Based on interviews and observations, the facility failed to ensure sufficient clean linen, washcloths, towels, and protective bed pads, to meet the care needs of residents Findings include:During an interview on 8/13/2025 at 4:30 PM, Resident #5 stated, At the end of a shift, we have to wait for the laundry to deliver or someone has to go get some from the laundry. The laundry is not open during the night shift.During an interview on 8/13/2025 at 4:45 PM Resident #1 stated, I do not have anything to wash my face and hands.During an interview on 8/13/2025 at 6:15 PM, Resident #6 stated, The aids scramble at the end of shift to find bed pads that help keep the sheets dry. They do not have enough.During an interview on 8/13/2025 at 8:40 PM Resident #2 stated, I have reported it [not enough linens, washcloths or towels]. They do not have enough to last the night. I have had to wait to get clean washcloths and towels.During an interview on 8/13/2025 at 4:58 PM Staff L, Laundry Staff stated, Generally the CNAs will let me know if they need any linen. I work until 12 midnight. They do run out before the end of the shift and let me know when I come in here. I try to make sure they have what they need to start their night shift.During an interview on 8/13/2025 at 5:00 PM Staff A, LPN (Licensed Practical Nurse) stated The aides are always running out of wash cloths and bed pads before the shift is over and before laundry brings more.During an interview on 8/13/2025 at 5:05 PM Staff C, RN (Registered Nurse) stated, The aids struggle at times with not having enough linen and pads.During an interview on 8/13/2025 at 5:10 PM Staff E, CNA stated, We still have problems with not having enough supplies gloves and washcloths and bed pads before the shift is over. Right now, we do not have any gloves except for the small size. During an interview on 8/13/2025 at 5:17 PM Staff G, CNA, stated, I do run out of washcloths usually before the shift is over.During an interview on 8/13/2025 at 5:18 PM, Staff H, CNA stated, I have enough to start my shift [linen] but run out sometimes before the end of shift. During an interview on 8/13/2025 at 5:20 PM Staff I, CNA stated, We do not have enough supplies. I bring my own wipes for the residents, and we do not have enough washcloths, towels and pads to last the night. We have no large size gloves [while pointing to the Personal Protective Equipment supply container outside of a room with Enhanced Barrier Precautions sign]. I have come in and had the laundry cart be empty. It is hard to provide toileting care if you do not have supplies to use for the Residents.During an interview on 8/13/2025 at 6:20 PM Staff D, RN stated, The CNAs [Certified Nursing Assistants] can let you know if they have enough linen.During an interview on 8/13/2025 at 11:30 PM, Staff J, CNA (11PM-7 AM shift) stated, I have seven bed pads and I can definitely run out of pads because I have a lot of heavy frequent wetters.During an interview on 8/13/2025 at 11:45 PM Staff K, CNA stated, I only work part time but linen is an issue, we have linen to begin the shift but usually run out before the shift is over. I have five pads and that is not enough when you have residents that are frequently incontinent. Laundry is locked up so we cannot get anything from there.During observations on 8/13/2025 beginning at 11:45 PM of the linen carts it showed one cart had four protective bed pads (which are absorbent layers placed on beds to absorb moisture and protect the underlying material from leaks and stains, primarily due to urinary incontinence, bedwetting, or excessive sweating), two carts had five protective bed pads, and one cart had seven protective bed pads available for the entire shift.

Based on interviews, observations, and policy and procedure review the facility failed to ensure snacks were offered and/or served to 5 of 5 residents, Residents #1, #2, #3, #4, and #5, sampled for evening snacks.Findings include:During an interview on 8/13/2025 at 4:30 PM Resident #3 stated, I am a diabetic. They never come to you or your room and ask if you want a snack. You can get a snack if you go to the nurses' station and ask for one. Residents #4 and #5 were present during the interview. Resident #4 stated, That is if there is someone at the desk to ask. Resident #5 added, Not all the residents can come to the nursing station. My roommate can't come to the nurses' station. The CNAs (Certified Nursing Assistants) should check with all the residents and ask them if they want a snack.During an interview on 8/13/2025 at 4:45 PM with Resident #1 when asked when snacks are provided Resident #1 stated, They don't come around and give you snacks.During an interview on 8/13/2025 at 8:40 PM, Resident #2 stated, I don't like to leave my room because I have seizures, and I am photosensitive. No one ever comes to my room and offers me a snack.During observations on 08/13/2025 beginning at 5:05 PM there were three drawer plastic containers at each nurses' station with snacks observed inside the containers.During an interview on 8/13/2025 at 5:00 PM Staff A, LPN (Licensed Practical Nurse) stated, Residents can come to the desk, and we give them a snack upon request.During an interview on 8/13/2025 at 5:03 PM, Staff B, LPN stated Snacks are available in the plastic three drawer container at the nursing station. The Residents come up to the station and request snacksDuring an interview on 8/13/2025 at 6:20 PM, Staff D, RN (Registered Nurse) stated The CNAs can let you know how snacks are provided.During an interview on 8/13/2025 at 5:10 PM Staff E, CNA stated, Snacks are available for residents when requested. During an interview on 8/13/2025 at 5:17 PM Staff G, CNA, stated, The Resident come to the nursing desk, and we provide snacks or if they request one.During an interview on 8/13/2025 at 5:18 PM, Staff H, CNA stated, Snacks are provided when requested.During an interview on 8/13/2025 at Staff I, CNA stated, Snacks are available at the nursing station.Record review of the policy and procedure titled, Offering/Serving Bedtime Snacks with a review date of 6/6/2025, read Policy: It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs preferences and requests at bedtime on a daily basis. 1. The nursing staff offers bedtime snacks to all residents in accordance with the residents' needs, preferences, and requests on a daily basis. 2. Dietary services staff deliver bedtime snacks to each nurses' station. The Charge Nurse is made aware of the delivery of the snacks. 3. Nursing staff delivers and serves snacks to residents within (specify time frame) from arrival to the unit.

