed the Depakote and put it through his tube. During an interview on 8/2/2023 at 11:57 AM, Staff G, LPN, stated, I do not recall. I do not know of any other way I would have administered medication other than [Resident #180's name] gastric tube. Honestly, I did not realize the Depakote was delayed release. I would have called the doctor since the resident is NPO [Nothing by Mouth] and had the doctor change it to something else. During an interview on 8/2/2023 at 12:01 PM, Staff H, LPN, stated, I administered the medication via g-tube [gastric tube]. I did not realize the order was delayed released since I gave it via g-tube. I would have called the doctor to clarify and get it changed to something crushable. During an interview on 8/2/2023 at 1:24 PM, the Director of Nursing (DON) stated, I would have expected staff to call the doctor and get the medication changed to something that is not extended release and can be administered via gastric tube. [Resident #180's name] is NPO. During an interview on 8/2/2023 at 4:57 PM, Staff F, LPN, stated, I crushed and administered via [Resident #180's name] gastric tube. Next time, I will call the doctor and get clarification on the orders. Review of the facility policy and procedure titled Medication Administration Via Enteral Feeding Tube last reviewed on 1/17/2023 reads, Policy: Medications shall be prepared and administered according to the following established guidelines . Residents with enteral tubes should be provided liquid medications whenever possible to prevent buildup of residue within the tube inner lumen. Procedure . Common Medications Not to Crush: Some medications and dosage form should not be crushed. If there are any questions regarding the crushing of medications, call the pharmacy.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 4 residents reviewed for respiratory services, Residents #26, #30, and #35 (Photographic evidence obtained). Findings include: 1. During an observation on 7/31/2023 at 12:10 PM, Resident #26 was lying in bed, with the nebulizer mouthpiece on top of the drawer with no bag. There were vials of Albuterol next to the mouthpiece, and the oxygen tank tubing was dated 04/09. During an observation on 8/1/2023 at 8:32 AM, Resident #26 was lying in bed, with the nebulizer mouthpiece on top of the drawer with no bag. There were vials of Albuterol next to the mouthpiece, and the oxygen tank tubing was dated 04/09. During an observation on 8/2/2023 at 7:34 AM with Staff I, License Practical Nurse (LPN), Resident #26 was resting in bed with her eyes closed. The nebulizer mouthpiece was on top of the drawer with no bag. There were vials of albuterol next to the mouthpiece. The nebulizer mask was on top of the chair with no date on tubing or bag. The oxygen tubing connected to the oxygen tank attached to the wheelchair was dated 4/9/2023. During an interview on 8/2/2023 at 7:38 AM, Staff I, LPN, stated, Tubing should be changed every week by night shift. Tubing and mask should be bagged when not in use. Review of Resident #26's physician order dated 4/7/2023 reads, Continuous O2 [oxygen] at 3 L/MIN [liters per minute] via NC [Nasal Cannula] q [every] shift every shift. Review of Resident #26's physician order dated 4/18/2023 reads, Check oxygen saturations Q shift every shift. Review of Resident #26's physician order dated 6/7/2023 reads, Albuterol Sulfate (2.5 MCG/3 ML) [2.5 microgram per 3 milliliters] 0.083% Nebulization Solution, 3 ml inhale orally via nebulizer every 8 hours and as needed for COPD [Chronic Obstructive Pulmonary Disease]. Review of Resident #26's physician orders revealed no orders for tubing change. 2. During an observation on 7/31/2023 at 10:26 AM, Resident #30 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. During an observation on 8/1/2023 at 8:00 AM, Resident #30 was lying in bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. Review of Resident #30's physician order dated 1/19/2023 reads, Continuous O2 at 2 L/MIN via NC q shift. During an interview on 8/2/2023 at 7:44 AM, the Director of Nursing stated, Oxygen tubing should be changed weekly, and equipment should be stored in a bag when not in use. Staff are expected to follow physician orders and verify flow rates unless resident is prn [as needed] or has orders to wean. 3. During an observation on 7/31/2023 at 10:27 AM, Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Oxygen tubing was not dated. During an observation on 8/2/2023 at 6:05 AM with Staff K, Registered Nurse (RN), Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Oxygen tubing was not dated. During an interview on 8/2/2023 at 6:07 AM, Staff K, RN, stated, [Resident #35's name] oxygen is supposed to be running at 2 liters per minute not at 3 liters and tubing should be dated. Review of Resident #35's physician order dated 7/27/2023 reads, Continuous O2 at 2 L/MIN via NC q shift. Review of the facility policy and procedures titled Oxygen Administration last reviewed on 1/17/2023 reads, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 3. Assemble the equipment and supplies as need . 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff but is only required to have tubing dated appropriately demonstrating that the tubing was changed.

