**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to ensure 1 (Resident #19) of 1 resident reviewed for activities, attended activities of their choice to ensure they maintained and/or improved their psychosocial well-being and independence. The findings included: On 2/26/24, observation of Resident #19 at 10:30 a.m., 11:16 a.m., 12:35 p.m., and 3:00 p.m. revealed she was in her room during those observations without the television or radio on. Resident #19 was not observed in any of the facility activities during the day. On 2/27/24, observation of Resident #19 at 8:30 a.m., 9:30 a.m., and 11:00 a.m. revealed she was in her room during those observations without the television or radio on. Resident #19 was not observed in any of the facility activities during those observations. On 2/27/24, a review of Resident #19's medical record revealed she was admitted to the facility on [DATE] with medical diagnoses of Parkinsonism, muscle weakness, and dementia without behavioral disturbance. A review of Resident #19's activity plan of care dated 11/22/2023 stated Resident #19 would benefit from associate support for resident programs to maintain involvement in cognitive stimulation with independent or assisted leisure and social activities as desired. Interventions included to invite Resident #19 to scheduled programs, lunch and dinner in the dining room, live entertainment, outdoors, dog visits and violinists. Review of the Activity Coordinator's progress note revealed 12 entries from 11/20/23 through 2/21/24 of 1:1 room visits by the violinist, Golden Paws service dogs, podiatrist, and Nurse [NAME] who plays the guitar. On 2/27/24 at 11:58 a.m., during an interview with Resident #19's daughter, she said due to her mother's Parkinson's disease, her mother needed a lot of assistance from staff. She said her mother was an active person prior to coming to the facility and one of her concerns was when she visited her mother she was always in her room without the television or the radio being on. She said she had asked the facility from the beginning to take her mother outside to enjoy the sunlight and fresh air. She said since the facility was not taking her mother out of her room for activities, she had another meeting with the Director of Nursing (DON) and the Activity Coordinator (AC) several weeks ago, reminding them to ensure her mother attended out-of-room activities and going outside to enjoy the sunshine and fresh air. The Activity Programs policy last revised on June 2018 stated the activity program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. On 2/27/24 at 12:34 p.m., in an interview with the Activity Coordinator, she said she had been working at the facility for one year. She said as part of her job she was to promote the physical, mental and psychosocial well-being of the residents, conduct an activity evaluation upon admission and at least quarterly and document any change of condition that could affect the resident's participation in the activity care plan. She said the Activity Coordinator was responsible for completing, directing, and/or delegating the completion of the activity interventions noted in each resident's activity plan of care. The Activity Coordinator confirmed after reviewing Resident #19's medical records, Resident #19's plan of care for activities dated 11/22/2023 stated Resident #19 would benefit from associate support for resident programs to maintain involvement in cognitive stimulation with independent or assisted leisure and social activities as desired. Interventions included inviting Resident #19 to scheduled programs, lunch and dinner in the dining room, live entertainment, outdoor activities, dog visits, and violinists. She said she had documented 12 activity progress notes from 11/20/23 through 2/21/24 of 1:1 room visits by the violinist, Golden Paws service dogs, the podiatrist, and Nurse [NAME], who plays the guitar. She said she was unable to find documentation that Resident #19 had done activities outside of her room as noted in the 11/22/23 activity plan of care and requested again several weeks ago in a meeting with the DON and Resident #19's daughter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of facility's policies and procedures, the facility failed to maintain, clean, and store respiratory care equipment in a sanitary manner and in accordance with manufacturer's specifications for 1(Resident #27) of 2 sampled residents with physician's orders for oxygen and breathing treatments. The findings included: Review of the clinical record revealed Resident #27 was admitted to the facility on [DATE] with primary diagnoses of Chronic Obstructive Pulmonary Disease and Emphysema (a lung disease that damages the tiny air sacs in the lungs). On 2/26/24 at 10:55 a.m., Resident #27 was observed receiving oxygen through a nasal cannula connected to an oxygen concentrator (medical device that delivers extra oxygen). The concentrator machine and the filter at the vented area were dusty. An Oxygen cylinder was observed on the back of the resident's wheelchair with a nasal cannula stored uncovered on the seat. A nebulizer (a medical device to administer aerosol medication) machine mask and medication cup with tubing were observed stored uncovered on the resident's nightstand. Photographic Evidence Obtained On 2/27/24 at 9:40 a.m., the nebulizer mask and medication cup were observed stored uncovered on the nightstand. The oxygen tubing with nasal cannula connected to the oxygen cylinder was hanging over the armrest of the wheelchair touching the wheel. On 2/28/24 at 9:37 a.m., the resident's nasal cannula was observed stored hanging uncovered over the back of the