Based on interview and record review the facility failed to ensure residents medical records were complete and accurate for 1 of 3 residents, Resident #1, reviewed for mood and behaviors. Findings include: Review of the Active Orders for Resident #1, physician's order dated 12/25/2024, provided for a documentation system to track Resident #1 for behavior monitoring and staff interventions that read as follows, Behavior code-0-no behavior, 1-Fear/panic, 2-anger, 3-Scream/yell, 4-Danger/self/others, 5-Delusions, 6-Hallucinations, 7-Sad/tearful, 8-Emotion/Acts withdrawal, 9-other. Interventions - 1-music/aromatherapy, 2-Reminiscence/reality orient, 3-Exercise/activity, 4-1:4 5-Reduce stim [stimuli] 6-PRN [as needed] med outcome I-improved S-Same, W-Worse, Side Effects - 0-none, 1-EPS [extrapyramidal symptoms] 2-Tardive Dys [Dyskinesia] 3-Hypotension, 4-Inc behavior, 5-Sedation/drowsy, 6-Inc Falls/dizzy as needed for behavior. Review of Resident #1 physician order dated 3/16/2025 read, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (milligram)give 250 mg by mouth two times a day related to dementia in other disease classified elsewhere unspecified severity with mood disturbance. Review of Resident #1's physician order dated 3/16/2025 read, Trazadone HCI Oral Tablet 50 mg [milligrams] give 1 tablet by mouth three times a day related to depression. Review of Resident #1 Treatment Administration Record for the month of April 2025 documented only check marks and staff initials for Behavior monitoring. During an interview on 4/30/2025 at 11:45 AM Staff A, License Practical Nurse (LPN) stated, We should document whether a resident is or is not having behaviors in our treatment record. Review of Resident #1's progress note dated 4/25/2025 written by Advance Registered Nurse Practitioner (APRN #1) read, Chief Complaint: Behaviors. History of present illness: Reports patient was blocking the door on 4/24/2025. Patient is in no acute distress at this time. Staff reports he is taking all medications as prescribed, tolerating well Review of Resident #1's progress note on 4/24/2025 read, Resident is stable. Still refusing to take his meds. Providers are aware. No behaviors noted throughout this shift. During an interview on 4/30/2025 at 11:54 AM ARNP #1 stated, The staff did tell me he [Resident #1] was refusing all his medications. During an interview on 4/30/2025 at 12:57 PM the Director of Nursing stated, Behavior documentation in the treatment record and the supplementation option was not added. It should have had the option for a number to be coded which would provide details of the behaviors if any. The ARNP [ARNP #1] stated she dictates her notes and it should have said [Resident #1's name] does not take his medications. Staff and providers should document accurately. Review of the facility policy and procedure titled Documentation with a last reviewed date of 1/25/2025 read, Policy: Each Resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of the facility policy and procedure titled Behavior and Psychoactive Management Program with a last reviewed date of 3/2/2019 read, Procedure: 3. Monitoring the resident's behavior(s) to establish patterns, determine intensity and behavior frequency, and identifying the specific (targeted) behaviors that are distressing to the resident which are decreasing resident's quality of life.

Based on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 of 2 residents who were diagnosed with serious mental disorder, Resident #58. Findings include: Review of Resident #58's admission record with an initial admission date of 10/20/2022 and the most recent admission date of 7/25/2024 revealed Resident #58 had diagnosis of bipolar disorder, with an onset date of 1/6/2020. Review of Resident #58's Level I PASRR screening dated 10/6/2023 showed depressive disorder documented under PASRR Screen Decision-Making section for mental illness. Review of Resident #58's clinical records failed to show documentation Resident #58's diagnosis of bipolar disorder had been included on his Level I PASRR screening dated 10/6/2023. During an interview on 10/16/2024 at 10:04 AM, the Director of Nursing confirmed Resident #58's diagnosis of bipolar disorder had not been included on his Level I PASRR screening dated 10/6/2023.