Based on observation, interview, and policy and procedure review, the facility failed to ensure foods in the refrigerator and storage area of the kitchen were dated and/or labeled, and failed to ensure the expired or outdated foods were discarded. Findings include: During an initial walk-through of the kitchen on 7/31/2023 at 9:17 AM with the Dietary Manager (DM), there were eight containers of cranberry juice cocktail with a manufacturer stamped expiration date of 7/18/23 on the shelves in the stock room; a container of sour cream with a manufacturer used by date of 7/23/23 in the reach-in cooler; an unidentified Styrofoam hinged container with no label or date in the walk-in cooler; and a large container of red potatoes, a large container of sauce, and a large container of sliced ham with no label identifying the contents and a date of 7/27/23 on the lid. During an interview on 7/31/2023 at 9:29 AM, the DM stated that the cranberry juice cocktail was expired and should have been pulled and discarded on 7/18/2023, the sour cream container showed an expiration date of 7/23/23 and should have been discarded on that date, the hinged Styrofoam container should have been labeled with the contents and dated, and the containers of potatoes, sauce, and ham should have had identifying labels as well as the date to show when the item was prepared and a use by date. Review of the facility policy and procedures titled Receiving with the last review date of 7/19/2023 reads, Policy Statement: It is the center policy that safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Action Steps . 6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.

Based on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 4 of 15 residents reviewed, Residents #42, #229, #61, and #182. Findings include: 1. Review of Resident #42's physician order dated 7/6/2023 reads, Weight resident daily on 11-7 shift. Notify MD [Medical Doctor] for 3 lbs [pounds] weight gain in 24 hours or 5 lbs weight gain in 1 week. every night shift for prophylaxis. Review of Resident #42's Treatment Administration Record (TAR) for July 2023 revealed no weights recorded for 7/6/2023, 7/10/2023, 7/15/2023, 7/23/2023, 7/24/2023, and 7/25/2023, and NA [Not Applicable] recorded for 7/7/2023, 7/8/2023, 7/9/2023, 7/12/2023, 7/17/2023, 7/21/2023 and 7/22/2023. Review of Resident #42's Weight and Vital Summary reads, 7/7/2023: 260 lbs, 7/12/2023: 259 lbs, 7/15/2023: 262 lbs, 7/17/2023: 261.7 lbs, 7/19/2023: 260 lbs, 7/20/2023: 258.4 lbs, 7/27/2023: 261 lbs, 7/31/2023: 259.6 lbs. Review of Resident #42's care plan revised on 6/28/2023 reads, Interventions . Provide diet as ordered. Observe for compliance with diet. Weights as scheduled. During an interview on 8/1/2023 at 1:29 PM, the Director of Nursing (DON) stated, [Resident #42's name] has some refusals and some weights documented. The empty spaces on the treatment record mean staff are not documenting the weights in the system like they should be. 2. During an observation of Staff E, Licensed Practical Nurse (LPN), and Staff F, LPN, providing wound care for Resident #229 on 8/2/2023 at 4:25 PM, Staff E washed her hands and proceeded to place barrier under the resident's legs. Resident #229's right leg had a gauze dressing dated 8/2/2022. Staff E performed wound care on the resident's right leg. During an interview on 8/2/2023 at 4:26 PM, Staff E, LPN, stated [Resident #229's name] wounds are all located in his right leg. Review of Resident #229's physician order dated 7/26/2023 reads, Cleanse left shin with ns [normal saline], pat dry, apply xeroform, abd [abdominal] and wrap with kerlix daily every evening shift for wound healing. Review of Resident #229's physician order dated 8/1/2023 reads, Cleanse left heel with ns, pat dry, apply betadine and leave open to air every evening shift for wound healing . Cleanse top of left foot with ns, pat dry, apply Santyl and medihoney and cover/wrap with kerlix daily every evening shift for wound healing. Review of Resident #229's Healing Partners Wound Assessment Report dated 7/28/2023 reads, Location: right heel, Etiology: Pressure, Stage/Severity: Unstageable . Location: right foot, Etiology: Pressure, Stage/Severity: Stage 3. During an interview on 8/3/2023 at 9:15 AM, the Regional Nursing Consultant stated, I will review [Resident #229's name] record and see. Sometimes it can get confusing, the labeling of side. 3. Review of Resident #182's bladder continence task record from 7/14/2023 through 7/31/2023 reads, Task: Bladder Continence: Resident is incontinent of bladder and requires assistance of 1 for all per care. Review of the calendar showed no entries documented for 7/24/2023 and 7/25/2023. During an interview on 8/1/2023 at 11:30 AM, the DON stated that her expectations was for the staff to chart in the task area when changing an incontinent resident, and staff were expected to accurately document and only document when they performed the task. During an interview on 8/1/2023 at 1:55 PM, Staff D, Certified Nursing Assistant (CNA), stated, We check incontinent residents every 2 hours, and it is an error of data input as I don't put it in the computer every time. Review of the facility policy and procedure titled Perineal/Incontinent Care last reviewed on 7/17/2023 reads, Procedure . 