wheelchair. The concentrator vented area remained dusty. Photographic Evidence Obtained. On 2/28/24 at 10:26 a.m., in an interview, Registered Nurse (RN) Staff C stated, When a resident is using a nebulizer, the tubing gets changed weekly or as needed and dated. The nebulizer would get washed with soapy water, rinsed and air dried. It would be placed in a bag when dry. A policy provided by the facility titled, Nebulizer Cleaning Policy and Procedure indicated device will be cleaned and dried after each nebulizer treatment and placed in a bag. Take apart medication cup and mouthpiece or mask, use soap and water, rinse, and place on clean towel to dry. Place in plastic bag when dry. On 2/28/24 at 10:35 a.m., in an interview, the DON stated, The nasal cannula should be placed in a bag when not in use. The concentrators are owned and maintained by a contracted company. We do not have a policy to maintain the machines. They come weekly and they maintain the cleaning of machines and filters. The DON stated, the company was just here yesterday (2/27/24). On 2/28/24 at 10:40 a.m., the DON observed and confirmed Resident #27's oxygen concentrator, and the vented filter area were dusty. She also verified the oxygen tubing was stored uncovered. The DON provided the maintenance logs from the contracted company from 1/9/24 through 2/27/24. The logs included multiple brand names of oxygen concentrators but did not include Resident #27's brand of oxygen concentrator. Review of the manufacturer's oxygen concentrator manual for Resident #27 provided by the facility noted, Ensure the air intake filter and exhaust locations are not clogged or restricted. If a gross particle filter is in place, it should be inspected and cleaned once a week. On 2/29/24 at 9:43 a.m., in an interview, RN Staff D said after administering a nebulizer treatment to a resident, the mask and container are washed with warm soapy water, air dried and placed in a bag and the bag is dated. On 2/29/24 at 10:12 a.m., in an interview, the DON verified after administration of a nebulizer treatment, the medication cup and mask should be washed with soap and water, air dried and bagged until next use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to provide a written copy of the transfer notice to residents and the Office of the State Long Term Care Ombudsman (LTCO) for 2 (Residents #388, and #389) of 28 sampled residents transferred to the hospital and subsequently discharged from the facility. The findings included: The facility policy dated October 2022 titled Transfer or Discharge, Facility Initiated stated, Residents have the right to remain in the facility. Facility initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long term care ombudsman when practicable; Notice of Facility Bed Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer; Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. On 2/28/24 at 1:00 p.m., review of the Hospital Tracking Portal log provided by the Director of Nursing (DON) showed 28 residents were transferred to an acute care hospital from [DATE] to 2/28/24. On 2/28/24 at 2:10 p.m., in an interview the Social Services Coordinator said she notifies the office of the Long Term Care Ombudsman each month of all residents discharged home. On 2/28/24 at 2:21 p.m., the Social Services Coordinator provided a fax cover sheet, and discharge information addressed to the office of the LTCO for all residents discharged home. The discharge notifications did not include residents transferred to acute care hospitals. The Social Service Coordinator said she did not know the LTCO had to be notified of transfers to the hospital. She verified the LTCO was not notified of residents transferred to an acute care hospital and had not returned to the facility. Review of Resident #388's clinical record revealed an admission date of 1/15/24. Diagnoses included Acute Renal Failure. The Nursing progress note dated 1/16/24 stated Resident #2 was unable to follow commands, she was still sleepy, and had not been able to drink fluids or eat food. The physician issued an order to transfer the resident to an acute care hospital. Further review of Resident #388's medical record revealed no documentation a Nursing Home Transfer and Discharge Notice form was completed and given to the resident and the LTCO was notified of Resident #388's transfer to the hospital. The clinical record showed the resident was discharged from the facility on 1/16/24. Review of Resident #389's medical record revealed a date of admission of 12/26/2023 with a primary diagnosis of Sepsis. The Nursing progress notes dated 12/29/23 stated Resident #3 had increased sob (shortness of breath), palpitations, and tachycardia (Heart rate over 100 beats a minute). The resident was sent to the hospital via Emergency Medical Services. Further review of Resident #389's clinical record revealed no documentation a Nursing Home Transfer and Discharge Notice form was completed and given to the resident and the LTCO was notified of Resident #389 transfer to the hospital. Resident #389 was discharged from the facility on 12/29/23. On 2/29/24 in an email communication the representative of the LTCO office said the facility only sends a list of residents discharged home on a monthly basis. The facility does not send a list of residents transferred to the hospital. On 2/29/24 at 11:15 a.m., in an interview the Director of Nursing (DON) verified the facility was not providing discharge notices to residents transferred to the hospital before discharging the residents from the facility. He also verified the facility has not been sending a copy of the hospital transfer notices to the office of the LTC Ombudsman.