Based on record review and interview, the facility failed to ensure residents received treatment and care according to professional standard of practice by administering narcotic pain medication out of parameters for 2 of 3 residents reviewed, Residents #73 and #318. Findings include: 1) Review of Resident #73's physician order dated 10/2/2024 read, Tramadol HCl Oral Tablet 50 mg [milligrams] (Tramadol HCl) Controlled Drug Give 1 tablet via G-Tube [gastrostomy tube] every 8 hours for pain scale 5-10. Review of Resident #73's care plan dated 3/8/2022 read, Focus: [Resident #73's name] has the potential for alteration in comfort related to: limited mobility, general body aches, diabetes . Interventions . Medicate for pain as ordered. Review of Resident #73's Medication Administration Record (MAR) for October 2024 showed the resident received 6:00 AM dose of Tramadol 50 mg on 10/4/2024, 10/5/2024, 10/6/2024, 10/7/2024, 10/8/2024, 10/9/2024, 10/10/2024, 10/11/2024, 10/12/2024 and 10/15/2024 with the pain level documented as zero, and on 10/8/2024 with the pain level documented as NA (not applicable), 2:00 PM dose of Tramadol 50 mg on 10/5/2024, 10/6/2024,10/7/2024, 10/8/2024, 10/9/2024, 10/10/2024, 10/11/2024, 10/13/2024 and 10/14/2024 with the pain level documented as zero, and 10:00 PM dose of Tramadol 50 mg on 10/3/2024, 10/4/2024, 10/5/2024, 10/6/2024, 10/8/2024, 10/9/2024, 10/10/2024, 10/11/2024, 10/13/2024, and 10/14/2024 with the pain level documented as zero, and on 10/7/2024 at with the pain level documented as X. 2) Review of Resident #318's physician order dated 10/9/2024 read Hydrocodone- Acetaminophen Oral Tablet 10-325 mg (Hydrocodone-Acetaminophen) Controlled Drug Give 1 tablet by mouth every 8 hours as needed for chronic pain, non-acute 7-10 do not exceed 3000 mg of acetaminophen daily. Review of Resident #318's care plan dated 10/8/2024 read, Focus: [Resident #318's name] has the potential for alteration in comfort related to: general discomfort . Interventions . Medicate for pain as ordered. Review of Resident #318's MAR for October 2024 showed the resident received Hydrocodone-Acetaminophen 10-325 mg on 10/10/2024 at 7:20 AM and 5:22 PM for pain level documented as 5, on 10/11/2024 at 4:56 AM for pain level documented as 5 and at 10:01 PM for pain level documented as 6, on 10/12/2024 at 6:08 AM for pain level documented as 6, on 10/13/2024 at 10:36 AM for pain level documented as 6, and on 10/14/2024 at 9:49 AM for pain level documented as 2. During an interview on 10/15/2024 at 2:35 PM, Staff A, LPN, stated, The medication are to be given when the pain is rated by the patient and the pain rating falls within the parameters. The hydrocodone should not have been given with a pain scale rated less than 7. During an interview on 10/16/2024 at 9:20 AM, Staff B, Licensed Practical Nurse (LPN), stated, Tramadol was administered to the resident out of parameters. If the orders are written with parameters, the medication should only be given if the pain is rated within those parameters. During an interview on 10/16/2024 at 11:28 AM, the Director of Nursing stated, Pain medication should only be given when pain falls within the parameters that were written by the physician. The physician orders need to be followed. Review of the facility policy and procedure titled General Dose Preparation and Medication Administration revised on 1/1/2022 read, Procedure . 4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, included but not limited to the following: 4.1. Facility staff should: 4.1.1 Verify each time a medication is administrated that is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule.

2) During an observation on 10/14/2024 at 10:17 AM, Resident #8 was lying in bed watching television. There was one tube of Diclofenac Sodium gel in a plastic bin on the resident's overbed table. During an observation on 10/15/2024 at 8:15 AM, Resident #8 was lying in bed sleeping. There was one tube of Diclofenac Sodium gel in a plastic bin on her overbed table. During an interview on 10/15/2024 at 11:19 AM, Resident #8 stated, I keep the gel there all the time because I use it a lot. Review of Resident #8's physician order dated 10/8/2024 read, [Brand Name of Product] (Diclofenac Sodium) Topical, Apply to affected area topically every day and evening shift for pain. During an interview on 10/16/2024 at 11:28 AM, the Director of Nursing stated, It is my expectation that all residents are assessed to be able to self-administer their medications, and if they are able to, then those medications should be kept in a lockbox. Review of the facility policy and procedure titled Storage and Expiration Dating of Medications, Biologicals dated 1/11/2024 read, Procedure . 3. General Storage Procedures . 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access . 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/ Prescribed order and approval by the Interdisciplinary Care Team and Facility administration. 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in a secured manner in 1 of 3 halls. Findings include: 1) During an observation on 10/14/2024 at 9:30 AM, there were one bottle of zero sugar C gummies and one bottle of red grape seed vitamins on the bedside table in Resident #38's room. During an interview on 10/14/2024 at 10:00 AM, Resident #38 stated, I take my vitamin C and red grape for my circulation daily. During an observation on 10/15/2024 at 11:20 AM, there were one bottle of vitamin C chewable gummies and one bottle of red juice powder pills on the bedside table in Resident #38's room. During an observation on 10/15/2024 at 2:35 PM, with Staff A, Licensed Practical Nurse (LPN), there were one bottle of vitamin C chewable gummies and one bottle of red juice powder pills on the bedside table in Resident #38's room. During an interview on 10/15/2024 at 2:35 PM, Staff A, LPN, stated, Medications cannot be at the bedside unless the resident has been assessed for self-administration and the medications still need to be secured. During an interview on 10/16/2024 at 11:28 AM, the Director of Nursing (DON) stated, Patients are not to have medication in their room unless they have been assessed for self-administration and the physician writes an order for self-administration and a lockbox is placed in the residents' room so the medication is secured.

Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen and reach-in coolers (Photographic evidence obtained). Findings include: During an observation on 10/14/2024 at 9:00 AM, while conducting the initial walk-through tour of the kitchen with the Certified Dietary Manager (CDM), there were assorted cut melon and other fruit that were not in the original container without an identifying or date label in the reach-in cooler, two 10-pound rolls of raw ground beef laying on the counter not prepped in a pan or under running water, and uncovered and undated pans containing cake. During an interview on 10/14/2024 at 9:05 AM, the Morning Charge [NAME] stated she should not have placed the dirty rolls of raw ground beef on the counter and the beef should have been in the prep sink with running water. During an interview on 10/14/2024 at 9:07 AM, the CDM verified the unmarked fruit container was in the reach-in cooler without an identifying label or date and confirmed that the raw ground beef should not have been placed on the stainless-steel counter and should have been under running water or prepped and covered and ready to cook. The CDM confirmed the dessert pans of cake should have been covered and dated. Review of the facility policy and procedure titled Food Preparation and Handling revised on 6/1/2019 read, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the State and US Food Codes and HACCP [Hazard Analysis & Critical Control Points] guidelines. Procedure . 2. Thawing Foods. A. Thaw meat, poultry and fish in a refrigerator at 41 F or less. b. Foods may also be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70 F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow. Review of the facility policy and procedure titled Food Storage revised on 1/25/2023, read, Procedure . 2. Refrigerators . d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.

Based on observation, interview, and record review, the facility failed to ensure staff used proper personal protective equipment while providing high contact care to the residents on Enhanced Barrier Precautions to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 10/16/2024 at 1:55 PM, Resident #1's room was had a signage on the door that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. The Infection Prevention Officer was applying a wound dressing on Resident #1's lower left leg. The Infection Prevention Officer did not wear a gown during the dressing change for Resident #1. Review of Resident #1's physician order dated 10/15/2024 read, Wound care-left-lower leg: Cleanse open area on left shin with wound cleanser, pat dry, apply xeroform, wrap with [Brand Name of Dressing] dry dressing daily and prn [as needed] for soiled or dislodged dressing. Review of Resident #1's physician order dated 8/22/2024 read, Enhanced Barrier Precautions: Chronic Wound -Indwelling Medical device. Review of Resident #1's care plan dated 4/3/2024 read, Interventions: Enhanced barrier precautions: Wear gown and gloves during resident high-contact activities in room, therapy gym or shower room [i.e. dressing, bathing/showering, transferring, providing hygiene, changing line, toileting/changing briefs, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care]. During an interview on 10/16/2024 at 2:20 PM, the Infection Prevention Officer stated, I didn't use a gown. We need to use gloves and gowns when providing wound care, I forgot. During an interview on 10/16/2024 at 2:28 PM, the Director of Nursing stated, When the residents are on enhanced barrier precautions, the staff must wear a gown and gloves when providing direct wound care. Review of the facility policy and procedure titled Enhanced Barrier Precautions issued on 4/1/2024, read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities Policy Explanation and Compliance Guidelines . 4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, Wound care: any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflects the resident's status for 2 of 3 residents, Residents #38 and #121. Findings include: 1) Review of Resident #38 physician's order dated 2/23/2023 documented, oxygen at 2 liters/min [2 liters per minute] via nasal cannula for sob [shortness of breath] as needed. Review of Resident #38's Oxygen Sats [saturation] Summary documented, Oxygen via nasal cannula on 5/26/2023, 5/23/2023, 5/22/2023, 5/19/2023, 5/18/2023, and 5/15/2023. Review of Resident #38's MDS (Minimum Data Set) Annual dated 5/27/2023 documented, Section O Special Treatment procedures, and programs. 2. While a Resident. Oxygen. No. 2) Review of Resident #121's medical record documented the resident was admitted on [DATE] with diagnoses to include aftercare following joint replacement. Review of the physician's order dated 5/23/23 read, Pt. [patient] to discharge home on 5/26/23 patient declined home health but therapy wants to discharge w/front [with] wheel walker. Review of the IDT [Interdisciplinary Team] Resident Planned Discharge summary dated [DATE] read, 4. Attitude about discharge: Happy to be going home. Review of the MDS dated [DATE] doucmented under Section A2100 Discharge Status, 3. Acute hospital. During an interview on 6/14/2023 at 8:39AM the MDS Coordinator stated, [Resident #121's name] was sent home not to the hospital. It was a miscoding error. [Resident #38's name] did use oxygen during the look back of the MDS I was not checking the oxygen vital summary section, the MDS for the oxygen section is not accurate. Review of policy and procedure titled, Resident Assessment Instruments (RAI) last review date 1/25/2023 documented, Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development.