8. Document completion of care rendered as is appropriate or required to demonstrate needs of resident have been met. 4. Review of Resident #61's shower task record for July 2023 reads, Task: Resident shower days are on Monday-Wednesday-Friday on 7-3 with assist of 1 and shower chair between the hours of 7 am and 8 am. Review of the calendar showed no entries documented for Friday 7/14/2023, Monday 7/17/2023, Friday 7/21/2023, and Wednesday 7/26/2023. During an interview on 8/2/2023 at 2:20 PM, the DON stated, My expectation is for the staff to document on the shower task sheet each time they give a shower or when the resident refuses. During an interview on 8/3/2023 at 8:03 AM, Staff J, CNA, stated, When it shows on the task list that a resident is due a shower, we mark on the list on the computer that we give it or that they have refused. We also document any PRN [as needed] showers on the list. Review of the facility policy and procedures titled Charting and Documentation with last review date of 1/17/2023, reads, Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards to help prevent the possible development and transmission of communicable diseases and infections during wound care for 1 of 2 residents reviewed for pressure ulcers, Resident #229. Findings include: During an observation of Staff E, Licensed Practical Nurse (LPN), and Staff F, LPN, providing wound care for Resident #229 on 8/2/2023 at 4:25 PM, Staff E washed her hands and proceeded to place barrier under the resident's legs. The resident's right leg had a gauze dressing dated 8/2/2022. Staff E removed the old dressing and placed the resident's leg on top of the barrier. Staff F handed Staff E a sterile saline wipe. Staff E used the wipe to clean the right shin without washing her hands. Staff F handed Staff E a 4x4 gauze. Without performing hand hygiene or changing gloves, Staff E patted dry the area. Staff E applied xeroform to the right shin, covered it with an abdominal pad and wrapped the right shin area with kerlix gauze. Staff E removed her gloves and washed her hands with soap and water. Staff E donned gloves and Staff F handed a sterile saline wipe. Staff E lifted the resident's right leg and cleaned the right heel open wound with wipe. Staff E did not perform hand hygiene and patted dry the right heel. Staff E did not change the contaminated barrier. Staff E placed the resident's clean open heel wound back down on the contaminated barrier. The barrier had blood stains where the heel wound had been placed before cleaning. Staff F handed Staff E betadine. Staff E lifted the resident's right foot, applied betadine to the right heel wound, and returned the right heel back down on the contaminated barrier. Staff E removed her gloves and washed her hands. Staff F handed Staff E a sterile saline wipe. Staff E cleaned the resident's top of right foot wound. Staff E did not perform hand hygiene. Staff E patted dry the area. Staff E removed her gloves and performed hand hygiene. Staff E donned her gloves and washed her hands. Staff F handed Santyl to Staff E, and Staff E applied it to the right foot wound. Staff F applied medihoney to abdominal pad and Staff E placed it on top of the resident's foot wound. Staff E wrapped the resident's right foot wound with kerlix gauze. During an interview on 8/2/2023 at 4:54 PM, Staff E, LPN, stated, I thought I had washed my hands. I do not recall if I did or not. I should have changed the barrier once I cleaned the heel wound before placing the foot back down. During an interview on 8/2/2023 at 4:54 PM, Staff F, LPN, stated, I am not sure if [Staff E's name] washed her hands since I was standing on the other side. We should have washed our hands three times instead of just two times. We skipped the step. The barrier should have been changed once it was contaminated before putting the foot back down after it was cleaned. Review of Resident #229's physician order dated 7/26/2023 reads, Cleanse left shin with ns [normal saline], pat dry, apply xeroform, abd [abdominal] and wrap with kerlix daily every evening shift for wound healing. Review of Resident #229's physician order dated 8/1/2023 reads, Cleanse left heel with ns, pat dry, apply betadine and leave open to air every evening shift for wound healing . Cleanse top of left foot with ns, pat dry, apply Santyl and medihoney and cover/wrap with kerlix daily every evening shift for wound healing. During an interview on 8/3/2023 at 8:55 AM, the Director of Nursing (DON) stated, The staff should not have placed clean foot back down on the barrier. They should have washed their hands in between wound care steps. Review of the facility policy and procedures titled Wound Care with the last review date of 1/17/2023 reads, Procedure . 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. Review of document presented by the facility titled Non-Sterile Dressing Change Aduit reads, Procedure . Preform Treatment According to Orders: Put on clean gloves, Remove dirty dressing and place in plastic bag (unless infection is present or saturated w/ [with] blood then place in red bag), Place dirty scissors on established barrier separate from existing clean field, Remove gloves, Place soiled gloves in plastic bag, Wash hands, Prepare supplies (open dressing, etc.), Put on clean gloves, Measure wound, Clean from inner edge to outer, Remove gloves, Place soiled gloves in plastic bag, Wash hands, Put on clean gloves, Apply medication and dressing.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 3 reviewed medication carts, and failed to ensure the medications were not unattended (Photographic evidence obtained). Findings include: During an observation on 7/31/2023 at 9:00 AM, there was a bag on the floor in the conference room, which contained four unopened normal saline syringes. During an interview on 7/31/2023 at 9:15 AM, the Director of Nursing (DON) stated, We had an IV [intravenous] class for nurses that is why it was there. During an observation of North Wing Medication Cart on 7/31/2023 at 9:30 AM with Staff A, License Practical Nurse (LPN), there were one opened Advair with opened date of 5/14/2023, three opened bottles of Latanoprost with no opened date, and one opened Lantus insulin pen with no opened or expiration date. During an interview on 7/31/2023 at 9:37 AM, Staff A, LPN, stated, Upon opening medication, we should label it with an open and expiration date, and if medication is expired, it should come off the cart and it should be reordered. During an observation of [NAME] Wing Medication Cart on 7/31/2023 at 9:41 AM with Staff B, LPN, there were two opened bottles of Artificial Tears eye drops with opened dates of 6/25/2023, and two opened bottles of Artificial Tears eye drop with opened dates of 6/20/2023. During an interview on 7/31/2023 at 9:47 AM, Staff B, LPN, stated, Once expired, medication should be taken out of the cart. During an observation of East Wing Medication Cart on 7/31/2023 at 9:50 AM with Staff C, LPN, there were two opened bottles of Artificial Tears eye drops with no opened dates. During an interview on 7/31/2023 at 9:55 AM, Staff C, LPN, stated, Once medication is opened, the bottle should be labeled with an open date. The staff wrote the actual expiration of the medication. I think eye drops are good for 90 days after opening them. During an observation of Resident #13's room on 7/31/2023 at 9:58 AM, there was a tube of Zinc Oxide ointment on top of the drawer. During an observation Resident #26's room on 7/31/2023 at 10:26 AM, there were vials of Albuterol Sulfate Inhalation Solution on top of the drawer next to the nebulizer mouthpiece. During an interview on 8/2/2023 at 7:34 AM, Staff I, LPN, stated, [Resident #26's name] should not have any Albuterol vials in her room. During an interview on 8/2/2023 at 7:40 AM, the Director of Nursing stated, There should not be any expired medications in the medication carts. Anything that is open should be labeled. We administer [Resident #13's name] medication for her. The ointment should not have been in her room. [Resident #26's name] does not have a self-administration order. The staff would do a self-administration assessment making sure resident is able to administer the medication. We would provide a lock box for medication storage in room. Review of the facility policy and procedures titled Medication/Biological Storage last reviewed on 1/17/2023 reads, Policy: It will be the policy of this facility to store medications, drugs and biologicals, in a safe, secure and orderly manner. Procedure . 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals.