Based on observation, staff interview, review of facility's policy and procedure and manufacturer's specification, the facility failed to ensure appropriate storage and labeling of prescribed medications in one (400 hall cart) of two medication carts observed. The findings included: The facility's Storage of Medications policy (revised November 2020) read, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. The facility's Administering Medications (Revised April 2019) read, . When opening a multi-dose container, the date opened is recorded on the container. On 6/21/22 at 9:30 a.m., observation of the 400-hall medication cart with Registered Nurse (RN) Staff A revealed an insulin glargine kwikpen stored in a clear plastic bag. The pharmacy label affixed to the bag had Resident #8's name. Glargine was handwritten on the bag. Part of the pharmacy label on the storage bag was crossed out in black making it unreadable. The insulin pen in the bag was opened but not dated. Photographic evidence obtained A second opened undated glargine insulin kwikpen was stored on the top drawer. On 6/21/22 at 10:40 a.m., RN Staff A verified both insulin pens were opened and not dated. She said once opened the insulin is only good for one month. RN Staff A removed both insulin pens from the cart. Review of the insulin glargine patient's instructions for use revealed to throw away the pen in use after 28 days, even if it still has insulin left in it. On 6/21/2022 at 1:00 p.m., the Director of Nursing (DON) verified the insulin pen should have been labeled with the date opened to be discarded within 28 days.

Based on observation, review of facility policy and procedure, and staff interview, the facility failed to assure 1 of 3 medication carts were locked and under direct observation of authorized staff in an area where residents and staff could access it. This has the potential to cause harm for residents if they were to ingest medications. In addition, the facility failed to implement a system to account for periodic receipt, reconciliation, and disposition of all controlled substances. The findings included: 1. The facility policy Storage of Medications (revised April 2019) specified drugs and biologicals used in the facility were stored in locked compartments. Access to controlled medications was limited to authorized personnel. Personnel access to controlled medications is recorded. On 11/16/20 at 10:10 a.m., observation of the 400-hall medication cart revealed the cart was not locked. Two certified nursing assistants, two therapy staff members, one resident and the Assisted Director of Nursing (ADON) were observed walking past the unlocked medication cart. On 11/16/20 at 10:16 a.m., Registered Nurse (RN) Staff K was observed exiting from a room with a closed door and approached the unlocked medication cart. On 11/16/20 at 10:17 a.m., RN Staff K verified the medication cart was not locked and was not in direct view. RN Staff K confirmed the medication cart should have been locked when it was not in direct view. 2. On 11/17/20 at 10:01 a.m., the ADON said when a controlled medication was discontinued, she collected them from the medication carts, or the nurse would bring them to her. The ADON said she checked the amount of medications with the controlled medication count sheet and then she signed the count sheet indicating the count was accurate for the medication. The ADON said she brought the medications to the Director of Nursing (DON) office and the count sheet and the medication were placed in a locked box on the wall in the DON's office. The ADON said she did not know what medications were currently in the locked box and said, I won't know until we remove them for destruction. On 11/17/20 at 10:08 a.m., the ADON confirmed there was no documentation to reconcile the identification and drug count for controlled medications that were in the locked cabinet. On 11/19/20 at 4:20 p.m., the DON said he did not know what medications were in the locked box in his office. The DON confirmed he had no documentation to periodically reconcile the medications in the locked box.

Based on observation, policy review, record review, and staff interview, the facility failed to accurately document the care and services provided to 1 (Resident #3) of 1 resident reviewed for intravenous therapy. This failure led to a delay in care that had potential for infection to occur. The findings included: The facility's policy on Central Venous Catheter Dressing Changes (Revised April 2016) stated . Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN [as needed] (when wet, soiled, or not intact). Review of the clinical chart revealed a physician order dated 10/17/20 to change midline (intravenous access) dressing as needed AND every day shift every 7 day(s). On 11/17/20 at 8:56 a.m., Resident #3 was observed with a midline present. The dressing to midline was dated 10/25/20. Photographic evidence obtained. On 11/18/20 at 2:49 p.m., the Assistant Director of Nursing (ADON), said residents that are admitted with peripheral venous access sites are monitored every shift. The ADON said dressing changes occur every seven days or as needed. The ADON confirmed that a dressing dated 10/25/20 was not in compliance with facility policy. Review of the Treatment Administration Record (TAR) showed a dressing change to the midline was documented as completed on 11/3/20 and 11/10/20. On 11/19/20 at 4:00 p.m., Registered Nurse (RN) Staff L verified her initials on TAR dated 11/3/20. She said she did not do Resident #3's dressing. She said she signed off treatment and intended to do it later. She stated she did not remember why she did not do it and did not believe she reported to it to the oncoming shift. On 11/19/20 at 4:13 p.m., RN Staff M confirmed familiarity with Resident #3 and confirmed she worked on 11/10/20. RN Staff M said she signed the TAR for the dressing change prior to completing. RN Staff M said when she attempted to do the dressing change, Resident #3 was unavailable. She said she intended to go back but got busy and forgot to change the dressing.