**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 received re-admission screening and resident review (PASARR) to ensure the resident receives care and services in the most appropriate setting for 1 of 3 residents, Resident #23 for PASARR. Findings include: Review of Resident #23's admission record documented Resident #23 was admitted on [DATE] with a diagnosis of paranoid schizophrenia on 1/26/2023. Review of Resident #23's Quarterly MDS (Minimum Data Set) dated 3/28/2023 documented, Section I, subcategory 1600, of the MDS indicates an active diagnosis of Paranoid Schizophrenia. Review of Resident #23's medical record revealed no level II preadmission screening and resident reviewed (PASARR) was in the medical record. Review of Resident #23's (Name of the Psychiatry Provider Group) Psychiatry Subsequent Note dated 12/15/2023 documented, Chief Complaint: Patient reported hallucinations and delusions. Reason for today's encounter: Today, I saw patient as it was reported to me that patient is unstable requiring psychiatric assessment. History of present illness: Patient was seen today for staff reports that he has been actively hallucination [sic] and delusional. Plan of action: I decided to increase Haldol from 5 mg daily to 5 mg bid [twice a day] for hallucinations/delusions. During an interview on 6/14/2023 at 3:15PM the Director of Nursing stated, [Resident #23's name] should have had a second assessment done once he was diagnoses with Paranoid Schizophrenia. Review of the policy and procedure titled, Coordination-Pre-admission Screening and Resident Review (PASRR) Program last review dated 1/25/2023 documented, 2. Coordination includes: b. Referring all level II residents and all residents with newly evident or possible mental disorder, intellectual disability, or related condition for level II resident review upon a significant change in status assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care and services for central venous access devices in accordance with professional standards of practice for 1 of 3 residents, Resident #174, and for treatment and care of contractures for 1 of 3 residents, Residents #92. Findings include: 1) During an observation on 6/12/2023 at 11:30 AM Resident #174 was lying in bed with a single lumen midline covered with a transparent dressing dated 6/4/2023. During an observation on 6/13/2023 at 8:45 AM Resident #174 was lying in bed with a single lumen midline covered with a transparent dressing dated 6/4/2023. During an observation on 6/14/2023 at 8:10 AM Resident #174 was lying in bed with a single lumen Midline covered with a transparent dressing dated 6/4/2023. During an interview on 6/14/2023 at 8:14AM with Staff C, Licensed Practical Nurse (LPN) stated, I just flushed the line. The dressing is dated 6/4/2023, midline dressing should be changed every seven days, the dressing should have been changed on 6/11/2023. During an interview on 6/14/2023 at 8:21AM the Director of Nursing stated, Midline dressings should be changed every week. We do not have a policy to change the midline dressings on admission we change it every week. Review of Resident #174's admission record documented an admission date of 6/8/2023 with diagnoses to include sepsis, disorder of urinary system, obstructive and reflux uropathy, hemiplegia and hemiparesis, cerebral infraction, chronic pulmonary embolism, type 2 diabetes, morbid obesity, and acute respiratory failure with hypoxia. Review of Resident #174's physician orders dated 6/8/2023 documented, Mid Line: Change Dressing to insertion site RUE [Right upper extremity] every 7 days and PRN [as needed] using sterile technique every night shift every Wed. Review of Resident #174's 3008 (medical certification for Medicaid long-term care services and patient transfer form) dated 6/8/2023 documented, V. Treatment Devices: Midline 5/28/2023. Review of the policy and procedure titled, 4.3 Short Peripheral Intravenous Catheter (PIVC) Dressing Change last review date of 1/25/2023 documented, Guidance: 1. Transparent dressings are changed with each site rotation every seven days, or sooner if the integrity of the dressing is compromised (wet, loose, or soiled). 2) Resident #92 was admitted to the facility on [DATE] with diagnosis to include falls, muscle weakness, and difficulty walking. Review of Resident #92's physician orders dated 6/5/2023 read: Ace [all cotton elastic] wrap right wrist and right ankle two times a day for joint pain. Apply to right wrist and right ankle daily. Apply in am [morning] remove at hs [hour of sleep]. An observation on 6/12/2023 at 10:20 AM of Resident #92 showed the resident did not have an ace wrap on his right wrist or on his right ankle. An observation on 6/13/2023 at 9:20 AM of Resident #92 showed the resident did not have an ace wrap on his right wrist or on his right ankle. During an interview on 6/13/2023 at 9:20 AM Resident #92 stated, I've asked for the ace wraps to be applied but they won't do it. An observation on 6/13/2023 at 12:00 PM of Resident #92 showed the resident did not have an ace wrap on his right wrist or on his right ankle. (Photographic evidence obtained). During an interview on 6/13/2023 at 1:20 PM Staff A, License Practical Nurse (LPN) stated, [Resident #92's name] is supposed to have an ace wrap on his wrist and ankle. He asked for them last week, but I do not know where to get them from. I did not apply his ace wraps last week or this week. During an interview on 6/14/2023 at 1:20 PM Staff B, LPN/Unit Manager stated, The resident should have an ace wrap on his right wrist and right ankle. During an interview on 6/14/2023 at 2:22 PM the Director of Nursing stated, Physician orders need to be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 4 residents, Residents #84 and #95. Findings include: 1) During an observation on 6/13/2023 at 8:19 AM Resident #84 was lying in bed and had a nasal cannula and tubing lying on the floor by the resident's shoe. The tubing was dated 6/5/2023. (Photographic evidence obtained). During an observation on 6/13/2023 at 9:30 AM Resident #84 was lying in bed with oxygen being administer via nasal cannula at 3.5 liters per minute. The oxygen tubing was dated 6/5/2023. During an interview on 6/13/2023 at 4:10 PM Staff D, License Practical Nurse stated, Oxygen is being administer close to 4 liters I will adjust it a little. The oxygen tubing is dated 6/5/2023 it should have been changed. During an interview on 6/13/2023 at 4:25 PM Director of Nursing stated, The nasal cannula and tubing should have been replaced once the staff found it on the floor. Staff should be checking the oxygen rate every shift. The oxygen [tubing] should have been changed this past Saturday [6/10/2023]. Review of Resident #84's admission record documented the resident was admitted on [DATE] with diagnoses to include acute respiratory failure with hypoxia, chronic kidney disease, pleural effusion, and essential hypertension. Review of Resident #84's physician order dated 5/17/2023 documented, Change oxygen set up and bag weekly and as needed every night shift every Saturday for infection control place in labeled O2 [oxygen] bag and tie to handle of O2 concentrator. 