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered consistent with professional standards of practice for 1 of 3 residents, Resident #30, in a total sample of 34 residents. Findings: During an observation on 03/08/2022 at 10:52 AM of Resident #30 it showed the resident was being administered oxygen at 2 liters per minute (2L/min) via nasal cannula. During an observation on 03/09/2022 at 10:03 AM of Resident #30 it showed the resident was being administered oxygen at 3.25 L/min (liters per minute) via nasal cannula. During an observation on 03/09/2022 at 12:23 PM of Resident #30 it showed the resident was being administered oxygen at 3.25 L/min via nasal cannula. Review of the physician's order dated 2/28/2022 read: Continuous oxygen at 4 liters/min via nasal canula each shift. During an interview conducted on 03/09/2022 at 2:00 PM Staff A, Licensed Practical Nurse (LPN) stated, Looks like it's [oxygen setting] is between 3 to 3 1/2 liters per minute. The Certified Nursing Assistants never adjust the oxygen, only the LPNs adjust the oxygen; even the respiratory therapist will ask the LPNs, before they adjust it. I'd be surprised if he could get out of bed alone and change it. Review of the physician's order for Resident #30 was conducted with Staff A, LPN. Staff A verified the physician's order as written is for oxygen at 4L/min. Review of Resident #30's care plan initiated on 01/21/2022 read: Resident #30 has a potential for complications of respiratory distress r/t (related to) dx (diagnosis) of: SOB (shortness of breath), PNA (pneumonia) HX (history), hypoxia HX, COPD (chronic obstructive pulmonary disease), and CHF (congestive heart failure). Goal: Resident will remain free from cardiovascular complications thru the next review dated. Interventions: O2 sats [saturation] as ordered. Administer O2 [oxygen] as ordered. Observe for signs and symptoms of respiratory distress; update physician if noted. Vital signs as ordered and as needed. Elevate HOB [head of bed]>30 degrees to minimize SOB as needed.

Based on interview and policy review, the facility failed to ensure dietary staff met required qualifications. Finding: An initial tour of the kitchen was conducted on 03/07/2022 at 09:19 AM with the Assistant Manager (AM). An interview was conducted with the AM on 3/07/22 at 9:30 AM. The AM stated the facility does not have a Certified Dietary Manager (CDM) or full time Dietician that oversees the day-to-day operations of the dietary department. She is the full-time day cook and tries to see to some of the needs of the department but has no training as a Dietary Manager. She currently orders the food and makes the schedule for the dietary staff. The department is supposed to have a CDM and has been without a CDM for four months. She was hired as a cook by the previous CDM but was not trained on all the duties of a Dietary Director. The AM stated that a consulting dietician is scheduled each week on Thursday to complete assessments and does not oversee the kitchen operations. An interview was conducted with the consulting Registered Dietician (RD) on 3/7/2022 at 11:45 AM. The RD confirmed that the dietary department does not currently have a CDM and that the company is actively seeking to hire one. Review of the policy titled, Professional Staffing dated October 2019, under the section titled Policy Statement read, It is the center policy that the Dining Services department employs sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutritional services, taking into consideration the resident assessments, individual plans of care and the number, acuity and diagnosis of the center's resident population. If a qualified dietician or other clinically qualified nutrition professional is not employed full-time, a qualified director of food and nutrition will be employed. Review of a document titled, Responsibilities and Duties read, Article II, Section 2.1 Engagement and Initial Culinary Responsibilities read: (e) Next Level will provide a full-time culinary services manager (the Culinary Manager), support from a registered dietician and adequate staffing to meet all applicable Federal, state, and local legal requirements.