2) Review of Resident #95's medical record documented the resident was admitted [DATE] with diagnosis to include atrial fibrillation (irregular heartbeat), congestive heart failure, pleural effusions (fluid in lungs), pneumonia, anxiety disorder, acute and chronic respiratory failure, and non-rheumatic aortic stenosis (narrowing of the aorta). Review of physician orders for Resident #95 dated 3/7/2023 read, Ipratropium albuterol inhalation solution .5-2.5(3) MG/ 3 ML (Ipratropium - Albuterol) 1 unit inhale orally every 8 hours for SOB/Congestion [shortness of breath]. An observation on 06/12/23 at 12:25 PM of Resident #95's nebulizer mask showed the mask was lying on the floor in the corner beside the bed and the bedside table. There was no date on the tubing to indicate when the nebulizer tubing was changed. (Photographic evidence obtained). An observation on 6/13/2023 at 2:00 PM of Resident #95's nebulizer mask showed the mask was lying on the floor in the corner beside the bed and the bedside table. There was no date on the tubing to indicate when the nebulizer tubing was changed. During an interview on 6/13/2023 at 3:00 Staff B, License Practical Nurse/Unit Manager stated, The nebulizer mask should never be lying on the floor and the tubing should be dated. All nebulizer tubing is to be changed weekly and tubing is to be dated at that time. During an interview on 6/13/2023 at 3:45 PM the Director of Nursing stated, Tubing is to be changed out every Saturday night and dated. The nebulizer [mask] and tubing should not be lying on the floor and if they are then they are to be thrown away and replaced.

2) During an observation on 6/12/2023 at 9:39 AM in Resident #14's room, the resident was lying in bed and there was an ampule of Albuterol on the dresser next to the nebulizer machine. (Photographic evidence obtained). During an interview on 6/12/2023 at 9:39 AM Resident #14 stated, That is [ampule of Albuterol] for my breathing treatment, the nurse will give me the treatment. During an interview on 6/14/2023 at 10:35 AM the Director of Nursing stated, I do not see an order for [Resident #14's name] to self-administer medication. 3) During an observation on 6/12/2023 at 9:46 AM Resident #90 was sitting at the edge of her bed. A Budesonide-Formoterol Fumarate inhaler was lying on top of the bedside table. (Photographic evidence obtained). During an interview on 6/12/2023 at 9:46 AM Resident #90 stated, The nurse left it [inhaler] and forgot to pick it up. During an interview on 6/14/2023 at 10:33 AM the Director of Nursing stated, [Resident #90's name] has no orders for self-administration of medication. 4) During an observation on 6/12/2023 at 9:55 AM in Resident #84's room, the resident was lying in bed. On top of the dresser was a syringe containing normal saline. (Photographic evidence obtained). During an interview on 6/14/2023 at 10:36 AM with the Director of Nursing stated, [Resident #84 name] had an IV [intravenous] catheter for hydration because she was not eating but no longer has the IV. 5) During an observation on 6/12/2023 at 9:59 AM Resident #88 was lying in bed watching television. On top of the dresser there were three bottles of multivitamins, one bottle of vitamin C, one bottle of calcium plus vitamin D3, one bottle of Lubricant eye drops, and one tube of Mentholatum ointment. (Photographic evidence obtained). During an interview on 6/12/2023 at 9:59 AM Resident #88 stated, I drink my multivitamins by myself every day. During an interview on 6/14/2023 at 10:37 AM the Director of Nursing stated, I thought she had orders to self-administer but I do not see an order for self-administration of medications for [Resident #88's name]. 6) During an observation on 6/12/2023 at 10:06AM Resident #57 was lying in bed. Three small packages of A&D (vitamin A and D) ointment and one bottle of Nystatin powder (treats fungal or yeast infections of the skin) were on top of the dresser. (Photographic evidence obtained). During an interview on 6/14/2023 at 10:32 AM the Director of Nursing stated, I do not see an order for [Resident #57's name] to self-administer medication. 7) During an observation on 6/12/2023 at 10:09 AM Resident #36 was lying in bed. A bottle of Acetic Acid 0.25% Solution (used as a constant or intermittent bladder rinse to help prevent the growth and proliferation of susceptible urinary pathogens) was on top of Resident #36's dresser. (Photographic evidence obtained). During an interview on 6/12/2023 at 10:09 AM Resident #36 stated, The nurses use the medication [Acetic acid 0.25% Solution] to flush my catheter twice a day. During an interview on 6/14/2023 at 10:33 AM the Director of Nursing stated, I do not see an order for [Resident #36's name] to self-administer medication. 8) During an observation on 6/12/2023 at 10:30 AM Resident #106 was lying in bed, on top of the dresser there were two ampules of normal saline and a bottle of Nystatin powder. (Photographic evidence obtained). During an interview on 6/12/2023 at 10:30 AM Resident #106 stated, The nurses give me my medication and perform my wound care. During an interview on 6/14/2023 at 10:34 AM the Director of Nursing stated, I do not see an order for [Resident #106's name] to self-administer medication. The residents need to have a self-administration assessment, the nurse needs to call the physician and get an order, provide a lock box or lock for the top drawer, and the nurse needs to observe that the resident is actually able to self-administer the medication. Based on observation, record review, and interview the facility failed to ensure all drugs and biologicals were stored in locked compartments to permit only authorized personnel to have access for 1 of 3 hallways, the South Unit. Findings include: 1) During an observation on 6/12/23 at 10:30 AM in Resident #8's room there was a tube of Mupirocin Ointment (a medicated ointment used to treat certain skin infections) on the bedside table. (Photographic evidence obtained). During an observation on 6/13/23 at 11:30 AM in Resident #8's room there was a tube of Mupirocin Ointment on the bedside table. During an observation on 6/14/23 at 10:20 AM in Resident #8's room there was a tube of Mupirocin Ointment on the bedside table. Review of the physicians' orders did not have an order for Resident #8 for Mupirocin Ointment or an order for Resident #8 to have medications at bedside. During an interview on 6/12/23 at 10:28 AM Resident #8 stated, That is my cream for my skin sore. I use it anytime my sore opens up. During an Interview on 6/14/23 at 10:28 AM the Director of Nursing stated, [Resident #8's name] is not ordered to have that medication [Mupirocin Ointment] and [Resident #8's name] is not allowed to have medications at bedside. My expectation for the nurses is to make sure that there are no medications at the patients' bedside. Review of the policy and procedure titled, 5.3 Storage and Expiration Dating of Medications, Biologics with a revision date of 07/21/22 read, 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration.

Based on record review and interview, the facility failed to ensure the attending physician or prescribing practitioner documented their rationale to extend the use of as needed (PRN) psychotropic drugs with projected duration of use for 2 of 3 residents reviewed for psychotropic drugs, Residents #1 and #3. Findings include: Review of Resident #1's physician orders dated 10/19/2022 reads, Haldol Solution (Haloperidol Lactate) inject 10 milligrams intramuscularly every 8 hours as needed for agitation and aggression . Ativan Solution 2 MG/ML [milligrams/ milliliter] (Lorazepam) inject 1 ml intramuscularly every 8 hours as needed for agitation and aggression. Review of Resident #1's records failed to reveal documentation the attending physician or prescribing practitioner documented their rationale in the resident's medical record and indicated the duration for the PRN order. Review of Resident #3's physician orders dated 10/13/2022 showed the resident was prescribed with Xanax tablet 0.5 milligrams (Alprazolam) by mouth as needed for anxiety disorder twice a day. Review of Resident #3's records failed to reveal documentation the attending physician or prescribing practitioner documented their rationale in the resident's medical record and indicated the duration for the PRN order. During an interview on 11/21/2022 at 11:45 AM, the Director of Nursing stated she was unable to find records the attending physician or prescribing practitioner documented their rationale in Resident #1's or Resident #3's medical records and indicated the duration for the psychotropic PRN orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records, accordance with accepted professional standards and practices, for each resident that are complete and accurately documented for 1 (Resident #4) of 3 residents sampled for catheter care. Findings: Resident #4 was re-admitted to the facility on [DATE]. Review of the Minimum Data Set Quarterly Assessment for Resident #4 dated 1/20/2022, Section H0100 reads Appliances. Indwelling catheter. Review of the physician orders for Resident #4 contained no orders for a Foley catheter, for catheter care, or for changing of the catheter bag. Review of the Medication Administration Record and Treatment Administration Record for Resident #4 follow re-admission revealed no documentation related to care of the indwelling catheter. Review of the Resident Centered Comprehensive Care Plan for Resident #4 read Focus: Resident has a urinary elimination condition/concern or is at risk for complications related to Obstructive Uropathy. Goal: The resident will maintain optimal status and quality of life without complications. Interventions included empty catheter bag every shift and PRN (pro re nata-as needed) and change catheter 18 French/20 Cubic Centimeter indwelling catheter per MD (Medical Doctor)/urologist order. Review of the Point of Care Response History for Resident #4 for catheter care from 1/15/22 - 2/1/22 revealed catheter care was not documented on 1/17/22, 1/18/22, 1/20/22, 1/24/22, and 1/27/22. During an interview on 2/01/2022 at 2:00 PM the Director of Nursing confirmed Resident #4 currently had an indwelling catheter and his medical record did not contain orders for the indwelling catheter, catheter care, or changing of the catheter bag since Resident #4 returned from the hospital on 1/14/2022. She stated catheter care was being provided by the staff and that Resident #4 was sent to the emergency room today due to blood colored drainage which continued after flushing of the catheter by the Registered Nurse on duty.

2. On 1/30/2022 at 9:30 AM, an observation of the South Unit medication room revealed the refrigerator door was not locked. The lock was hanging open on the refrigerator door, the lock was not closed in a locked position and secured. During an interview on 1/30/2022 at 9:30 AM Staff A, LPN confirmed the lock was opened and not locked and the lock was hanging on the refrigerator. She stated that the refrigerator is supposed to be locked at all times. During an interview on 1/30/2022 at 9:30 AM Staff B, RN, Weekend Supervisor, stated that the refrigerator was to be locked at all times. All nurses are responsible to complete this task. During an interview on 1/30/2022 at 1:32 PM the DON stated that the medication refrigerator is to be locked at all times. On 1/30/22 at 9:45 AM an observation of the South Unit medication cart #1 revealed the following medications opened and not dated when opened: 1) Geni-Kot, 2) Iron tablets, 3) Senna Plus, and four (4) single individual plastic tubes of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution not labeled for a specified resident. During an interview on 1/30/2022 at 9:45 AM, Staff A, LPN verified the medications were opened and not dated and stated that all medications are to be labeled with the open date when they are opened. Ipratropium Bromide and Albuterol Sulfate Inhalation Solution should be labeled with a resident identifier. On 1/30/2022 at 10:15 AM an observation of South Unit medication cart #2 revealed one bottle of opened insulin, Humulin 70/30, vial with an expired date of 1/19/2022 and labeled for Resident #92 and multiple medications opened with no open date placed on the bottle as follow: 1. Multivitamin, 2. Acidophilus with Pectin, 3. Loratadine 10 mg, 4. Melatonin 5 mg, 5. Omeprazole 20 mg, 6. Iron 325 mg, 7. Aspirin 81 mg, 8. Laxative Geni-Kot, and 9. Gamotidine 10 mg. During an interview on 1/30/2022 at 10:15 AM, Staff D, LPN verified that Humulin Insulin 70/30 vial labeled for Resident #92 expired on 1/19/2022 and should have been wasted (discarded). She verified the following: 1. Multivitamin, 2. Acidophilus with Pectin, 3. Loratadine 10 mg, 4. Melatonin 5 mg, 5. Omeprazole 20 mg, 6. Iron 325 mg, 7. Aspirin 81 mg, 8. Laxative Geni-Kot, and 9. Gamotidine 10 mg. should have be dated when open and should be written on the bottle. During an interview on 1/30/2022 at 10:15 AM Staff B, RN, Weekend Supervisor, stated that all nurses are responsible for checking medication carts for expired medications and disposing of them. All medications are labeled with the open date when a nurse opens the vial. The Humulin 70/30 expired 1/19/2022 and should have been disposed of by expiration date. During an interview on 1/30/22 at 1:32 PM the DON stated that all medication carts are to be checked by the nurses daily and expired medication are to be thrown away. New medication when opened are to have the opened date written on the vial. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 4 of 5 medication carts and 1 of 2 medication rooms observed for medication storage. Photograph evidence obtained. Findings: On 1/30/2022 at 9:45 AM, an observation of the North Unit medication cart #1 with Staff C, Licensed Practical Nurse (LPN) revealed one bottle of eye drops labeled Latanoprost Solution 0.005% for Resident #89 with an opened date of 12/18/2021 and expired date of 1/29/2022 and one opened vial of insulin, Humulin R, with no residents name in the medication cart drawer. During an interview on 1/30/2022 at 9:45 AM with Staff C, LPN, she stated the eye drops showed an expired date and should have been discarded. The insulin vial of Humulin R should not be used for multiple residents and should have a label with residents name and order on the vial or it should not be in the medication cart drawer. On 1/30/2022 at 10:00 AM, an observation of the North Unit medication cart #2 revealed one opened vial of insulin, Humulin R, with no label with a residents name, one bottle of Fluticasone Propionate Suspension 50 MCG (micrograms) for Resident #36 with a label that read Fluticasone Propionate Suspension 50 MCG, one spray each nostril two times a day for nasal congestion with an opened date of 7/16/2021. Two Trulicity 0.75 milligrams (mg)/0.5 milliliters (ML) pens with a label that read Inject 0.75 mg subcutaneously one time a day every 7 days for Diabetes Mellitus before breakfast for Resident #77. One Trulicity injection pen read open date 7/2021. Dispose of after 14 days. The second Trulicity pen was in the medication cart drawer, for Resident #77, was observed unopened and the label read refrigerate until opened. During an interview on 1/30/2022 at 10:00 AM, Staff E, LPN stated, I cannot find the expiration date on Resident #36 Fluticasone Propionate nasal spray label but the open date reads 7/16/2021 and I know it expired way before 6 months. Staff E confirmed that Resident #77's Trulicity injection pen open date was 7/2021. The label read dispose of after 14 days and should not be left in the medication cart. The second Trulicity pen for Resident #77 was unopened and the label read to refrigerate until opened and should not be in the medication cart but in the refrigerator until it was ready for use for the resident. During an interview on 1/30/2022 at 10:15 AM, Staff B, Registered Nurse (RN) confirmed the eye drops were expired and should have been discarded. The insulin vial, Humulin R, should not be used for multiple residents and should be labeled with residents name and order on the vial or it should not be in the medication cart drawer. She stated, I cannot find the expiration date on Resident #36's Fluticasone Propionate nasal spray label but the open date reads 7/16/21 and I know it was opened 6 months ago. She confirmed that Resident #77's Trulicity injection pen read an open date 7/2021. Trulicity Label read dispose of after 14 days and should not be left in the medication cart. The second Trulicity pen for Resident #77 was unopened and the label read refrigerate until opened and should not be in the medication cart but in the refrigerator until it was ready for use for the resident. During an interview on 1/30/2022 at 11:30 AM the Director of Nursing (DON) confirmed she had been informed of all medication storage concerns. She stated, I expect all expired medications to be disposed of or returned to the pharmacy. I expect medications to be stored in their original packages according to the manufacturer's directions and labeled with the dates opened or expired. Record review of the facility policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles effective date 12/01/07, revised 10/31/16 reads Applicability: This policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. Procedure: 4. Facility should ensure that medications and biologicals that; (1) have an expired date on the label: (2) have been retained longer than recommended by manufacturer or supplier guidelines: or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges.