**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure surgical wounds were assessed and measured for three residents (#2, #6, #7) out of three sampled residents. Findings included: 1. Review of the admission Record showed Resident #2 was admitted on [DATE] with diagnoses included but not limited to rhabdomyolysis, open wound right hip, paroxysmal atrial fibrillation, congestive heart failure, hypertension, anemia, dementia, chronic kidney disease, generalized muscle weakness, history of falls, intervertebral disc degeneration, lumbar region with discogenic back pain only. Review of the admission, Minimum Data Set (MDS) dated [DATE] showed in Section C, Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section M, Skin Conditions showed surgical wound. On 06/16/2025 at 11:35 a.m. Resident #2 was observed sitting in his wheelchair at bedside. The resident was dressed and groomed for the day. The resident stated he was told the wound vac was supposed to be discontinued yesterday (Sunday). Review of physician orders showed wound care every Tuesday, have resident up and dressed before 8:00 a.m. for pick up. Apply wound vac 125mmhg/change Monday, Wednesday, Friday, apply black foam and as needed if dislodged as of 06/03/2025. Wound MD/NP (Medical Doctor / Nurse Practitioner) may evaluate and treat as indicated. Review of the progress notes dated 05/17/2025 showed skin warm and dry, skin color within normal limits, and turgor is normal. Review of the internal wound physician's progress note dated 05/20/2025 showed post-surgical wound size 6 x 6 x 0.5 cm (centimeters); moderate serous exudate; 100% granulation. Review of the Wound-Weekly Observation Tool dated 05/21/2025 showed right trochanter hip surgical wound, size 6 x 6 x 0.5. No odor. Serous drainage. Well-approximated edges. Review of the Skin only progress note dated 05/21/2025 showed skin warm and dry. Resident has current skin issues. Skin issue: surgical wound. Review of the Skin only progress note dated 05/28/2025 showed skin warm and dry. No current skin issues noted at this time. Skin note: There are no skin impairments or treatment orders in place at the time of this assessment. Review of the external wound physician's progress note dated 06/03/2025 showed right trochanter wound size 5.5 cm x 6.6 cm x 1.6 cm. Review of the Wound-Weekly Observation Tool dated 06/05/2025 showed right trochanter surgical incision. No measurements. Overall impression is wound improving. Granulation tissue present. 20% necrosis/and or slough in the wound bed. Moderate amount of serous drainage. No odor. Well approximated wound edges. Wound progress improved. Review of the Skin only progress note dated 06/10/2025 showed skin warm and dry. Resident has current skin issues. Skin Issue: Open lesion (other than ulcers, rashes and cuts). Skin issue location: right hip. Skin note: treatment in place for right hip. Review of the Wound-Weekly Observation Tool dated 06/14/2025 showed right trochanter surgical incision. No measurements. Wound/vac continuous. Overall impression is improving. Granulation tissue present. Moderate serous drainage. No odor. Well approximated edges. Review of the care plans the resident has potential/actual impairment to skin integrity related to fragile skin, use/side effects of medication, incontinence of bladder, admitted with wounds to right hip/hematoma. Resident non-compliant with wound vac, will remove at times. date Initiated: 05/16/2025 and revised on 06/16/2025. Interventions included but not limited to weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations as of 06/05/2025. Monitor / document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD (Medical Doctor) as of 06/05/2025. During an interview on 06/16/2025 at 11:41 a.m. Staff A, Licensed Practical Nurse wound care nurse, wound certified stated Resident #2 laid on the floor for 4 days at his home per the family member. The resident laid on his right side / hip and caused necrosis in that area. They did an incision and drainage of the right hip at the hospital. Staff A stated the facility's wound care doctor saw him once. Staff A stated the facility's wound doctor classified the wound as a surgical wound. Staff A stated the facility's wound care doctor discharged him to the external surgeon. Staff A stated the resident was being followed by his surgeon on the outside. Staff A stated the resident had been seen by the surgeon once or twice. Staff A stated either him or Staff B, Registered Nurse (RN) sees the residents weekly. Staff A, LPN stated the wound care sizes are performed by the doctor. During an interview on 06/16/2025 at 12:11 p.m. the Director of Nursing (DON) stated they (hospital) put a graph patch on the wound during surgery. The DON verified the 05/21/2025 Wound-Weekly Observation Tool note showed wound sizes. The DON reviewed the medical record, and the DON stated there were gaps in the wound assessment and measurement documentation. The DON verified the 06/05/2025 and 06/14/2025 Wound-Weekly Observation Tool lacked documentation regarding the wound measurements and assessment. The DON stated there was documentation of the wound size from the outside wound care doctor / surgeon on 06/03/2025 showed the measurements were 5.5 x 6.6 x 1.6, with undermining at 3-6 and of 1.8 centimeter (cm). The DON stated this documentation should have been in the medical record. The DON verified there were no wound sizes since 06/03/2025 when the resident went to the outside doctor/surgeon. The DON stated either Staff A, LPN or Staff B, RN can do wound sizes. The DON stated they have four staff members in the building that attended the wound certification class. The DON stated they should be doing surgical measurements and notes. The DON stated without this documentation they cannot see if the wound was better or not. The DON stated, Staff A, LPN should be driving the boat, he is responsible. Staff B, RN just fills in on weekends. The DON agreed the care plan showed to measure the wounds each week. 2. Resident #7 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to unspecified organism sepsis, cellulitis of left lower limb, diabetic foot ulcer, hypertension, peripheral vascular disease, Review of the physician orders showed to cleanse surgical incision of the left foot with normal saline, pat dry, apply calcium alginate with silver and wrap with gauze roll every day for surgical incision. Review of the Skin Only Evaluation dated 6/14/25, written by Staff B, RN, showed an open area to the left planter foot. Measurements and description were left blank. Surgical incision to left planter foot, treatment in place. Bruising to the right upper arm near IV site. Review of the Nursing admission Screening/History dated 06/13/2025 showed SKIN. Treatment ordered or required, yes. Resident has a diabetic foot ulcer to the right foot. No description or measurements documented. Review of the progress notes showed an admission summary dated [DATE] showed resident arrived at approximately 6 p.m. Resident's admitting diagnoses was septic diabetic foot ulcer to right foot. Resident also has MRSA (Methicillin Resistant Staphylococcus Aureus) in blood and was a type 2 diabetic. Isolation precautions in place. Review of the Skin Only progress note dated 06/14/2025 showed skin warm and dry. Resident has current skin issues. Surgical wound. Skin issue location: open area to the left planter foot. No wound odor. Tunnelling: yes. No undermining. Review of the baseline Care Plan dated 06/13/2025 and closed on 06/16/2025 (during survey) showed H. Safety Risks 4. Skin risk 4a. current skin integrity issues. 4a1. Specify skin integrity issue: left foot. During an interview on 06/16/2025 at 1:25 p.m. the DON stated the Skin Only Eval was the form the floor nurses do. The DON stated the Skin Only form filled out by Staff B, RN on 06/14/2025 would have been for Staff B doing the wounds. The DON stated the misconception that both Staff A, LPN and Staff B, RN had was that we do not size surgical wounds. The DON stated that Resident #7's wound would have been draining due to the use of calcium alginate. The DON stated that surgical wounds still have to be sized. The DON stated there was no description of the wound found. The DON stated, I did not see what I need to see. The DON stated she should have seen an observation on this wound from the weekend. The DON stated they need sizes to show smaller or larger (of the wound). The DON stated a baseline care plan had not been done, it was not in the assessment section of the medical record. 3. Resident #6 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to unspecified organism sepsis, cutaneous abscess of groin, Methicillin Resistant Staphylococcus Aureus infection (MRSA), cellulitis of abdominal wall, extended spectrum [NAME] lactamase (ESBL) resistance, acute bronchitis, diabetes, chronic obstructive pulmonary disease (COPD), hypertension. Review of the physician's orders showed abdominal permanent suture: cleanse and cover every other day; cleanse right inguinal area with Dakin's solution apply 3 ABD (abdominal) pads and secure with tape daily. Do not pack the wound with dressings. Review of the Nursing admission Screening / History dated 06/11/2025 showed SKIN abdomen surgical incision, groin surgical incision, right lower leg (rear) surgical incision. Treatment as ordered. No description or measurements noted. Review of the Skin Only Evaluation dated 06/11/2025 showed skin issue #1, location of groin and right abdomen. No wound sizes or wound description documented. Skin issue #2, abdomen no wound sizes or description documented. Skin issue #3, RLE (right lower extremity) no wound measurements or description. Skin note showed resident has open areas on right inguinal area, right abdomen, right lower leg. Treatments in place. dry, clean dressing on old previous surgical area middle of abdomen. Review of the baseline care plan dated 06/11/2025 showed H. Safety Risks 4. Skin Risk 4a. current skin integrity issues. 4a1. Specify skin integrity issue: wound. During an interview on 06/16/2025 at 1:25 p.m. the DON stated the wound evaluation should have been on the Wound Weekly Observation Tool. The DON stated the resident had been there since 06/11/2025. The DON reviewed the progress notes also and stated there was not a description or measurements of these wounds. The DON verified Resident #6 also did not have a Baseline Care Plan in his medical record. During an interview on 06/16/2025 at approximately 2:00 p.m. the DON stated the staff closed the Baseline Care Plans for both Resident #6 and Resident #7. The DON stated they had not been closed which was why they were not showing up in the medical record. Review of the facility's policy, Pressure Ulcers / Skin Breakdown, revised September 2017 showed 2. The staff and practitioner will examine the skin of newly admitted residents/patients for evidence of existing pressure ulcers and other skin conditions. Monitoring: 11. During the resident/patient visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly healing wounds. This should be based on looking at the wound periodically and on reviewing pertinent information about the patient. Review of the facility's policy, Charting and Documentation, revised July 2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in their resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 2. The following information is to be documented at the resident medical record: a. Objective observations; c. Treatments or services performed; d. Changes in the resident's condition; f. Progress toward or changes in the care plan goals and objectives. 7. Documentation procedures and treatments will include care specific details, including: a. the date and time the procedure / treatment was provided; b. The name and title of the individual who provided the care; c. The assessment data and / or any unusual findings obtained during the procedure last treatment; g. The signature and title of the individual documenting. Review of the facility's policy, Care Plans-Baseline, revised January 2020 showed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy and Interpretatoin and Implementation: 1. To assure that the resident's' immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission. 2. The interdisciplinary team will review the health care practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: B. Physician orders. 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 3/25/2025 at 10:00 a.m. with the Director of Nursing (DON), the DON stated no PASRRs were submitted for a Level II review. Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for one resident (Resident #79) of ten residents sampled for PASARR. Findings included: Review of Resident # 79's admission Record showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to schizoaffective disorder, unspecified, dated 1/13/2025; other specified anxiety disorders, dated 1/10/2023; unspecified dementia, unspecified severity, with agitation, dated 12/12/2022; and Post Traumatic Stress Disorder (PTSD), unspecified, dated 7/28/2022 Review of the Preadmission Screening and Resident Review, signature dated 7/22/2022, revealed in Section 1: PASRR Screen Decision-Making: only Anxiety Disorder was marked as a Mental Illness (MI) or suspected MI. Review of Resident # 79's medical record revealed a new diagnosis of schizoaffective disorder on 1/13/2025 and the resident was not assessed for PASARR Level II.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed, and three errors were identified for three residents (#90, #27, and #38) out of four residents observed. These errors constituted a 8.33% medication error rate. Findings included: 1. Review of Resident #90's active orders revealed the following order: Lisinopril Tablet 5 milligrams (mg). Give 1 tablet by mouth one time a day for hypertension. On 3/26/25 at 8:39 a.m., an observation was made of Staff A, Registered Nurse (RN) during medication administration for Resident #90. Staff A, RN did not administer Lisinopril Tablet 5 mg during the observation. The staff member stated he was holding the medication due to a low blood pressure. Review of Resident #90's March 2025 Medication Administration Record (MAR) revealed the following order: - Lisinopril Tablet 5 mg. Give 1 tablet by mouth one time a day for hypertension. The chart code on the MAR was documented as 4 for the dose scheduled to be administered on 3/26/25. Further review of the MAR revealed the definition of chart code 4 = Vitals Outside of Parameters for Administration. Upon review of Resident #90's electronic health record, vital signs were not observed nor able to be located related to the medication administration. 2. On 3/26/25 at 8:52 a.m. an observation was made of Staff B, Licensed Practical Nurse, (LPN) during medication administration for Resident #27. Staff B, LPN dispensed the following medication for Resident #27: - Lidoderm External Patch 5% (Lidocaine). Staff B, LPN labeled the patch with the date 3/26 and her initials. The staff member donned gloves and applied the patch to Resident #27's left upper arm. Review of Resident #27's active orders revealed the following order: - Lidoderm External Patch 5% (Lidocaine). Apply to right shoulder topically one time a day for pain. 3. Review of Resident #38's active orders revealed the following order: - Arthritis Pain Reliever External Gel 1% (Diclofenac sodium (topical)) apply to Hands topically two times a day for Dx [diagnosis]: Arthritis. On 3/26/25 at 9:49 a.m. an observation was made of Staff C, RN during medication administration for Resident #38. Staff C, RN did not administer Arthritis Pain Reliever External Gel 1% during the observation. During the observation, Resident #38 stated her hands were hurting her badly. Staff C, RN looked for the Arthritis Pain relieving medication but could not find it. He ordered it from the pharmacy. Staff C, RN stated he does not need to notify the doctor of the missed dose and the resident will just have to wait until tomorrow. On 3/27/25 at 10:55 a.m. an interview with the Director of Nursing (DON) was conducted. The DON stated if a medication is held for vital signs outside of parameters, there should be parameters in the order to hold the medication. She went on to state the doctor should be contacted if a medication is held. A review of the policy titled Administering Medications, with a revision date of April 2019, revealed the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy interpretation and Implementation: . 8. The individual administering medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide food to accommodate preferences for two residents (#39 and #66) out of twenty-two residents sampled for food. Findings included: 1. An observation on 3/24/2025 at 12:40 p.m. revealed Resident #39 sitting up at the bedside for mealtime. She stated she was not supposed to have red meat per her cardiologist and sometimes she felt like she still got it anyway. An observation on her lunch tray revealed a slice of beef covered in sauce. Her meal ticket showed she was supposed to have a Bacon, Lettuce, & Tomato (BLT) sandwich as her entrée. She stated she wasn't ever sure what she was being given until she took a bite of it because she had deteriorating vision and could not see what was on her plate. She stated she doesn't ever order anything and they just give her whatever they have that day. She stated most of the time when she realized they gave her something she wasn't supposed to eat, she would just leave it and eat everything else, but she worries she's not getting the protein she needs. An interview was conducted on 3/24/2025 at 12:50 p.m. with Staff D, Certified Nursing Assistant (CNA). Staff D, CNA confirmed the meal ticket showed BLT but the resident had a beef with sauce entrée. She stated she does not lift the lids off of the plates for certain residents if they're independent and do not need assistance. Staff D, CNA stated she was not aware of the wrong food item provided to Resident #39 and, that's on the kitchen because they are supposed to be making sure they matched up what the residents pick with what they are giving them. I know those two ladies in there don't like to have their food touched by anyone, so I just deliver their trays and don't open them or anything. An observation and interview were conducted on 3/26/2025 at 12:55 p.m., which revealed Resident #39 sitting up in bed eating her lunch. The resident's meal ticket showed the resident was to have No fish/seafood, No Red Meat, No Pork. The observation revealed her entree was the pork loin entree option. The resident stated she wasn't sure the reason she wasn't supposed to have pork, but she wouldn't eat it. A record review revealed Resident#39 was admitted to the facility on [DATE] with diagnoses to include unspecified severe protein-calorie malnutrition and unspecified macular degeneration. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (Brief interview for Mental Status) score of 13, indicating intact mental cognition. 2. An observation and interview was conducted on 3/26/2025 at 1:10 p.m. with Resident #66, which revealed the resident laying in her bed during mealtime. She stated she regularly received food she was not supposed to be having. She stated she regularly received eggs for breakfast when her ticket specifically showed no eggs. Resident #66's meal ticket on date 3/26/2025 showed she was to have a ground hot dog, however, her meal tray had ground pork as her main entree. A record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses to include hyperglycemia. A review of Resident #66's annual MDS dated [DATE] revealed Resident #66 to have a BIMS score of 15, indicating intact mental cognition. An interview was conducted on 3/26/2025 at 1:25 p.m. with the Food Services Director (FSD). He explained the process of making sure meals matched the meal tickets. The FSD observed the two days of Resident #39 having lunches served to her that did not match her ticket, and also had the main protein being two of the types of meat she was not supposed to get. He reviewed the meal ticket for Resident #66, who had a lunch entrée that also did not match her ticket. The FSD confirmed it was an issue, and staff was not checking the tickets like they should have been. An interview was conducted on 3/27/2025 at 10:26 a.m. with the Staff E, Unit Manager (UM). UM explained the expectation for facility staff was to check meal tickets before they served meals to the residents. Staff E, UM confirmed Resident #39 and #66 received the wrong food for their lunch. Review of a facility policy titled Resident Food Preferences, revised July 2017, showed: Policy Statement: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. 1. Upon the resident's admission (or within Seventy-two (72) hours after his/her admission) the Dietician or staff will identify a resident's food preferences. 2. When possible, the staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 4. The dietician and nursing staff, assigned by the Physician, will identify any nutritional issues and dietary recommendations that night be un the conflict with the resident's food preferences. 5. The Dietician will discuss with the resident or representative the rationale of any prescribed therapeutic diet. The Physician and Dietician will communicate the risks and benefits of specialized therapeutic vs liberalized diets. 6. Therapeutic diets will be ordered only after the resident/representative agrees with and consents to such a diet. 7. The resident has the right to not comply with therapeutic diets. 8. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. 9. Documenting that a resident is refusing meals due to non-compliance with diet orders is not appropriate. 10. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 11. The facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review for issue related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. Photographic Evidence Obtained

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During facility tours on 3/24/2025 at 9:40 a.m., 3/25/2025 at 8:10 a.m., and on 3/26/2025 at 7:45 a.m. and 9:00 a.m., the following was observed: a. Resident room [ROOM NUMBER]'s bathroom was observed with two plastic straight edge razors on the sink counter. Neither were labeled as to who they belonged to. There were two residents residing in the room during all days observed. b. In resident room [ROOM NUMBER], in the right corner of the room near the window, an approximately one foot section of the ceiling was observed peeling and appeared water logged from a water leak. The area of the ceiling was peeled and falling to the floor. The wall area behind the head board of the window bed and to the side of the head of the bed appeared unpainted. c. In resident room [ROOM NUMBER], the wall behind the window bed was scratched/gouged and in need of repair and paint. d. In resident room [ROOM NUMBER], the walls behind the window bed were gouged and in need of repair and paint. The ceiling near the right side of the window was observed with heavy water damage and ceiling paint peeling up. e. In resident room [ROOM NUMBER], the ceiling near the window appeared with damaged and peeling due to what appeared to be water damage. f. In resident room [ROOM NUMBER], the ceiling near the window appeared with damaged and peeling due to what appeared to be water damage. Based on observations, interviews, and review of facility policy, the facility failed to ensure a safe and homelike environment was provided in 13 resident rooms (#201, #203, #118, #114, #108, #107, #110, #112, #259, #253, #138, #137, and #146) of 74 resident rooms in the facility. Findings included: 1. During an observation made on 3/24/2025 at 9:14 a.m., room [ROOM NUMBER] was observed with a hole in the wall behind the room door. During an observation made on 3/24/2025 at 9:30 a.m., room [ROOM NUMBER] was observed with a loose toilet seat attached to the resident's bathroom toilet. 4. During an observation on 3/24/2025 at 10:00 a.m. in room [ROOM NUMBER], the walls appeared gouged behind the bed and in need of repair and paint. During an observation on 3/24/2025 at 10:10 a.m. in room [ROOM NUMBER], the walls under the window appeared gouged and in need of repair and paint. During an observation on 3/24/2025 at 10:12 a.m. in room [ROOM NUMBER], a white, unpainted square patch was observed on the wall behind the bed. During an interview on 3/27/2025 at 11:36 a.m., the Nursing Home Administrator (NHA) and Maintenance Director stated they were in the process of ordering melamine or vinyl to put behind the beds to keep the beds from rubbing on the walls and causing the holes. They stated the concerns related to the ceilings in the rooms were likely caused by the hurricane curtains and they had not seen them before today. They stated the holes behind the doors were caused by the door handles and needed to be fixed. The NHA stated he has been at the facility since September and has been working on repairing the rooms. Review of the facility's policy titled Quality of Life - Homelike Environment revised in May 2017 revealed: Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and implementation: . 2. The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Review of the facility's policy titled Maintenance Service revised in December 2009 revealed: Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building and compliance with current federal, state, and local laws, regulations and guidelines. b. Maintaining the building and good repair and free from hazards. During an observation on 3/24/2025 at 9:30 a.m. of room [ROOM NUMBER], a hole in the wall next to bed B was observed and the room windows appeared to have tape residue showing an x shape. During an observation on 3/24/2025 at 9:45 a.m. of room [ROOM NUMBER], a hole in the wall was observed underneath the light switch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #28 admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to bipolar disorder, current episode depressed, mild or moderate severity, unspecified; depression, unspecified; and panic disorder [Episodic Paroxysmal Anxiety]. Review of Resident #28's Level I PASRR screen, signature dated 3/22/22, in Section I: PASRR Screen Decision-Making, A. MI (Mental Illness) or suspected MI (check all that apply), no MI or suspected MI was selected. 3. Review of Resident #77's admission Record revealed an admission date of 8/29/24 with diagnosis to include depression, generalized anxiety disorder, and bipolar disorder. A diagnosis of schizoaffective disorder was added on 1/13/25. Review of Resident #28's Level I PASRR screen, signature dated 11/21/24, in Section I: PASRR Screen Decision-Making, A. MI (Mental Illness) or suspected MI (check all that apply), no MI or suspected MI was selected. Review of the facility's policy titled PASARR Re-Evaluation/Determination and Subsequent Review dated 1/29/20 revealed: Policy: Residents should be reevaluated when an individual's mental or physical condition has changed in a manner that effects their need for nursing facility level of care, specialized services, or recommended services of lesser intensity. Based on interview and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were accurate and updated to include current diagnoses for three residents (#29, #28, #77) out of 28 sampled residents. Findings included: 1. Review of Resident #29's admission Record showed Resident #29 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (added 12/23/20), anxiety (added 4/20/20), and major depressive disorder. Review of the Level I PASRR, dated 7/16/20 showed in Section I: PASRR Screen Decision-Making, A. MI (Mental Illness) or suspected MI (check all that apply), no MI or suspected MI was selected. During an interview on 3/25/25 at 3:28 p.m. with the Director on Nursing (DON), she stated she knew she had a problem because nobody has been doing PASRRs in the facility. She stated she will have to review all the PASRRs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 3/26/25 at 9:49 a.m., an observation was made of Staff C, Registered Nurse (RN). Upon entering Resident #38's room, no hand hygiene was performed. Staff C, RN obtained Resident #38's blood pressure using reusable equipment for multiple resident use. Throughout the observation, no had hygiene was performed and the reusable equipment was not observed to be cleaned prior to or after use. Based on observations, record reviews, and interviews, the facility failed to 1. Implement an effective infection control program related to the use of Personal Protective Equipment (PPE) in one resident (#162) room of four transmission-based precaution rooms; 2. Failed to store or dispose an indwelling catheter bag when not used for one resident (#78) of six sampled residents who utilized catheters; and 3. Failed to ensure staff completed appropriate hand hygiene during one of three meal observations, (3/24/2025) and during care for one resident (#38) of 42 sampled residents, and 4. Failed to sanitize shared resident equipment after use for one resident (#38) of 42 sampled residents. Findings included: 1. On 3/25/2025 at 7:40 a.m., Staff I, Licensed Practical Nurse (LPN) was observed in the hallway just outside Resident #162's room Staff I, LPN had her medication cart positioned in between the entry way of the room and the hallway. Staff I, LPN was observed standing inside the entry point of the room with her cart in the hallway. After she was finished preparing and pouring medications for Resident #162, she was observed to don clear plastic gloves. At 7:43 a.m. Staff I, LPN picked up the cup of medications off her medication cart and walked to Resident #162, who was seated upright in bed. From the hallway, Staff I, LPN could be observed passing the resident the cup of medications and touched the resident's hands and arms. Staff I, LPN was observed not wearing any other Personal Protective Equipment (PPE) such as a gown and face mask while in the room with Resident #162. Further observations revealed a PPE caddie hanging on the front of the resident's room door, which was stocked with PPE to include gowns, plastic gloves, and face masks. The left wall at the room door entrance had a plastic sign that read; STOP! CONTACT PRECAUTIONS EVERYONE MUST: 1. Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: 1. Put on gloves before room entry, and discard gloves before room exit; 2. Put on gown before room entry, and discard gown before room exit; 3. Do not wear the same gown and gloves for the care of more than one person; 4. Use dedicated or disposable equipment, and clean and disinfect reusable equipment before use on another person. (Photographic Evidence Obtained) Also, observed from the hallway at 7:47 a.m., Staff I, LPN, after completing her medication pass with Resident #162, was observed walking over to the room door and removing her gloves. The staff member proceeded to walk to her medication cart and began to start preparing mediations for another resident. Staff I, LPN, prior to entering Resident #162's room, did not wash her hands prior to donning plastic gloves, did not don a gown, and did not wash her hands after she touched Resident #162's hands and arms. Staff I, LPN also did not wash her hands prior to starting another medication preparation. At 7:48 a.m. Staff I, LPN was interviewed related to the infection precautions in the room. Staff I, LPN confirmed the room was on contact precautions. She revealed she should be wearing gloves and a mask and she forgot to don a mask when she entered the room. Staff I, LPN looked at the contact isolation sign on the outside room door wall and confirmed she should have, in conjunction with the gloves she wore, donned a gown. Staff I, LPN stated, I just forgot to wear a face mask and gown before going in the room and I know better. She was not sure about wearing a face mask but stated she should have worn one anyway. Staff I, LPN revealed she was trained and inserviced on the difference between contact isolation rooms and enhanced isolation rooms. Staff I, LPN also confirmed it's only rooms labeled Enhanced infection precautions where they do not need to gown up, unless they are doing physical care with the resident. During the previous day on 3/24/2025 at approximately 10:45 a.m., an interview with Staff E, LPN Unit Manager (UM) confirmed Resident #162 was on contact isolation precautions and upon entering the room, staff and visitors must follow the PPE signage and wash their hands prior to entering the room, and don plastic gloves and a gown. She confirmed Resident #162 was being treated for an infection which required contact isolation infection precautions. On 3/27/2025 at 9:00 a.m., Staff J, LPN, who was at a medication cart near resident room [ROOM NUMBER], was interviewed with relation to infection control and contact isolation precautions. Staff J, LPN revealed they have had rooms on contact isolation precautions to include Resident #162. She revealed the resident had signage on the door indicating the room was on contact precautions. Staff J, LPN confirmed when entering the room, staff should first wash their hands, then don plastic gloves and a gown. She further revealed when completed with care or service, staff should doff the gown and gloves while still in the room and wash hands prior to leaving. Staff J, LPN confirmed she and all other staff receive frequent infection control training from the Infection Preventionist and the Director of Nursing. Staff J, LPN also confirmed, as a nurse, she is to monitor other staff who need to go in contact isolation rooms and ensure they are following the proper PPE requirement. Review of Resident #162's medical record revealed she was admitted on [DATE]. Review of the diagnosis sheet revealed diagnoses to include pneumonia, staph aureus, and need for personal care. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had Active Diagnoses of Multidrug Resistant Organism, Pneumonia, and Septicemia. Review of the resident's March 2025 physician's orders revealed the following: A. Initiate Contact Precautions: MRSA (Methicillin-resistant Staphylococcus aureus) Bacteremia every shift Infection Control until 3/26/2025 (Start date 3/18/2025 and end date 3/26/2025). On 3/27/2025 at 10:20 a.m., Staff E, LPN and Unit Manager (UM) was interviewed and she confirmed Resident #162 was on contact isolation precautions 3/25/2025. Staff E, LPN UM revealed she, along with the Infection Preventionist and the Director of Nursing, provide staff education related to infection control and prevention. She revealed she monitors staff to ensure they follow infection prevention and PPE requirements when it comes to Special Contact isolation precautions, contact isolation precautions, and enhanced barrier precautions. She revealed if staff don't follow the PPE requirements, she will provide immediate education. Staff E, LPN UM confirmed when Resident #162 was on contact isolation precautions, there was a sign on the door that indicated contact isolation precautions and listed the required PPE to wear to include; wash hands prior to entering the room, don gloves and gown prior to entering room, doff PPE, and wash hands prior to leaving the room. Staff E, LPN UM was made aware that Staff I, LPN forgot to wear a gown prior to entering the room for medication pass on 3/25/2025 and stated that should not have happened. Staff E, LPN UM revealed she was confident all staff know the difference of what types of contact isolation precautions and what PPE to wear in those rooms. Staff E, LPN UM also revealed she, the supplies person, and other staff as needed, will ensure the PPE caddy is stocked with the required PPE for each room on contact precautions. 2. On 3/24/2025 at 10:20 a.m., 11:30 a.m., and 12:50 p.m., Resident #78's room was observed seated upright in his bed and with the covers pulled up to his waist, or seated in his wheelchair, while dressed for the day. The room had a faint urine odor, but it could not be determined where the odor was coming from. There were no observations of urinals or use of a catheter. Resident #78 was interviewed and he revealed he used an indwelling catheter at night when he is in bed, but was not observed utilizing one at the time. The bathroom was observed and once entered, the room had a stronger odor of urine. Further observations revealed a blue catheter bag and its tubing were draped and hanging off a metal hand bar directly above the toilet tank. The catheter bag and tubing were hanging off the bar in between the toilet and the sink counter. The catheter bag appeared to have been used previously and still had some yellow liquid in some of the tubing. It was noted Resident #78 had a roommate who shared a bathroom with him. (Photographic Evidence Obtained) During observations on 3/25/2025 at 8:30 a.m., 3/26/2025 at 8:00 a.m., 10:51 a.m., and 2:14 p.m., and on 3/27/2025 at 8:15 a.m.; Resident #78's bathroom was observed each time with the catheter bag and tubing hanging down from the wall metal hand rail, located between the toilet tank and the sink counter. The bathroom had faint urine odor. There were observations during several of the listed dates and times where Resident #78's roommate used the bathroom on his own. On 3/27/2025 at 10:20 a.m., an interview was conducted with Staff E, LPN UM. She revealed Resident #78 was ordered and utilized an indwelling catheter and all care with it and maintenance of the bag and tubing are completed by nurses. She confirmed Resident #78 did not do catheter care and catheter maintenance on his own. Staff E, LPN UM revealed the resident is supposed to have it on at all times to include bed and when out from bed in wheelchair. She was able to go to Resident #78's room and bathroom and found the catheter bag and tubing was hanging on the wall between the toilet tank and sink counter. She confirmed the catheter bag and tubing should never be hung in the bathroom and she was not sure why that happened, who put it there, and was not sure why there were multiple days of this observed. Staff E, LPN UM could not be certain if the catheter bag and tubing were cleaned and sanitized and the resident should not be doing that on his own. Staff E, LPN UM stated storing the catheter bag and tubing freely on the wall can cause risk for infections. She confirmed Resident #78's roommate uses the bathroom on his own. 3. On 3/24/2025 at 11:45 a.m., the first floor main dining room was observed during the lunch meal service. There were seven residents seated at various tables and with three staff members assisting with lunch meal tray service and set up. At 11:50 a.m. the Admissions Director (AD) was observed walking from a table near the back corner of the room and to the tray cart, which was positioned near the sink counter and doors leading to the kitchen. With her bare hands, she took a tray of food from the cart and brought it over to a resident. She lifted off the lid with her bare hand and placed the lid on the table. She touched the resident's arm and hand as a gesture, picked up a knife and fork and started to cut food items into smaller pieces. The AD gave the fork to the resident and touched her arm and shoulder with her bare hands. The AD picked up an empty tray and lid with her bare hands and brought it over to another cart near the meal tray cart. The AD picked out another meal cart with her bare hands and then walked it over to another resident, where she set up the meal using her bare hands, and touched the resident's fork and knife. After she set up the meal for the resident she continued back to the meal tray cart, removed another meal tray, and brought it to another resident for meal service. The AD never washed or sanitized her hands between, and after resident contact, and did not wash and sanitize her hands after receiving a new meal tray for three residents. The AD was interviewed at 12:04 p.m. She explained she should be sanitizing her hands after each tray pass, after any resident contact, and after touching any contaminated surfaces. She did not remember if she sanitized her hands between the three residents she passed and set up meal trays for. On 3/27/2025 at 2:00 p.m., the Director of Nursing (DON) provided the Isolation - Categories of Transmission-Based Precautions policy and procedure with a revised date of October 2018, for review. The policy revealed the following: Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation: 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 3. The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions. 4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. . Contact Precautions: 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 2. The decision on whether contact precautions are necessary will be evaluated on a case by case basis. 3. The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the Infection Preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate). 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves will be removed and hand hygiene performed before leaving the room. c. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. On 3/27/2025 at 2:00 p.m. the DON provided the Isolation - Initiating Transmission-Based Precautions policy and procedure, revised October 2018, for review. The policy revealed the following: Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation: . 3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee: a. Clearly identifies the type of precaution, the anticipated duration, and the personal protective equipment (PPE) that must be used; . c. Provides and/or oversees the education of the resident, representative and/or visitors regarding the precautions and use of PPE; d. Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. 1. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. On 3/27/2025 at 2:00 p.m. the DON provided the Handwashing/Hand Hygiene policy and procedure, revised August 2015, for review. The policy revealed the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. The Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non- antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; . i. After contact with a resident's intact skin; . m. After removing gloves; n. Before and after entering isolation precaution settings; . p. Before and after assisting a resident with meals.

Based on observations, record reviews, and interviews, the facility failed to assess and obtain wound care orders for one (#12) of two residents reviewed for wound care. Findings included: On 8/24/24 at 9:51 a.m., Resident #12 was observed sitting in a wheelchair inside the second floor activity room across from the nursing station. The observation revealed a tan-colored 4 x 4 shiny plastic-looking border dressing near the resident's right elbow. The dressing was undated with an approximate quarter-sized area of discoloration staining the near-center of the dressing. The resident's speech was non-sensical. An interview and observation of Resident #12's dressing was conducted with Staff A, Licensed Practical Nurse (LPN) on 8/24/24 at 9:57 a.m. Staff A stated when an area of (disrupted) skin integrity was observed, the area was assessed, a head-to-toe assessment was completed, and a physician order was obtained for treatment. The staff member viewed Resident #12's right elbow dressing and reported seeing the area also that morning. Staff A confirmed the dressing should be dated, there should be a physician order for the dressing, and an assessment of the area should have been done. Review of Resident #12's medical record, including progress notes, Interdisciplinary Team (IDT) Quick View notes, and Wound/Skin notes did not reveal an assessment or note was completed regarding the cause of the resident's right elbow injury. The record did not reveal a treatment order had been obtained from the physician (prior to the observation) or the resident's responsible party was notified of the injury. The record showed on 8/17/24 at 7:55 p.m., Resident #12's skin was intact. A IDT note dated 8/20/24 at 8:11 p.m. revealed the resident was status/post (s/p) fall with no delayed injuries. An interview was conducted with the Director of Nursing (DON) on 8/24/24 at 3:44 a.m. The DON stated when a skin issue was noted, staff were to obtain a physician order and let management know so they could investigate the cause and circumstances. The DON confirmed not knowing about Resident #12's skin injury. Review of the policy - Wound Care, dated October 2010, revealed The purpose of this procedure guidelines for the care of wounds to promote healing. The preparation instructed staff to 1. Verify that there is a physician's order for this procedure. The procedure portion of the policy included instructions for staff to 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. The policy showed the following documentation should be recorded in the resident's medical record: 1. Wound care provided. 2. The date and shift the wound care was provided. 3. The name and title of the individual performing the wound care. 4. Any change in the resident's condition. 5. Assessment data (i.e. Wound bed color, size, drainage, etc.) Obtained when inspecting the wound. 6. How the resident tolerated the procedure. 7. Problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment and the reason(s) why. 9. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure laboratory testing was obtained per physician orders for one (#12) of two residents sampled. Findings included: On 8/24/24 at 9:51 a.m., Resident #12 was observed in the second floor activity room with other residents and a television was playing. The resident's speech was non-sensical. On 8/24/24 at 9:57 a.m., Staff A, Licensed Practical Nurse (LPN), confirmed the resident's identity. The resident appeared to be a frail elderly resident, clean and appropriately dressed. Review of Resident #12's medical record revealed the resident was admitted on [DATE] and 11/22/22. The record included the diagnoses: Adult failure to thrive, unspecified stage 3 chronic kidney disease, unspecified anemia, unspecified vitamin deficiency, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #12's active physician orders, dated August 2024, revealed an order written and to start on 1/18/23 for a Complete Blood Count (CBC)/Comprehensive Metabolic Panel (CMP)/Ammonia level every (Q) 4 months. The laboratory testing should have been scheduled during the months of January, May, and September, according to the calendar cycle of every 4 months per the physician order. Review of Resident #12's Laboratory results and Treatment Administration Records (TAR) from January 2023 to August 2024 revealed the following: - 1/19/23: CMP/CBC/Ammonia level, signed on 1/20/23. - 5/18/23: The TAR revealed a CBC/CMP/Ammonia level was to be drawn on Thursday 5/18/23 and did not show it had been completed/administered. Review of the resident's electronic record did not reveal any laboratory results for May 2023 and the facility did not provide as requested. - 9/5/23 laboratory results revealed a CMP and CBC had been drawn without an Ammonia level. The September 2023 TAR revealed a CBC/CMP/Ammonia level had been drawn on Friday 9/15/23. Review of the laboratory results located in the electronic record did not reveal any results dated 9/15/23 and the facility did not provide those results as requested. - 1/8/24: Laboratory documentation show Vitamin D and parathyroid hormone (PTH) results were pending, and the facility had received Potassium and CBC results. - 1/13/24: The TAR revealed a CBC/CMP/Ammonia level had been drawn on 1/13/24. Review of the resident's medical record did not reveal those results and the facility did not provide the results for 1/13/24. - 5/12/24: The TAR did not show a CBC/CMP/Ammonia level had been drawn on Sunday 5/12/24. The facility did not provide any laboratory results from May 2024. Review of Resident #12's progress notes revealed the following: - 5/18/23: no progress note from 5/18/23 showing the reason laboratory testing had not been completed. - 9/15/23: no progress note from 9/15/23 showing the reason laboratory testing had not been completed. - Follow up Cardiology provider note, dated 6/14/24, revealed laboratory results reviewed were dated 1/8/24, No new labs to review. During an interview on 8/24/24 at 3:44 p.m., the Director of Nursing (DON) stated the night shift nurses put in the laboratory requests, the order pops up for them and they were supposed to have them done and print out the results. A review of Resident #12's May TAR revealed the order for laboratory testing had been scheduled for the 7:00 p.m.-7:00 a.m. shift, she stated the lab vendor came to the facility at 4:30 a.m. and saw the issue, if the order pops up at 7 a.m. the vendor was gone. During a follow up interview on 8/24/24 at 4:48 p.m., the DON said nurses compared the lab log and the results that came through, the nurses and Unit Manager were responsible for the laboratory results. The nurses reached out to the physician's (if necessary). The nurses had to print out the results so they could be scanned into the record. The physician's were able to access the laboratory and radiology systems. Review of the policy - Lab and Diagnostic Test Results: Physician Role and Follow Up, dated September 2017, revealed The facility shall use a systematic process for obtaining and reviewing lab and diagnostic test results and reporting to the physicians. Physicians shall address lab test results appropriately and in a timely manner. The Outcomes review showed Clinically significant test results will be reviewed and acted upon appropriately and in a timely manner. The procedure section of the policy included the following: 1. the physician will identify an order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 4. A nurse will review all results. - If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 8. A nurse will try to determine whether the test was done: a. As a routine screen or follow up; b. To assess a condition change or recent onset of signs and symptoms; or c. To monitor a serum medication level. - The reason for getting a test often affects the urgency of reporting and acting upon the result.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with facility staff and residents, and facility policy review, the facility failed to ensure allegations of drug use by staff on facility premises, and allegations of staff reporting to work under the influence of drugs were investigated potentially impacting the health and safety of 114 residents within the facility's care. Findings included: On 08/23/23 at 12:53 p.m. an interview was conducted with a resident in room [ROOM NUMBER]. The resident stated the Certified Nurse's Assistants (CNAs) come to work smelling like marijuana. The resident said, That is not pleasant at all. I do not like the smell. The staff are impaired while caring for patients. The resident stated it was not just one incident. She stated she could not give names or state when the incidents occurred. The resident said, It is a culture here. Everybody knows about it including the administration. On 8/23/23 at 12:55 p.m., an interview was conducted with the former resident council president. He said, The facility sometimes [NAME] of weed. Some staff smoke marijuana casually and roll up in here smelling some type of way. It's not cool for the folks that do not. The former council president stated it mostly happened during evenings, nights, and weekends. He stated everyone talks about it. He said, It's not a secret. 08/24/23 at 10:13 a.m., an interview was conducted with the Assistant Social Services Director (ASSD). She stated she had not witnessed any staff smelling like marijuana in the facility. She stated she heard about it. She said, People were saying it smells like marijuana in the halls. It is an ongoing rumor that there are staff smoking in the parking lot. 08/24/23 at 11:50 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). She stated she had heard the CNA's were smoking marijuana in the facility parking lot. She stated her first weekend at the facility she smelled marijuana in the elevator. She stated she reported the incident to the Nursing Home Administrator (NHA). The ADON said, It happened over the weekend of 8/12/23 and 8/13/23. I was on call. The elevator was smelling strongly. I walked through the parking lot and did not see any staff in the cars smoking marijuana at the time. The ADON stated some of the staff have dark windows and they get into the cars in two's. She stated she could not say if they were smoking or not, but the smell was apparent inside the facility. The ADON said, I called the NHA right away. She did not tell me to do anything. The ADON stated a nurse who was no longer employed, had reported that same day that a resident's family had complained that they smelled marijuana inside the facility. The ADON confirmed she did not receive direction to investigate or rule out the allegation. The ADON said, I did not speak to any of the staff who were working that day. It was not apparent to me that anyone was impaired. It was just the smell. It is an on-going problem. The ADON stated the facility policy prohibits drug use in the facility. On 08/24/23 at 12:18 p.m., an interview was conducted with the Director of Nursing (DON). She stated someone from the Department of Children and Families (DCF) had come to the facility the previous week and reported an allegation of drug use in the facility. The DON stated that was how she learned there was a complaint filed with DCF about three employees smoking drugs in the facility's parking lot. She stated about two weeks prior the ADON had reported she smelled marijuana in the facility's elevator. The DON stated the following Monday they did not address the drug issue allegation in their morning meeting. She stated she had taken it upon herself to check cars when she arrived at the facility but had not encountered anyone smoking of marijuana in the parking lot. The DON stated she, Did not interview the three employees who were named in the allegation (Staff C, LPN [Licensed Practical Nurse], Staff D, CNA and Staff E, CNA). She stated she had not interviewed any staff members or residents. She stated she thought the NHA might have initiated the investigation. The DON stated the facility has policy about coming to work while impaired. She said, our policy prohibits employees from reporting to work while under the influence of any mood-altering substances. On 08/24/23 at 1:22 p.m., an interview was conducted with the NHA. She stated DCF had come to the facility the previous week and reported staff were using drugs at the facility's premises. She stated the allegation did not allege drug use inside the building. She stated the DCF representative had come to investigate the three staff members who were allegedly smoking marijuana in the parking lot. The NHA stated DCF spoke with each of the staff members. The NHA confirmed she did not initiate her own investigation. She said, I was communicating with DCF based on their conversation. She stated she did not speak with the three employees because she thought the DON would. The NHA stated their policy was to drug test employees based on reasonable suspicion and evidence of impairment. The NHA confirmed she had received a text message from the ADON regarding the smell of marijuana inside the facility. The NHA said, It was on a weekend. I did not respond to the test message. I don't know why. Multiple interviews conducted with employees on 08/24/23 revealed staff had not received in-services related to drug use in the facility. Interviews further confirmed that none of the staff had been part of the investigation. The staff further confirmed they did not know the facility's policy on drug use. On 08/24/23 at 1.24 p.m. an interview was conducted with Staff E, CNA. She stated she did not know of the facility's policy on drugs. She stated she had not heard that there was a DCF allegation. She said, No one spoke with me. I don't do drugs you can ask my residents if I smell like marijuana. Staff E confirmed she did not write a statement related to the allegation. On 08/24/23 at 1.50 p.m., an interview was conducted with Staff D, CNA. She stated she had not participated in any investigation and had not heard of allegations of drug use in the facility. Staff D said, I don't use any drugs. On 08/24/23 at 1.54 p.m. an interview was conducted with Staff C, LPN. She stated the issue of drug use was brought up to her when DCF was at the facility. She stated the DON said DCF reported 3 staff went out to the parking lot and were smoking marijuana. She stated the report showed staff were coming back from break smelling like marijuana. She stated she was told it was herself, [Staff D] and [Staff E] that were allegedly smoking in the facility's parking lot. Staff C said, We don't hang out. There was no investigation that I knew of. No one asked me any questions. I did not give a statement, they did not ask anything. I was not drug tested. I would have given a urine sample to clear my name. On 08/24/23 at 1:30 p.m., an interview was conducted with Staff F, an NHA from a sister facility. She said, Yes, they should have conducted interviews to narrow down the problem staff. Staff F stated the NHA was trying to prioritize impact on residents and the drug use compliant was not directly related to resident's care. Staff F said, We do not drug test all staff. We could if we witnessed any signs of impairment. We should have interviewed staff and residents. Staff F stated they follow their Human Resources (H/R) policy. An interview was conducted on 08/24/23 at 2:13 p.m. with the facility's H/R Manager. She stated per their policy, they do not drug test employees unless they are injured or if there is suspicious behavior, or if there was a reason. She stated she was not notified there was an allegations of drug use on the facility premises. She stated that would have been a reason to send the individuals involved out to be drug tested. She stated she was not aware DCF was at the facility related to use of drugs. The H/R Manager said, If they are using while on the clock, that is a problem. They can't come in high or smelling like alcohol or any kind of drugs. That is against facility policy. Review of a facility policy titled, Substance Abuse, Revised July 2014, revealed the following: Our work environment must be free from the effects of drugs, alcohol, or other intoxicating substances. Compliance with our substance abuse policy is made a condition of employment. 1) employees are prohibited from illegally . possessing or using alcohol or illegal drugs in the workplace. 2.) Employees may be subject to random drug testing at any time. 5.) In the employee reporting to work under the influence of alcohol, drugs or other intoxicating substances will not be permitted to work his/her assigned shift. 7.) The facility may inspect the contents of any package brought on to or taken from the premises. 11.) Employee of this facility will receive a copy of this substance abuse policy. 12.) Documentation of any and all violations of this policy must be made by the supervisor of the employee committing the violation(s). A copy of the documentation must be filed in the employees personnel record. 13.) All workplace incidents involving alcohol or drugs among our employees must be reported to the administrator. Review of a facility document subtitled, 3.4 Drug and Alcohol Policy, dated January 1, 2021, showed the following: The company has a longstanding commitment to provide a safe and productive work environment and to minimize the risk of accidents and injuries. Alcohol and drug abuse pose a threat to the health and safety of employees and to the security of our equipment and facilities. For these reasons, the company is committed to the elimination of drug and/or alcohol use in the workplace. This policy outlines the practice and procedure designed to correct instances of identified alcohol and/all drug use in the workplace. This policy applies to all employees and all applicants for employment. The human resource department and/or the administrator is responsible for policy administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review the facility failed to implement control measures to prevent the potential re-infection or transmission of scabies among residents in the facility related to four residents (#4, #10, #11, and #12) out of twelve sampled who were treated or exposed to scabies. Findings included: Review of medical records showed Resident #10 was seen by a dermatology practice on 8/16/23 and treated for scabies on 8/16 and 8/17/23 with oral and topical medications. Review of admission records showed Resident #10 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, dementia, and disorder involving the immune mechanism. Review of Resident #10's August Orders and Medication Administration Record (MAR) showed the following: -Ivermectin 3 milligram (mg.) Give 4 tablets at morning medication pass. Start date 8/16/23. End date 8/17/23. The MAR shows medication was administered on 8/17/23. -Permethrin 5% topical cream. Apply head to toe once at bedtime. Rinse off 8-14 hours after. Start date 8/17/23. End date 8/18/23. The MAR shows the medication was applied on 8/17/23 and rinsed off on 8/18/23. No order was found for contact precautions since 8/16/23. A review of provider notes showed Resident #10 was visited by the Dermatology Physician Assistant (PA) on 8/16/23. The provider described the rash as erythematous macules in a linear distribution with scaling to skin folds and finger web spaces. A biopsy was performed to rule out scabies. The notes showed The day you start treatment, wash your clothes, bedding, towels, and washcloths. Mites can survive for a few days without human skin. If a mite survives, you can get scabies again. To prevent this, you must wash clothes, sheets, comforters, blankets, towels, and other items. Be sure to follow these instructions when washing: Wash all items in a washing machine and then dry it in a dryer, take it to a dry cleaner or seal in plastic bag for at least 1 week. On 8/23/23 at 2:19 p.m. an interview was conducted with the dermatology PA that visited Resident #10 on 8/16/23. She stated the biopsy came back and was unable to isolate but cannot exclude scabies. The PA explained scabies mites are difficult to isolate on a skin scraping and when they said they cannot exclude scabies it usually means they see the inflammation that indicates a mite passed through the area. The PA said the facility should have taken any clothes or sheets the resident had used for the past 7 days and washed them separately. She said items that could not be washed should have been bagged for 7 days. She stated she doesn't typically treat roommates unless they have a rash or have had known skin to skin contact. The roommate should be looked at for rashes. Record review showed Resident #11 is the roommate of Resident #10. She was admitted to the facility on [DATE] with diagnoses including displaced bimalleolar fracture of lower leg and atopic dermatitis. A Wound/Skin note, dated 8/17/23, showed the resident had a skin inspection and her skin was intact. There have been no further skin inspections done from 8/18/23 to 8/24/23. On 8/23/23 at 12:13 p.m. an interview was conducted with the Housekeeping Account Manager. She stated the room of Resident #10 and #11 is getting their regular daily cleaning. She said she is aware of Resident #10 having scabies but has not done a deep cleaning of the room for scabies. She said when nursing tells housekeeping the resident has finished treatment, her staff deep clean the room and they had not notified her yet. She said the Certified Nursing Assistants (CNA) bag all the resident's personal items and housekeeping cleans, including changing the curtains, cleaning the mattress and beds. The housekeeping manager said according to her regular schedule for deep cleans Resident #10 and #11's room was last deep cleaned on 8/8/23. An observation was made on 8/23/23 at 12:30 p.m. of Resident #10 in the dining room for lunch, sitting with three other residents. Her room was observed to not have any precaution signs present. On 8/23/23 at 12:45 p.m. an interview was conducted with the Infection Preventionist (IP)/Assistant Director of Nursing (ADON.) She stated only one resident in the facility has had scabies recently and it stayed contained to only that resident, but she couldn't remember their name. She said she started in the facility in July and was handed a blank slate as far as tracking infections. The IP/ADON provided a map of the first floor with current infections being tracked. Resident #10 and #11's room was not marked on the map. On 8/23/23 at 2:33 p.m. the IP/ADON provided an Infection Control Surveillance Log for July 2023 but said for August she hasn't gotten it together yet. On 8/23/23 at 12:55 p.m. an interview was conducted with Staff O, Registered Nurse (RN.) Staff O, RN confirmed she was caring for Resident #10 and #11 on her current shift. She said she had no idea Resident #10 had scabies in the last week or that Resident #11 should be getting checked for scabies. Staff O, RN did say she was aware a resident on the second floor was treated for scabies recently but was unsure of who it was. On 8/23/23 at 12:58 p.m. an interview was conducted with Staff P, CNA. She stated she was caring for Resident #10 and #11 during her current shift and she also cared for her the week prior. She said the residents were not on precautions the week prior. She said she had no idea Resident #10 had scabies the week she was caring for her. On 8/23/23 at 1:03 p.m. an interview was conducted with Staff Q, CNA. She confirmed there was a resident on the second floor that was recently treated for scabies, but she hadn't heard of any other cases in the facility. She said the resident treated was Resident #4. Review of medical records showed Resident #4 was last admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, multiple sclerosis, dementia, history of rash and other nonspecific skin eruption, and artificial openings of urinary tract. Review of Resident #4's progress notes showed the following: 7/29/23 6:48 a.m. Writer called resident's POA (power of attorney) [name and #] to notify of resident having scabies. Writer got a voicemail and left a message. 7/30/23 7:37 a.m. Oral Ivermectin and Permethrin cream was applied neck to toes last night at bedtime and tolerated without difficulty. Resident has what appears to be scabies dermatitis from scalp to toes with scratch marks from head to mid thigh. Did provide resident with patient education regarding microbes underneath her fingernails and the potential for a skin infection and she verbalizes understanding. Remains on contact isolation due to exposure. Will have on coming shift give Resident shower upon arising for the day, strip and disinfect bed as well as provide clean linens. Will continue to monitor. Review of medical records showed Resident #12 is the roommate of Resident #4. Resident #12 was admitted on [DATE] with diagnoses including intervertebral disc degermation in lumbar region, Alzheimer's disease, and disorder involving the immune mechanism. Review of Resident #12's MAR showed an order for Permethrin 5% topical cream every 7 days. Treat at bedtime. Start date 7/29/23 Stop date 8/6/23. Review of progress notes showed the following: 8/7/23 at 6:30 p.m. Patient received 2nd shower today. Status post scabies treatment. No complaints of pain or discomfort. Patient is resting comfortably in bed throughout the shift. No issues or concerns at this time. Call light in reach. The Infection Control Surveillance Log for July 2023 provided by the IP/ADON did not show Resident #4 being tracked for having scabies. On 8/24/23 at 2:56 p.m. an interview was conducted with the Housekeeping Account Manager. She confirmed she had not been told to deep clean Resident #10 and #11's room. As far as the room of Resident's #4 and #12 she said it was not deep cleaned on 7/29 or 7/30/23 when they received treatment. She provided a checklist from 8/8/23 showing that was the day Resident #4 and #12's room was scheduled to be deep cleaned for scabies. She said it would be her staff that does the deep cleaning, and she schedules them. On 8/24/23 at 2:31 p.m. an interview was conducted with the Regional Nursing Home Administrator (NHA), who is also a nurse. She said a resident with scabies would go on isolation for 24 hours after treatment. She said the resident's personal items get bagged and everything gets cleaned, including bed, furniture, and curtains. She said the shower/treatment and cleaning should all happen together. She said housekeeping would do the cleaning because nurses and CNAs are not trained to do terminal cleans and they wouldn't be doing that. She said if a resident was treated for scabies the night of 7/29/23 their room should have been terminally cleaned the morning of 7/30/23. She said she would expect it to have been done before 8/8/23. The Regional NHA also said the roommate of the resident exposed should be getting daily skin checks and that order should have been put in by nursing management. She added this should have been talked about in the morning meetings. She stated, no question why this is an infection control concern. On 8/24/23 at 3:01 p.m. an interview was conducted with the Director of Nursing (DON.) She said for a resident with scabies first we isolate them, then we treat and clean. She said they typically watch the roommate due to exposure but do not treat. She said the roommate should be getting daily skin checks. The DON said she knows they have been having issues with skin checks not being completed. As far as cleaning with scabies treatment, the DON said usually the room is cleaned while the resident is in the shower getting the first treatment and when the cream is washed off in the second shower, housekeeping comes back and terminally cleans the room. When told Resident #10 was treated on 8/18/23 and her room had still not been deep cleaned she said Wow, I will address. She said she would call the dermatologist to determine what they wanted to do as far as treatment for Resident #10 and #11. When asked about Resident #4 having scabies she said she had no knowledge that she had it. The DON said she had only been in the facility a couple of weeks. She said she would have expected the Infection Preventionist to have known Residents #4 and #12 were treated and to follow up with housekeeping. She said the IP should have known from her infection tracking. Review of a facility policy titled Scabies Identification, Treatment, and Environmental Cleaning, revised August 2016, showed the following: Purpose: The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabies and to prevent the spread of scabies to other residents and staff. General Guidelines 1. Scabies is an itching skin irritation caused by the microscopic human itch mite, which burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic rash. 2. Secondary bacterial skin infections may result from untreated scabies. 3, Incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure. Persons who have been previously infested develop more rapid symptoms, 1-4 days after re-exposure. . 6. Scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. 7. Diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or 2 mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings, although scrapings or preferred. . 11. A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved. 12. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing as established by the facilities infection and exposure control programs. 13. During a scabies outbreak among residents and/or personnel, the Infection Preventionist or Committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. Environmental Control: Typical Scabies 1. Place residence with typical scabies on contact precautions during the treatment; 24 hours after application of 5% Permethrin cream or 24 hours after last application of scabicides requiring more than one application. . 4. Place bed linens, towels and clothing used by an affected person during the 4 days prior to initiation of treatment in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for at 10-20 minutes. . 6. Place non-washable blankets and articles in a plastic bag for at least 72 hours. These items can also be dry cleaning or tumbled in a hot dryer for 20 minutes. . 10. Vacuum mattresses, upholstered furniture, and carpeting. Wrap vacuum cleaner bag in a plastic bag and discard. Review of a policy provided by the facility's housekeeping contract company titled Contaminated Isolation Room Cleaning-Scabies, undated, showed the following: Purpose: Review the process of cleaning an Isolation Room and preventing the spread of scabies. It is important that for each infectious disease an EPA approved solution is used to sanitize the patient room. Information on the EPA approved solution's use, preparation, and dwell time, also referred to as contact time, can be found on the Safety Data Sheet (SDS) and manufacturer's label. Isolation Room Cleaning Procedure . C. Begin the Isolation Room Cleaning using the guidelines below: 1. Empty Trash . 2. Horizontal Surfaces-disinfected . c. Thoroughly clean ,disinfect and vacuum the patient bed area, including the headboard, footboard, front panel, mattress-with high focus on any seams or crevices-side rails, bed frame, over-bed table, and base of the over-bed table. e. Vacuum the interior of the dresser drawers with a high focus on corners and joints. 3. Clean Walls . 4. Cubicle Curtains and Drapes a. Remove the cubicle curtains and drapes and double bag these items. Place inside room until you exit. 5. Clean and Disinfect Bathroom . 6. Dust Mop and Vacuum . 7. Damp Mop . 8. Exit Room . b. Take all double bagged linens, mops, and curtains to the dirty linen room and let the laundry employees know you have just completed an Isolation Room cleaning for scabies. Review of a facility job description titled Infection Preventionist, Revised July 2016, showed the following: The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and controlled policies and practices. Policy Interpretation and Implementation 1. The Infection Preventionist (or designee) shall coordinate the development and monitoring of our facilities established infection prevention and control policies and practices. 2. The Infection Preventionist shall report information related to compliance with our facilities established infection prevention and control policies and practices to the Administrator and Quality Assurance and Performance Improvement Committee. 5. The Infection Preventionist will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and healthcare practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidence-based infection prevention and control practices

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review the facility failed to properly store medication in three out of five medication carts, on one of two nursing units, and ensure medication were stored separate from food in one of two medication storage rooms. Findings included: On 8/23/23 at 9:21 a.m. a medication cart on the second floor was observed to be unlocked. There were no staff in sight and a resident was sitting five feet from the cart. At 9:41 a.m. the medication cart remained unlocked. Two staff members, including a nurse, were observed walking past the cart and not locking it. Photographic evidence obtained. On 8/23/23 at 9:38 a.m., a white, oval tablet was observed on the floor in room [ROOM NUMBER] suite A. Photographic evidence obtained. On 8/23/23 at 9:40 a.m. an observation was made of an orange tablet inscribed with a letter M on the floor in front of the resident's bed in room [ROOM NUMBER] suite B. Photographic evidence obtained. On 8/23/23 at 10:04 a.m., an observation was made of an orange gel tablet in a plastic medication up, stowed inside an open drawer in room [ROOM NUMBER]. Photographic evidence obtained. On 8/24/23 at 10:38 a.m., an observation was made of a white tablet in the doorway of room [ROOM NUMBER]. An immediate interview was conducted with Staff G, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS.) She picked up the tablet and stated she would investigate whose it was and why it was on the floor. She stated she would expect residents to be supervised during medication administration. Photographic evidence obtained. On 8/24/23 at 10:41 a.m., a blue tablet was observed on the floor in the doorway of room [ROOM NUMBER]. An immediate interview was conducted with Staff H, Certified Nursing Assistant( CNA.) He stated he would notify the nurse the tablet was on the floor. He stated when he finds medications unattended, he notifies the Unit Manager. Photographic evidence obtained. On 08/24/23 at 10:52 a.m. an interview was conducted with Staff C, LPN/Unit Manager (UM.) She stated her expectation would be for the nurse to make sure the resident takes their medication. She stated she would expect the nurses to make sure tablets remain in the cup during preparation. She stated she would follow up. On 8/24/23 at 12:01 p.m. an interview was conducted with Staff I, LPN who was assigned the hallway the pills were found. She stated she did not know why the tablets were on the floor. She said, I do not have anything to do with that. How do you know it was my responsibility? Staff I stated she would speak to the Unit Manager. On 8/24/23 at 12.14 p.m., an interview was conducted with the Director of Nursing (DON.) She reviewed the photographic evidence and stated she had instructed the Unit Manager to go through the rooms and make sure there were no medications on the floor. The DON said, We are doing an in-service for nurses to make sure they stay with the resident until they take their medications. On 8/24/23 at 10:28 a.m. an audit was completed on the 2 [NAME] medication cart with Staff K, LPN. The medication cart contained three loose pills, a phone charger, scissors, a sample collection cup, and two cookies. Staff K, LPN said she knows there should not be loose medication in the cart. She also said she does not know who cleans the medication carts. Photographic evidence obtained. On 8/24/23 at 10:45 a.m. an audit was completed on the 2 East medication cart with Staff L, LPN. The top drawer of the medication cart had at least 20 loose pills spilled inside. The bottom drawer had a liquid medication spilled and everything in the drawer was sticky. Behind the bottom medication cart drawer, a medication bubble pack, a box of medication and a loose pill were observed. Two other drawers contained four loose pills, totaling over 26 pills loose in the medication cart. The cart also was used to store a cell phone and a lighter. At interview was conducted with Staff L, LPN at that time. Staff L, LPN said there is no process in place to clean the medication cart and the cart had several things in it that don't belong there. Photographic evidence obtained. On 8/24/23 at 10:53 a.m. an audit was completed of the Unit 2 Medication Storage room with Staff M, Registered Nurse (RN)/UM. The medication refrigerator was observed to have an orange being stored with the medication. The cabinet in the medication storage room was dirty, appeared to have water damage and rust dripping down the cabinet. An interview was conducted with Staff M, RN/UM. She confirmed food should not be in the medication refrigerator and stated staff know that. Staff M, RN/UM said she had never looked in the cabinet to see how dirty it was. Photographic evidence obtained. On 8/24/23 at 11:01 a.m. an audit was conducted on the Unit 1 Center medication cart with Staff N, RN. The cart was being used to store a computer mouse, batteries, a hex tool and rubber bands. An interview was conducted with Staff N, RN. She said she is an agency nurse and doesn't know what the facility does for cleaning carts. Photographic evidence obtained. An interview was conducted with the DON on 8/24/23 at 11:09 a.m. The DON said she had only been in the facility a couple of weeks and had cleaned a couple of medication carts but had not gotten to the others. She said there should be a process in place to clean the carts and she is putting that in place. The DON said she is going to speak to maintenance about power washing the carts. On 8/24/23 at 11:35 a.m. an interview was conducted with the Maintenance Director. He said he was not aware of any leaks or issues with cabinets in the Unit 2 Medication Storage room. He looked at the pictures and said he would take care of it. On 8/23/23 at 11:39 a.m. an interview was conducted with the Assistant Director of Nursing (ADON.) The ADON looked at the picture of the Unit 2 Medication Storage room cabinet and said, That is disgusting. The ADON also said there had not been a process in place to clean medication carts. She confirmed carts should always be locked when unattended. The ADON said there are only six core nurses at the facility and a consultant is going to come and work on a process to clean carts. She said she was aware there had been issues with items being stored in medication carts that do not belong. Review of a facility policy titled Storage of Medications, revised April 2019, showed the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked area, under proper temperature, light and humidity controls. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended. 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.

Based on observations, interviews, and policy review the facility failed to ensure a system was being utilized to accurately account for all controlled substances (narcotics) related to Controlled Drugs Shift Audits not being completed on five out of five medication carts in the facility. Findings included: On 8/24/23 the Controlled Drugs Shift Audits on the 2 [NAME] medication cart were observed to be incomplete. The July 2023 Controlled Drugs Shift Audit form showed 44 out of 62 possible shifts were not signed properly by two nurses when counting narcotics at shift change. The August 2023 Controlled Drugs Audit form showed 36 out of 48 possible shifts were not signed properly by two nurses when counting narcotics at shift change. The Controlled Drug Shift Audit are where the off-going and on-coming nurse sign to confirm together they have counted the narcotics in a medication cart to ensure the number of pills are correct before handing off the keys to the medication cart. On 8/24/23 the Controlled Drugs Shift Audits on the 2 East medication cart were reviewed and observed to be incomplete. The July 2023 Controlled Drugs Shift Audit form showed 54 out of 62 possible shifts were not signed properly by two nurses when counting narcotics at shift change. The August 2023 Controlled Drugs Audit form showed 43 out of 48 possible shifts were not signed properly by two nurses when counting narcotics at shift change. On 8/24/23 the Controlled Drugs Shift Audits on the 1 East medication cart were reviewed and observed to be incomplete. The July 2023 Controlled Drugs Shift Audit form showed 45 out of 62 possible shifts were not signed properly by two nurses when counting narcotics at shift change. The August 2023 Controlled Drugs Audit form showed 39 out of 48 possible shifts were not signed properly by two nurses when counting narcotics at shift change. On 8/24/23 the Controlled Drugs Shift Audits on the 1 Center medication cart were reviewed and observed to be incomplete. The August 2023 Controlled Drugs Audit form showed 43 out of 48 possible shifts were not signed properly by two nurses when counting narcotics at shift change. On 8/24/23 the Controlled Drugs Shift Audits on the 1 [NAME] medication cart were reviewed and observed to be incomplete. The August 2023 Controlled Drugs Audit form showed 48 out of 48 possible shifts were not signed properly by two nurses when counting narcotics at shift change. The form contained no signatures for the month. On 8/24/23 at 10:28 a.m. an interview was conducted with Staff K, Licensed Practical Nurse (LPN.) She stated the Controlled Drugs Shift Audit should be signed by both nurses when narcotic counts are done every shift change. On 8/24/23 at 10:45 a.m. an interview was conducted with Staff L, LPN. She said narcotics counts are done every shift change or anytime there is a change in nurse and the form should be signed by both nurses. On 8/24/23 at 11:09 a.m. an interview was conducted with the Director of Nursing (DON.) The DON confirmed narcotic counts should be completed every shift and both nurses should sign the Controlled Drugs Shift Audit form. She said she does not believe there have been any missing narcotics but she had noticed the forms were not being signed as they should have been. Review of a facility policy titled Controlled Substances, revised August 2019, showed the following: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation 3. Controlled substances to be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, count the controlled substances together. Both individuals sign the designated controlled substance record. 8. Licensed nurses are to count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty count together. They must document and report any discrepancies to the Director of Nursing Services/designee at the time observed. 9. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to ensure one resident (#4) of forty-three sampled residents received timely meal service assistance for two meals (2/21/23 and 2/22/23) of three meals observed. Findings included: On 2/21/2023 at 8:04 a.m. Staff A, Certified Nursing Assistant (CNA) brought a breakfast meal tray into Resident #4's room, placed it on the over bed table and left the room to continue passing trays to other residents. Resident #4 was observed in his bed, lying on his side and facing the wall where his over bed table and meal tray were. The table and tray were out from his reach approximately three feet away and he required eating assistance from staff. Also, the lid/cover was left on the plate. At 8:34 a.m. Staff A returned to the room after passing other meal trays and lifted the lid to the tray, sat down and assisted the resident with eating assistance. He accepted bites of food once the food items were brought to his mouth. It was determined Resident #4 had his meal tray in the room without being assisted from 8:04 a.m. through to 8:34 a.m. (30 minutes). Further, his roommate was served and set up with his meal at 8:03 a.m. and he was eating his meal while Resident #4 had to look on to his own meal and while not able to eat. Resident #4 was not able to be interviewed to ask him about his meal service. On 2/21/2023 at 2:20 p.m. the resident was observed while in his room. Resident was laying on his left side with his knees pulled up toward his chest. Resident was laying on the low air loss mattress with an incontinent pad underneath him. Resident did not appear in any distress nor did he exhibit any pain indicators. Resident had facial hair as well as nose hairs. Resident did state he preferred close shave vs beard when asked. Resident did not have a would vac in the room. On 2/22/2023 at 8:02 a.m. Staff A, (CNA) was observed to take a breakfast tray from the tray cart and placed it in Resident #4's room on the over bed table; which was positioned up against the wall and out from the resident's reach. She left the lid on the plate and walked out from the room to assist with other residents tray pass. Resident #4 was observed with his eyes opened and with his face facing his breakfast meal tray. Resident #4's roommate had already been observed with his breakfast meal tray set up and he was eating. At 8:25 a.m. Staff B, Licensed Practical Nurse (LPN) was observed to park a medication cart just outside Resident #4's room. She prepared a medication at the cart and went into the room and provided the medication to the resident's roommate. She left the room at 8:26 a.m. as Staff B was observed preparing medications for Resident #4 in the hallway, at 8:28 a.m. Staff A (CNA) walked to the door way, sanitized her hands, knocked and went into the room and stated, Hello Mr. #4, are you ready for me to help you? The resident could not be heard verbalizing back to Staff A. Staff A brought over a metal chair to the bedside and began to lift the lid to the meal tray at 8:29 a.m. It was determined when Staff A loaded an eating utensil with food, the resident immediately accepted and took bites. It was determined the meal was placed in his room, out from his reach and with the lid on from 8:02 a.m. through to 8:29 a.m., (27 minutes). An interview at 8:30 a.m. with Staff A, revealed she did drop off the meal tray and left the room to assist passing out all the other trays. She confirmed it takes her a little bit to get back to the room as the resident requires Eating assistance with all meals. She revealed Resident #4 is on her assignment routinely but not all the time. She was aware Resident #4 requires full eating assistance and that he cannot eat on his own. She confirmed the tray was left in the room, and while the roommate was eating for a long period of time; the tray would have been better kept in the covered/enclosed tray cart, rather than the meal having a chance to cool faster by leaving it in the room. She revealed the staff had been made aware of this in the past but sometimes they just get used to passing the trays to residents who require eating assistance and then coming back at a later time. On 2/21/2023 at 10:00 a.m. an interview with Staff D, Licensed Practical Nurse (LPN), and who was the second floor Unit Manager, as well as interview with Staff E, (LPN), both revealed during meal tray pass, all staff are to pass meat trays to residents timely and the residents who require Eating assistance, are to be served generally last, because staff have to be seated with them during the entire meal service. Staff D revealed it may not be a good idea to just place trays in the room with the lid on and leave the room to come back later. She confirmed a resident should not have to look at their meal tray for long periods of time and not being helped, and meal trays should not be left in the room even with the lid on for long periods of time as the food could get cold. Staff D and E both confirmed Resident #4 was not able to eat on his own, required full assistance from staff for Eating Activities of Daily Living (ADL), and was not able to speak with regards to his care and services. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. A review of the advance directives revealed he had a Power of Attorney in place, who was a family member. A review of the diagnosis sheet revealed diagnoses to include but not limited to: Cerebrovascular disease, Parkinson's disease, convulsions, Schizoaffective disorder, dysphagia, cognitive communication deficit, major depression, psychosis, dementia, anxiety, Bipolar Disorder, and cerebral ischemia. A review of the current Minimum Data Set (MDS) assessment (5 day), dated 12/31/2022, revealed; (Cognition/Brief Interview Mental Score or BIMS score = 4 of 15, which indicated the resident was not able to make his medical or care needs); (Activities of Daily Living ADL - EATING = One person physical assist. A review of various nurse progress notes revealed the following: a. 2/27/2022 12:35 p.m. - New admit day 1. Requires total assist with meals/hydration and ADLs. b. 12/31/2022 12:29 p.m. - Good appetite fed x 1 assist. c. 1/14/2023 05:47 p.m. - Resident in bed fed x 1 with good appetite. d. 1/15/2023 02:27 p.m. - Resident stayed in bed throughout the shift. Resident is totally dependent on staff for completion of ADLs. e. 1/25/2023 07:09 p.m. - Resident continues to be fed x 1 assist with good appetite. f. 1/29/2023 12:06 p.m. - Good appetite good fluid intake fed x 1. g. 2/20/2023 06:07 p.m. - Fair appetite good fluid intake, fair appetite good fluids intake assist x 1 for meals. A review of the current care plans with next review date 4/5/2023 revealed the following pertinent problem areas: - Resident #4 has potential for nutrition risk related to dx (diagnosis). history of Cerebrovascular dx. Parkinson's, Schizoaffective disorder, Dementia, Sacral Stage IV pressure ulcer, need for mechanically altered diet, with interventions in place as reviewed, to include but not limited to: Provide diet and supplements as ordered, and assist with meal set up/intake as necessary. On 2/23/2023 at 3:00 p.m. the Nursing Home Administrator provided the Quality of Life - Dignity policy procedure with last revision date 2009, for review. The policy revealed; Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The Policy Interpretation and Implementation section revealed the following but not limited to: 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. On 2/23/2023 at 3:00 p.m. the Nursing Home Administrator provide the Assistance with Meals policy and procedure, with a revised date 2107, for review. The policy revealed; Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The Policy Interpretation and Implementation section revealed the following but not limited to: Resident Confined to bed: - The food service department will deliver food carts to appropriate areas - The nursing staff will prepare residents for eating. - The nursing staff and/or feeding assistants will take food trays into residents' rooms. Residents Requiring Full Assistance: - Nursing staff will remove food trays form the food cart and deliver the trays to each resident's room. - Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure an assessment for self-administration of medications was completed for two residents (#44 and #88) out of the 28 residents observed on the west hall of the first floor. Findings included: On 2/20/23 at 11:12 a.m., a bottle of eye drops was observed on the over-the-bed table in front of Resident #44 as the resident lay in bed. The resident stated the family provided them, they (the drops) were over on the counter and were used once a day. A review of Resident #44's physician orders, on 2/20/23 at 11:35 a.m., revealed the resident did not have an order to self-administer eye drops. The review of the assessments completed for the resident did not indicate the resident had been evaluated for the self-administration of medications. An observation on 2/22/23 at 12:08 p.m., was conducted with Staff N, Assistant Director of Nursing (ADON) of a bottle of eye drops and a tube of deep penetrating pain relief gel on Resident #44's over-the-bed table. Resident #44 reported the resident applied the gel a couple times a day on neck for arthritis. The staff member removed the eye drops and tube of gel from the residents room and at the nursing station reviewed the residents' physician orders confirming the resident did not have an order for the self-administration of medications. A review of Resident #44's facesheet indicated the resident was admitted on [DATE] and included diagnoses not limited to unspecified dementia, left hip unilateral primary osteoarthritis, and hypertensive heart disease without heart failure. A review of Resident #44's physician active orders for 2/2023, identified the resident did not have an order for any type of eye drops or any type of topical pain relief gel. The care plan for Resident #44 identified the resident was at risk for pain and discomfort and the goal was for the resident to express relief of pain after the administration of pain medication. The interventions related to the residents' pain and discomfort was for nursing to administer pain medication. The care plan did not include an intervention for the self-administration of medications. An observation was conducted on 2/20/23 at 9:58 a.m., of a brand name respiratory inhaler and a bottle of eye drops lying on the bedside dresser of Resident #88. A review of Resident #88's physician active orders for 2/2023, identified the resident had neither an order for a respiratory inhaler, eye drops, or an order allowing the self-administration of medications. The clinical record of the Resident #88 did not indicate the resident had been assessed for the ability to self-administer medications. An observation on 2/22/23 at 10:16 a.m., identified both the bottle of eye drops and inhaler were lying on top of Resident #88's bedside dresser. The resident stated the inhaler was administered twice a day without staff. An interview was conducted on 2/22/23 at 11:59 a.m., with Staff M, agency Licensed Practical Nurse (LPN). The staff member stated the residents are allowed to self-administer if there is a (physician) order for it. Staff N stated the residents are allowed to self-administer after they are assessed and able to return demonstrate. Staff N confirmed Resident #88 did not have an order to self-administer. An observation, on 2/22/23 at 12:04 p.m. was conducted of Resident #88 with Staff N. The resident stated the Albuterol inhaler and eye drops were from an outside pharmacy from the insurance company. The staff member removed the medications from the room and confirmed Resident #88 did not have an order for either medication. A review of Resident #88's facesheet identified the resident was admitted on [DATE] and diagnoses included but not limited to unspecified low back pain, acute pain due to trauma, other specified anxiety disorders, unspecified insomnia, and unspecified depression. The facesheet did not indicate the resident had any respiratory diagnoses. The care plan for Resident #88 did not include any intervention related to the ability to self-medicate and did not indicate the resident had any respiratory issues. The Director of Nursing stated, at 1:19 p.m. on 2/22/23, the residents should be assessed prior to being allowed to self-administer (medications). On 2/22/23 at 2:25 p.m., the Nursing Home Administrator (NHA) stated the facility was unable to locate a self-administration evaluation for Resident #44 and Resident #88 in the computer or the to be filed area. The policy titled, Self-Administration of Medications, revised December 2016, identified the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy identified the following: - 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. - 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: --a. Ability to read and understand medication labels; --b. Comprehension of the purpose and proper dosage and administration time for his or her medications; -- c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and --d. Ability to recognize risks and major adverse consequences of his or her medications. - 5. The staff and practitioner will document their findings and choices of residents who are able to self-administer medications. - 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. - 9. Staff shall identify and give to the Charge Nurse any medication s found at the bedside that are not authorized for self-administration, for return to the family or responsible party. - 13. The staff and practitioner will periodically (for example, during quarterly Minimum Data Set (MDS) reviews) reevaluate a resident's ability to continue to self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to do an ongoing re-evaluation of the need for a restraint for one resident (#43) out of one resident with a restraint. Findings included: An observation was made on 02/20/23 at 10:40 a.m. Resident #43 was observed to be in the common room sitting inside a PVC (lightweight plastic tubing) rolling chair, that wraps completely around the resident's waist and between her legs (known as a merry walker). A review of Resident #43's facesheet revealed she was admitted to the facility on [DATE] with medical diagnoses which include but not limited to unspecified dementia without behavioral disturbances, anxiety disorder due to known physiological condition, unspecified mood disorder, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, delusional disorder, muscle weakness, abnormalities of gait and mobility, difficulty in walking, unsteadiness on feet, lack of coordination, and a history of falling. A review of Resident #43's physician orders revealed orders with a start date of 12/2/22 check function of merry walker Q [every] shift. Every day. Another order with a start date of 12/2/22 Resident to be OOB [out of bed] in merry walker when awake *monitor resident for sleepiness, place resident to bed when drowsy for a time of Shift A (7:00a.m.-7:00p.m.) every day. A review of Resident #43's Minimum Data Set, section C, which was undated revealed her Brief Interview for Mental Status score was 1 out of 15 indicating severe cognitive impairment. A review of Resident #43's restraint care plan with a start date of 11/23/2022 revealed Restraint: [Resident #43] need to move and loves to walk. She becomes agitated and unhappy when not able to ambulate. She is unsteady and will fall without support the merry walker is used as a solution due to falls and unsteadiness for (the resident's) happiness, quality of life and psychosocial wellbeing and activity. Resident unable to exit the merry walker without assistance. Resident/Representative was involved/informed of this Care Plan. Care Plan Goal: Safe use of restraint/merry walker to enhance ambulation through the review date. Intervention: Check device daily for condition status; Ambulate in hallway with merry walker and to meals daily as desired/required; 1:1 while merry walker is broken and in regular wheelchair due to high galls risk. A review of Resident #43's medical record was conducted and there was no evidence of a quarterly assessment for restraint use. A review of Resident #43's Physical Restraint Record of Informed Consent dated 6/2/21 revealed . After careful consideration of the information provided to me, I hereby: [handwritten] merry walker Give permission for the use of restraints as established in the facility's restraint policies and procedures. .Resident unable to sign consent. Two nurses signed the document and hand written on the document revealed verbal from [family member name and telephone number] was giving consent and aware since she got the merry walker on 10/20/20. An interview was conducted on 02/22/23 at 11:47 a.m. with the Nursing Home Administrator (NHA) she said we talked about it, and we are supposed to have quarterly assessment for her merry walker but our system does not have an assessment for that. We do quarterly assessments with the care plan so I can see if we discussed it with the family and documented it there. An interview was conducted on 02/22/23 at 12:55 p.m. with the Director of Nursing and she confirmed Resident #43's merry walker is a restraint and there should be quarterly reviews related to the merry walker. A review of the facility's Use of Restraints policy revised on April 2017 revealed the following: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident(s) medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation 1. physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the residence body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one 's body. 2. The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. .5. Restraints may only be used if/when the resident has s specified medical symptom that cannot be addressed by another less restrictive intervention AND a restrain is required to: a. Treat the medical condition b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well-being. .9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restrain (as it related to the resident's medical symptoms); b. How the restrain will be used to benefit the resident's medical symptom; and c. The type of restrain, and period of time for the use of restraint. .11. Reorders are issued only after a review of the resident's condition by his or her physician. .16. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to 1) develop a baseline care plan within 48 hours of admission; and 2) provide a written summary of the baseline care plan to the resident/resident representative for two residents (#367 and #214) out of 43 sampled residents. Findings included: The facesheet for Resident #367 indicated the resident was admitted for short term rehabilitative care on 10/1/22 and was discharged on 10/7/22. The facesheet included diagnoses not limited to unspecified osteomyelitis, Type 2 Diabetes with foot ulcer, and personal history of unspecified adult abuse. The progress notes for Resident #367 indicated a note on 10/1/22 at 6:59 p.m., that identified the resident arrived via wheelchair transport with an admitting diagnosis of exostectomy of left foot with wound vacuum (vac). The admission Data Collection Tool was completed at 3:12 p.m. on 10/3/22. The baseline care plan for Resident #367 was not available in either the closed record or the electronic clinical record. The facility provided an undated copy of the Baseline Care Plan that identified the resident was admitted on [DATE]. The care plan indicated in box #62 Signatures of Interdisciplinary Team Members Contributing to Baseline Care Plan was empty, box #63 Written Summary of Baseline Care Plan was empty, box #65 Baseline Care Plan Completion Date was empty, and box #66 Date reviewed with Resident/Representative was written, Resident left to go home 10/7/22. The Comprehensive Care Plan, located in the electronic record, included one care plan description that indicated Resident #367 had a potential for imbalanced nutrition/hydration related to diagnosis of osteomyelitis, anxiety, hypertension, generalized weakness, Diabetes Mellitus, neuropathy, Charcot foot deformity, partial left foot amputation (9/23/22), right foot toe amputation, wound vac in place for healing, often requests alternate meals as desires, multiple sugar free drinks/snacks at bedside, overweight. The care plan identified the resident/representative was involved/informed of this care plan that was started on 10/6/22. On 2/22/23 at 11:04 a.m. the Nursing Home Administrator (NHA) provided the baseline care plan for Resident #367 and indicated they were done on paper. The NHA stated the care plan had been received from Staff P, a sister facility NHA who was in the building assisting. On 2/22/23 at 12:50 p.m., Staff P stated she had obtained the baseline care plan for Resident #367 from Minimum Data Set (MDS) in the to be filed file. The staff member stated the facility had identified issues with baseline care plans and the plans should be completed within 48 hours. The baseline care plan was reviewed with the staff member and identified it did not include a completed date, did not identify who had completed the care plan or if the resident had received a copy. Staff P confirmed the admission Data Tool was completed 2 days after the resident had arrived at the facility. Resident#214 was admitted to the facility on [DATE] with multiple diagnose but not limited to pneumonia with antibiotic treatment. Resident is alert and oriented with a BIMS of 13 indicating cognitively intact. A review of Residnet#214 medical record was conducted which revealed a Baseline Care Plan dated 10/5/2022 started at 4:19 PM and completed at 4:21 PM with no input from the resident/family or Interdisciplinary Team (IDT). There was no indication in the medical record the resident or family had received a copy of the summary of the Baseline Care Plan. On 02/22/23 at 12:49 PM. An interview was conducted with the visiting Nursing Home Administrator from the sister facility who stated they realize there is a problem with the facility base line care plans. On 02/22/23 at 1:11 PM an interview was conducted with the Director of Nursing. She was asked to review the Baseline Care Plan and the medical record for Resident #214 for any documented evidence that the resident/family, IDT or physician participated in the Baseline Care Plan. She confirmed she would expect to see documentation in the medical record as to the participants which should include the resident/family and IDT members as well as documentation indicating the resident received a copy of the summary of the Baseline Care Plan. The facility omitted any documentation regarding the participation of the required individuals. A review of the facility policy titled Care Plans- Baseline indicated the following: #4. The resident and their representative will be provided a summary of the baseline care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of Resident #55's facesheet revealed he was admitted to the facility on [DATE] for long term nursing care. He was admitted with diagnosis that include but are not limited Type 2 Diabetes Mellitus with hyperglycemia. A review of Resident #55's physician orders revealed an order to start on 2/3/23 for sliding scale: Level 2-Novolin N Subcutaneous Suspension 100 unit/ML 0-150=No coverage 151-199=1 unit 200-249=2 units 250-299=3 units 300-349=4 units 350 or greater-5 units and call MD [medical doctor] A review of Resident #55's care plans did not reveal a care plan for his diabetes and insulin use. On 2/23/23 at 2:3pm. an interview was conducted with the Nursing Home Administrator (NHA) she confirmed the resident does not have a care plan related to his diabetes diagnosis. An interview was conducted with Resident #103 on 02/20/23 at 9:55 a.m. she said I am a smoker; I sleep with my most important items like my lighters because they keep getting stolen. I keep my important items in my bag and I sleep with it because if you get caught with cigarettes and lighters they will take them away from you. You can go get your smoking stuff from the desk if you want. One night I got caught smoking in my room. They are not happy with me because I was smoking in my room, but I thought I was at home and they told me I can't smoke in the room. An interview was conducted with Resident #103's roommate and she said on 02/20/23 at 9:57 a.m. She smoked in this room with me in it and they caught her and they told her she cannot do that. Neither resident was observed to be on oxygen. A review of Resident #103's facesheet revealed she was readmitted from an acute care hospital on 2/8/2023 with diagnoses that included but are not limited to muscle weakness, difficulty in walking, need for assistance with personal care, encounter for surgical aftercare following surgery, congestive heart failure, chronic kidney disease, acute kidney failure, Type 2 Diabetes Mellitus, Sarcopenia, convulsions, intervertebral disc degeneration, lumbar region, disorders of bone density and structure, benign neoplasm of left adrenal gland, occlusion and stenosis of bilateral carotid arteries, and occlusion and stenosis of left vertebral artery. A review of Resident #103's Minimum Data Set (MDS), section C, dated 12/8/2022 revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating no cognitive impairment. A review of Resident #103's care plans did not reveal a smoking care plan with appropriate interventions. An interview was conducted on 02/22/23 at 9:47 a.m. with Staff B, Agency Registered Nurse (RN). She said I did hear about her (Resident #103) smoking in her room in report. I think it was last week that I heard about it. Now what day and time that happened I'm not sure. But we had an agreement with her that she needs to return her lighters to us or if we find them, we need to take them from her and she would sometimes be good about giving us her lighters. It looks like on December 2nd she went out for a seizure and came back so her smoking assessment was on her original admission stay. She was discharged yesterday. An interview was conducted on 02/22/23 at 10:04 a.m. with Staff N, Assistant Director of Nursing (ADON) she said, I did not know anything about her (Resident #103) smoking. We have a safe smoking assessment that we do upon admission. Therapy will also do an assessment to determine if they are a safe smoker and if they are then they can smoke and if they are not then unfortunately, they cannot smoke. I did not know she was a smoker, we do not have her as a smoker. Staff B, ADON reviewed her safe smoking evaluation and she stated the smoking assessment was from her original admission and it says that she is not a smoker. An interview was conducted on 2/23/23 at 1:11 p.m. with Staff R, Occupational Therapist (OT) she stated when she performs a smoking assessment her role is to conduct orientation questions like if they have oxygen, and if they can manage their oxygen line, do they know to take it off before they smoke, then I asses their fine and gross motor skills, I ask them to show me how to manipulate the lighter and show me how they put it out. I also look at their functional abilities, do they know how to get to the smoking patio safely, self-propel, open the door, get up to the table, lock their breaks. She stated, from there she determines if they are safe to go out on their own to the patio independently or if they are going to need someone to assist in smoking. When Resident #103 was originally here she was not a smoker she did not go out and smoke. On the day she discharged from therapy she was sent out to the hospital either that day or the day after. Then she came back, and we did have her on therapy and we found out that she was going out on the patio and getting cigarettes from the other residents and I was told to go out and do a smoking assessment on her so that's when I did that on the 16th. I did not hear she was smoking in her room. I don't educate them on where to keep their smoking materials that might be a nursing thing, I just assess their abilities to smoke safely and if they are independent or need assistance. It's my understanding that the resident can keep all their smoking materials on them. A review of Resident #103's Safe Smoking Evaluation dated 12/3/2022 revealed Family or Medical Representative informed of smoking policy restrictions-Comment N/A [not applicable] nonsmoker. A review of Resident #103's therapy smoking assessment titled Screening for Smoking Privileges dated 2/16/23 . Assessment Pt [patient] demonstrates good safety measures and judgment; able to safely manipulate smoking materials. Her cognition has improved as she is able to recall safety steps with smoking. Results: smoke independently signed and dated by Staff R, OT On 02/22/23 at 12:55 p.m. an interview was conducted with the Director of Nursing (DON). She said everyone is supposed to get a smoking assessment on admission regardless of if they smoke or not. For smokers, therapy does dexterity assessments to determine safe smoking and then there is a nursing smoking assessment. Nursing is supposed to observe the smoking, make sure they can get to the smoking's area safely and ensure they are safe to smoke. I just learned today Resident #103 smoked in her room. Before she went to the hospital she was not going out to smoke. I'm not sure what happened after she returned from the hospital. The smoking assessment should have been redone when she returned from the hospital. We have liberalized smoking so, the residents are educated on where to smoke, assessed to be a safe smoker and they are able to keep their materials on them. They should also be care planned for smoking as well. Based on observations, record reviews, and interviews the facility failed to develop and implement care plans for three residents (#69, #55, and #103) of forty-three sampled residents. It was determined care plans were not developed and implemented related to dental/oral status for Resident #69, diabetic diagnosis and care for Resident #55, and smoking/ smoking safety for Resident #103. Findings included: On 2/20/2023 at approximately 2:00 p.m. Resident #69's was observed in the room with a family member. An interview with Resident #69's family member revealed she was the resident's Power of Attorney and makes medical decisions, but Resident #69 could make her daily choice decisions. Resident #69 was observed in her bed, and with head of the bed approximately forty-five degrees and the call light placed within her reach. The resident was observed in a private room, her television on, the over the bed table placed over her, with many personal belongings on it and all within her reach. Resident #69 was not presenting with any behaviors and was pleasant to speak with. Resident #69 allowed an interview and she and her family member explained there had been some dental issues. They stated her partials did not fit right, she had lost some back teeth recently and she had some broken teeth as well. The resident opened her mouth and there were several teeth that appeared broken with sharp edges. The upper partial appeared to be ill fitted, causing discomfort. Resident #69 and her family member both revealed the Dentist came in some time ago (neither could remember exactly how long ago), supplied her with the partials and has not returned. Resident #69's family member believed the Dentist was there maybe two months ago, in 12/2022. Resident #69 indicated her partial did not fit right, due to her losing more teeth since his last visit. She and her family member revealed they had spoken to nurses and aides (no names were provided) many times about getting the Dentist to return. Resident #69 and her family member both revealed staff have not followed up with her yet, and the nurse knows on a daily basis of her mouth discomfort. Resident #69 and her family member could not remember how long ago the Dentist or oral hygienist provided a visit and assessment and care to her. On 2/23/2023 at 7:15 a.m. Resident #69 was noted in room and in bed and dressed for the day. She was awaiting to be assisted to the dialysis center for her routine care. She had no complaints and indicated her pain level was low and staff provided medications per her request. She also revealed she did not have any chewing or tooth pain so far, but still had discomfort from the partial. On 2/23/2023 at 1:50 p.m. another interview with Resident #69 revealed she was not in any pain and did not want to cause any problems with staff. She revealed she feels guilty having to tell staff every day she is in pain and it gets tiring. She did confirm staff do provide her with relief medications when she has pain, but it is just a matter of her being tired of having to tell people every day. She wanted to ensure it was not the staff, but rather her just having a problem of having pain every day and feels she bothers the staff with it too much. The resident did appear during this observation free from any pain, behaviors, and discomfort. Resident #69 confirmed her mouth was in some discomfort, but not in any pain. Her call light was placed within her reach. A review of Resident #69's medical record revealed she was admitted on [DATE]. A review of the advance directives revealed the resident had a decision maker in place who was a family member. A review of the diagnosis sheet revealed diagnoses to include but not limited to: dysphagia, hemodialysis, pain, End Stage Renal Disease. A review of the most current Minimum Data Set (MDS) Quarterly assessment, dated 11/25/2022, revealed: (Cognition/Brief Interview Mental Status or BIMS score - 15 of 15, which indicated the resident was able to speak about her daily choices and decisions); (Activities of Daily Living ADL - EATING = Independent set up only); (ORAL = Checked for swallow disorder); (HEALTH CONDITION = Pain, with assessment should be completed). A review of the assessments revealed the following: : - admission Data Collection dated 9/13/2022 revealed: Does not have any obvious dental concerns during the time of assessment; Number of upper teeth = unable to tell; Number of lower teeth = unable to tell; Does resident wear dentures = No. - Social Service Review dated 11/25/2022 revealed: Comment = Some natural teeth, Referrals needed = Dental. Review of the current care plans with a last review date of 12/17/2022 revealed problem areas to include: - Pain risk for pain and discomfort, with interventions in place as reviewed. However, nothing was documented related to dental or oral pain status. A review of the last dental visits from Dentist and Hygienist dated 10/25/2022, and 12/19/2022 both indicated resident evaluated with sharp tooth but no pain or discomfort and to encourage to notify if any pain and that upper partial is in good condition at this time. Another dental visit dated 2/6/2023 indicated prophylaxis visit and no complaints with regards to her natural teeth and with moderate soft deposits. No other concerns noted. It was determined through the last Dentist assessment/review on 2/6/2023, there were no complaints made by Resident #69 with regards to ill fitted partials. However, since 10/25/2022, it had been evaluated that Resident #69 had sharp teeth. Further, a Social Service note dated 11/25/2022 revealed some natural teeth, and there was a need for a dental referral. This would indicate Resident #69 had a need to be care planned with problem areas, goals, and interventions with relation to Dental/Missing teeth/Oral care. A review of the current care plans revealed no such problem areas, nor any interventions that would accommodate Resident #69's dental needs. On 2/22/2023 at 1:00 p.m. an interview with Staff C, Social Worker Director revealed she has not been notified by the family member or resident to have a dental visit nor gave any indication of pain or discomfort with her teeth or partials. She will follow up immediately and have a visit. On 2/23/2023 at 1:15 p.m. an interview was conducted with the Minimum Data Set (MDS) coordinator. She reviewed Resident #69's medical record and she confirmed there were areas to include past notes and assessments in months 10/2022, 12/2022 and 2/2023 indicating Resident #69 had dental problems, missing teeth and that a care plan should have been developed to specify a dental problem area, with interventions and goals to ensure her mouth partial fitted correctly, to ensure mouth comfort, mouth care, staff monitoring and continued dental visits. The MDS Coordinator Indicated they had been short an MDS employee as of late and it had been difficult trying to catch up with care planning. The MDS coordinator confirmed Resident #69 should have had a Mouth/Dental/Oral care plan since at least 10/2022. On 2/23/2023 at 3:00 p.m. the Nursing Home Administrator provided the Care Planning - Interdisciplinary Team policy and procedure, with last revision date September 2013, which revealed the following: Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident (MDS). 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: (d.) The Social Services Worker responsible for the resident. (g.) Consultants (as appropriate). On 2/23/2023 at 3:00 p.m. the Nursing Home Administrator provided the Using the Care Plan policy and procedure, with last revised date of August 2006, for revealed: Policy Statement: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care and services to the resident. Policy Interpretation and Implementation: (1.) Completed care plans are placed in the resident's chart and /or in a 3-ring binder located at the appropriate nurse's station. (2.) The Nurse Supervisor uses the care pan to complete the CNA's daily/weekly work assignment sheets and/or flow sheets. (3.) CNAs are responsible for reporting to the Nurse Supervisor any changes in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved. (4.) Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and/or the MDS Assessment Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility did not ensure 1) a discharge care plan was in place, 2) a discharge summary was completed, and 3) post care discharge plans were documented for two residents (#112 and #113) out of three residents sampled for discharge. Findings included: A review of a document titled, Face Sheet, printed on 2/22/23 showed Resident #112 was admitted to the facility on [DATE] and was discharged on 11/27/22. The document showed under discharge status the resident's return was not anticipated. The document did not indicate where the resident was discharged to. A review of a document titled, Physician Orders List, dated 11/17/22 showed there were no discharge orders for Resident #112. A review of a care plan with a start date of 11/22/22, noted active on discharge, showed Resident #112 did not have discharge planning goals indicated. A review of a document titled, Face Sheet, printed on 2/22/23 showed Resident #113 was admitted to the facility on [DATE] and was discharged on 1/12/23. The document showed under discharge status, the resident's return was not anticipated. The document did not indicate where the resident was discharged to. A review of a document titled, Physician Orders List, dated, 2/2/22 to 2/22/23, showed there were no discharge orders for Resident #113. A review of a care plan with a start date of 7/11/22, status, active on discharge, showed Resident #113 did not have discharge planning goals indicated. On 02/22/23 at 01:14 p.m., an interview was conducted with Staff L, Minimum Data Set (MDS) coordinator. She stated the care plan is completed by nursing, MDS and Social Services Director (SSD). She reviewed Resident #112 and 113's care plans and stated they did not have a discharge plan. Staff L stated the SSD does discharges, care planning goals and discharge summary. On 02/22/23 at 01:36 p.m., an interview was conducted with Staff C, SSD. She stated they start discharge planning upon admission. Staff C stated she finds out the resident's goals through the resident and/or the family and uses that information to initiate discharge planning process. Staff C stated during their stay, she maintains their progress goals in the care plan and continues to work with the resident and/family to make ensure they are meeting the goals. Staff C stated upon discharge, she completes a discharge summary. On 02/22/23 at 02:57 p.m., a follow-up interview was conducted with Staff C, SSD. She stated she did not have a discharge care plan in place for these residents [Resident #112 and #113]. Staff C said, it should have been there. We should be documenting resident's discharge goals from admission, during stay, all the way to the end. Staff C confirmed a discharge summary should have been documented to indicate where the resident went and their aftercare plan. A review of an undated document presented by Staff C,SSD showed, Resident #112 did not have a discharge care plan and was transferred to a hospital. Resident #113 did not have a discharge care plan and was transferred to another skilled nursing facility (SNF). A review of a facility policy titled, discharge summary and plan, dated, December 2016, showed when a resident's discharge is anticipated, and a discharge summary and post discharge plan will be developed to assist the resident to adjust to his or her new living environment. When the facility anticipates a resident's discharged to a private residence, another nursing care facility a discharge summary and a post discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The discharge summary will include recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and there's permitted by the resident. the discharge summary shall include a description of the residence currents diagnosis, medical history, course of illness, treatment and or therapy since entering the facility; current labs and diagnostic test results, physical and mental functional status, ability to perform activities of daily living, sensory and physical impairments, nutritional status and requirements, special treatments or procedures, mental and psychosocial status, discharge potential, dental condition, activities potential, and rehabilitation potential. a copy of the following will be provided to the resident and receiving facility and a copy will be filed in the residence medical record a. an evaluation of the residents discharge needs. b. the post discharge plan. c. the discharge summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one resident (#4), who was dependent on staff for Activities of Daily Living (ADL's), received shaving and hair care assistance out of forty-three residents sampled. Findings included: On 2/20/2023 at approximately 10:00 a.m. Resident #4 was observed in his room lying in bed on his right side. Resident #4 was noted with hair appearance as greasy/oily and disheveled. His entire neck, and both sides of his cheeks, as well as his chin and upper lip area was observed with heavy stubble. It appeared as though he had not been shaved in several days or more. Resident #4's nostrils were observed with large amounts of hair protruding out at least a ¼ to ½ inch. The resident was not able to answer questions about his daily medical care and services. On 2/21/2023 at 8:00 a.m. just before being served his breakfast meal, Resident #4 was observed lying in bed on his back with the call light placed within his reach. His eyes were open and he was staring at the wall. His hair appeared with the same oily greasy and disheveled appearance. He again did not appear shaved and was with heavy neck, and face stubble. His nostrils were still observed with large amounts of long hair protruding out at least ¼ to a ½ inch. On 2/21/2023 at approximately 11:00 a.m. an interview with the resident's family member, who was his Power of Attorney, revealed he visits Resident #4 about once every ten days as of recent but used to visit at least twice a week in the past. Resident #4's family member revealed every time he visits, he finds staff do not shave him, his hair looks a mess, and greasy and not combed. He revealed he had spoken with both aides who had come in the room and also had spoken with the nurses. He revealed Resident #4 had always shaved and kept his hair neat and staff are not honoring that choice. Resident #4's family member revealed he had lodged a complaint but does not know how far up the chain that went and had not heard back from any staff members as of yet, and this complaint had been voiced maybe a month ago. Resident #4's family member had also notice his nostril hair very long and bushy, coming out of his nose. On 2/21/2023 at 2:20 p.m. Resident #4 was observed in his room and lying on his side in bed. He was noted with the covers pulled up to his neckline and with his eyes open. The resident did not communicate back after this surveyor re-introduced himself. Resident #4 again did not appear to be shaven, his nostril hair was still very long, bushy and coming out from his nose. His face and neck still had not been shaved and his hair was still observed oily/greasy and not combed. On 2/22/2023 at 8:02 a.m. a Staff A. was observed taking a breakfast tray from the tray cart and placing it in the resident's room on the over bed table, which was positioned up against the wall and out from the resident's reach. She left the lid on the plate and walked out from the room to assist with other resident tray pass. Observations revealed Resident #4's hair was not combed and appeared very oily, resident's face to include his cheeks, neck and nose hair were not groomed. Extensive nose hair and resident has not been shaven. An interview at 8:30 a.m. with Staff A revealed Resident #4 does require ADL assistance to include: Eating, Bathing/Showering, Dressing, Transferring and Toileting. Staff A revealed the Resident #4 does have a shower schedule and he at times does not want to be showered. She was asked if that is ever documented when he refuses. She revealed she documents but was not aware if other staff document it. Staff A was not aware if there was any care plan problem areas that reflected Resident #4 has behaviors of refusing showers/bathing, hair care, and shaving. On 2/23/2023 at 8:17 a.m. Resident #4 was observed in his room and lying in bed. He had not received his breakfast meal tray as of yet. He was further observed still not shaven, hair disheveled, and with nostril hair still long and coming out from both nostrils about ¼ to ½ inch. He appeared to not have been shaven for many days and had not been shaven by way of observation at least three days since first observed on 2/20/2022. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. A review of the advance directives revealed he had a Power of Attorney (POA) in place, who was his family member. A review of the diagnosis sheet revealed diagnoses to include but not limited to: Cerebrovascular disease, Parkinson's Disease, convulsions, Schizoaffective disorder, abnormal posture, cognitive communication deficit, major depression, psychosis, dementia, anxiety, repeated falls, Bipolar Disease, and cerebral ischemia. A review of the current Minimum Data Set (MDS) assessment, 5 day, dated 12/31/2022 revealed; (Cognition/[NAME] Interview Mental Status or BIMS score - 4 of 15, which indicated resident was not able to speak with relation to his daily care and service needs); (Activities of Daily Living ADL - BED MOBILITY = Total Dependence on staff 2 person, EATING = One person physical assist, BATHING = Total Dependence on staff 1 person, SHOWER/BATHING = Dependent on staff, PERSONAL HYGIENE = Total dependent on staff 1 person assist. On 2/22/23 at 3:50 p.m. Staff B. (Licensed Practical Nurse), explained the CNAs document in the shower book. She then provided the shower book for review. The book was in date order. The shower book had the floor schedule on the back. Resident #4 shower schedule indicated his room is scheduled for Monday/Thursday, 7am-3pm. In review of the shower book only a few shower sheets for Resident #4. Staff B indicated the CNA is supposed to complete a sheet on all showers completed and/or refused, that way she is able to document information or refusal. Staff B looked in several places she thought the shower sheets could be at the nurses station, she went through stacks of paper that were in the file bin. She stated that she did not see any more shower sheets for Resident #4. A review of the shower schedule, as listed in the Shower Book; which was located at the second floor nurse station, revealed resident's normal shower schedule dates were Monday's and Thursday's, and to be completed during the 7-3 shift. The shower book contained completed shower sheets that were dated 1/2/2023 (yes for shave, hair shampoo), 1/19/2023 (yes for shave, nails, shower, hair shampoo), 1/23/2023 (nothing checked), 2/23/2023 (no to shave, yes to nails, hair shampoo), 2/6/2023 (yes nails, hair shampoo and, shave). Photographic evidence taken. A review of the actual completed shower sheets for Resident #4, revealed only the following documents for the last two months (1/2023 and 2/2023): - Shower/Skin sheet dated 1/2/2023 indicated resident was shaved and with hair shampoo. - Shower/Skin sheet dated 1/19/2023 indicated resident was shaved and with hair shampoo. - Shower/Skin sheet dated 1/23/2023 revealed there was no indication resident was shaven or had hair shampoo. There were no notes to indicate the resident refused. - Shower/Skin sheet dated 2/06/2023 revealed resident was shaved and with hair shampoo. - Shower/Skin sheet dated 2/23/2023 revealed resident was not shaved and with hair shampoo. There was no evidence the resident refused shave. It was determined through the Shower/Skin sheets review, the following dates indicated showers/shaves were not performed as scheduled for Resident #4: 1/5/2023, 1/9/2023, 1/12/2023, 1/16/2023, 1/26/2023, 1/30/2023, 2/2/2023, 2/9/2023, 2/13/2023, 2/16/2023, and 2/20/2023. Of the last two months (1/2023, and 2/2023). Interviews with both the Staff D, (Second Floor Unit Manager), and the Director of Nursing, confirmed there was no evidence Resident #4 had shower and or shaves for the above dates indicated. They further confirmed Resident #4 does not refuse showers/bed baths/shaving, and there are no care plans that indicate a behavior of refusing care, services, and personal hygiene. A review of nurse progress notes revealed the following: (a.) 12/27/2022 12:35 p.m. - New admit day 1. Requires total assist with meals/hydration and ADLs. (b.) 1/15/2023 02:27 p.m. - Resident stayed in bed throughout the shift. Resident is totally dependent on staff for completion of ADLs. A review of the current care plan with next review date 4/5/2023 revealed the following pertinent problem areas: - Resident requires staff assistance to complete activities of daily living and with goals to include : Resident will have assistance as needed to complete toileting, bathing, dressing, with interventions in place to include: Assist with grooming, denture care, comb hair, dentures, Provide level of assist per resident's needs for bathing and showering dependent, On 2/23/2023 at 3:00 p.m. the Nursing Home Administrator provided the Activities of Daily Living (ADL), Supporting Policy and Procedure with last revision date March 2018 for review. The Policy Statement indicated the following: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Policy Interpretation and Implementation section revealed: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or cognition does not alone justify a decline in a resident's ability to perform ADLs. b. Unavoidable decline may occur if he or she (1) Has debilitating disease with known functional decline; (2) Has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assisting with: a. Hygiene (bathing, dressing, grooming, and oral care). 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: a. INDEPENDENT = Resident completed activity with no help or staff oversight at any time during the last 7 days. b. SUPERVISION = Oversight, encouragement or cuing provided 3 or more times during the last 7 days. c. LIMITED ASSISTANCE = Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-wight bearing assistance 3 or more times during the last 7 days. d. EXTENSIVE ASSISTANCE = While resident performed part of activity over the last 7 days, staff provided weight -bearing support. e. TOTAL DEPENDENCE = Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7 day look back period. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident' s response to interventions will be monitored, evaluated and revised as appropriate.

Based on observations, interviews, and record reviews the facility failed to 1) ensure one resident (#103) smoked in the designated smoking area and was adequately assessed for smoking out of three residents sampled for smoking. Findings included: 1) An interview was conducted with Resident #103 on 02/20/23 at 9:55 a.m. she said, I am a smoker; I sleep with my most important items like my lighters because they keep getting stolen. I keep my important items in my bag and I sleep with it because if you get caught with cigarettes and lighters they will take them away from you. You can get your smoking stuff from the desk if you want. One night I got caught smoking in my room. They're not happy with me because I was smoking in my room but I thought I was at home and they told me I can't smoke in the room. An interview was conducted with Resident #103's roommate on 02/20/23 at 9:57 a.m. She stated Resident #103 smoked in the room with me in it and they caught her and they told her she cannot do that. Neither resident was observed to be on oxygen. A review of Resident #103's facesheet revealed she was readmitted from an acute care hospital on 2/8/2023 with diagnoses that included but are not limited to muscle weakness, difficulty in walking, need for assistance with personal care, encounter for surgical aftercare following surgery, congestive heart failure, chronic kidney disease, acute kidney failure, Type 2 Diabetes Mellitus, Sarcopenia, convulsions, intervertebral disc degeneration, lumbar region, disorders of bone density and structure, benign neoplasm of left adrenal gland, occlusion and stenosis of bilateral carotid arteries, and occlusion and stenosis of left vertebral artery. A review of Resident #103's Minimum Data Set (MDS), section C, dated 12/8/2022 revealed she had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating no cognitive impairment. An interview was conducted on 02/22/23 at 9:47 a.m. with Staff B, Agency Registered Nurse (RN). She said, I did hear about her (Resident #103) smoking in her room in report. It was last week that I heard about it. Now what day and time that happened I am not sure. But we had an agreement with her that she needs to return her lighters to us or if we find them we need to take them from her and she would sometimes be good about giving us her lighters. It looks like on December 2nd she went out for a seizure and came back so her smoking assessment was on her original admission stay. She was discharged yesterday. An interview was conducted on 02/22/23 at 10:04 a.m. with Staff N, Assistant Director of Nursing (ADON). She said, I did not know anything about her (resident #103) smoking. We have a safe smoking assessment that we do upon admission. Therapy will also do an assessment to determine if they are a safe smoker and if they are then they can smoke and if they are not then unfortunately they cannot smoke. I did not know she was a smoker, we do not have her as a smoker. Staff B, ADON reviewed her safe smoking evaluation and she stated the smoking assessment was from her original admission and it said that she was not a smoker. An interview was conducted on 2/23/23 at 1:11 p.m. with Staff R, Occupational Therapist (OT) she said when she performs a smoking assessment her role is to conduct orientation questions like, if they have oxygen, if they can manage their oxygen line, do they know to take it off before they smoke, then she assesses their fine and gross motor skills, she asks them to show her how to manipulate the lighter and show her how they put it out. She stated she also looks at their functional abilities, like do they know how to get to the smoking patio safely, self-propel, open the door, get up to the table, lock their breaks. From there I determine if they are safe to go out on their own to the patio independently or if they are going to need someone to assist in smoking. When Resident #103 was originally here she was not a smoker she did not go out and smoke. On the day she discharged from therapy she was sent out to the hospital either that day or the day after. Then she came back and we did have her on therapy and we found out that she was going out on the patio and getting cigarettes from the other residents and I was told to go out and do a smoking assessment on her so that's when I did that on the 16th. I did not hear she was smoking in her room. I don't educate them on where to keep their smoking materials that might be a nursing thing, I just assess their abilities to smoke safely and if they are independent or need assistance. It's my understanding that the resident can keep all their smoking materials on them. A review of Resident #103's Safe Smoking Evaluation dated 12/3/2022 revealed Family or Medical Representative informed of smoking policy restrictions-Comment N/A [not applicable] nonsmoker. A review of Resident #103's therapy smoking assessment titled Screening for Smoking Privileges dated 2/16/23 . Assessment Pt [patient] demonstrates good safety measures and judgment; able to safely manipulate smoking materials. Her cognition has improved as she is able to recall safety steps with smoking. Results: smoke independently signed and dated by Staff R, OT On 02/22/23 at 12:55 p.m. an interview was conducted with the Director of Nursing (DON). She said, Everyone is supposed to get a smoking assessment on admission regardless of if they smoke or not. For smokers, therapy does dexterity assessments to determine safe smoking and then there is a nursing smoking assessment. Nursing is supposed to observe the smoking, make sure they can get to the smoking's area safely and ensure they are safe to smoke. I just learned today that she (Resident #103) smoked in her room. Before she went to the hospital she was not going out to smoke. I'm not sure what happened after she returned from the hospital. The smoking assessment should have been redone when she returned from the hospital. We have liberalized smoking so, the residents are educated on where to smoke, assessed to be a safe smoker and they are able to keep their materials on them. They should also be care planned for smoking as well. A review of Resident #103's care plans was conducted and there was no evidence Resident #103 had a smoking care plan. A review of the facility's Smoking Policy-Residents Revised January 2020 indicated the following: Policy Statement This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation .6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. .8. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan. .11. Residents are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. 12. Resident are not permitted to give smoking articles to other residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure 1) respiratory care was provided consistent with professional standards of practice related to oxygen levels not set per physician orders for one resident (#72), and 2) respiratory equipment was stored appropriately for four residents (#72, #10, #62 and #73) out of five residents sampled during two of four days of survey. Findings included: Resident #72 was admitted to the facility on [DATE] with diagnosis to include pneumonia unspecified, adult failure to thrive, acute kidney failure and unspecified atrial fibrillation. An undated Minimum Data Set (MDS) for Resident #72 showed the resident is dependent on staff for activities of daily living (ADL) with one-person physical assistance. An observation was conducted on 2/20/23 at 12:15 p.m. of Resident #72 who was observed to be in her watching television. The resident was observed to have a nasal cannula on with her oxygen flow rate set to 5.5 liters per minute (LPM). The resident did not know what the settings of her oxygen should be. The resident stated, this is uncomfortable, pointing to her nasal cannula. Photographic evidence was obtained. On 02/20/23 at 09:45 a.m., Resident #72 was observed in her room, lying in bed. Her nebulizer was noted by bedside, uncovered. On 02/20/23 at 12:15 p.m., Resident #72's nebulizer cannula was observed at bedside, still uncovered. A review of a document titled, Physician Orders List showed oxygen orders with a start date 8/27/22, showing O2 (oxygen) at 2L/Min (liters per minute) via NC (nasal cannula) continuous as tolerated; DX (diagnosis) SOB (shortness of breath)/Cyanosis. The order list also showed, Iprat-[NAME] (Albuterol) 0.5-3 (2.5 MG (Milligrams)/3ML (milliliters) administer 1 vial via nebulizer 4 times daily. Rinse and spit after administered diagnosis COPD (chronic obstructive pulmonary disease). A review of a Medication Administration Record (MAR) for Resident #72, dated February 2023, showed Resident #72 was receiving oxygen at 2L/Min during 7 a.m. - 7 p.m. and 7 p.m. - 7 a.m., contrary to the observation on 2/20/23 and 2/21/23. On 02/21/23 at 09:44 a.m., Resident #72 was observed in her room, sleeping her cannula in her nose. The resident's oxygen was noted set at 5.5 liters. On 02/21/23 at 03:50 p.m., Resident #72's O2 was observed in her room in bed, her oxygen level noted at 2.5L. Photographic evidence was obtained. On 02/21/23 at 04:05 p.m. an interview was conducted with Staff K, Licensed Practical Nurse (LPN)/weekend supervisor. Staff K reviewed Resident #72's orders and stated her orders are to administer Oxygen at 2L/min. She stated it should not be 2.5L/min nor 5L/min. She stated 5L/min is way too high and would be concerning especially if the resident had a diagnosis of COPD. She stated she would address the issue with the DON. Staff K said, the expectation is to follow doctor's orders. There are no parameters here, the order reads 2L/min. that is what it should be. On 02/21/23 at 04:11 p.m., an interview was conducted with the Director of Nursing ( DON). She stated Resident #72's oxygen should be administered as ordered. The DON reviewed the resident's orders and stated her oxygen level should be 2L/min. She stated the nurses should strictly follow physician directions when it comes to administration of oxygen or medications. The DON said, administering oxygen at 5.5L/min when the order reads 2L/min is very concerning. She stated she would follow-up. During a facility tour on 02/20/23 02:09 p.m. and on 02/21/23 at 10:49 a.m., an observation was made of Resident #10's nebulizer machine at bedside, the mask was observed on her nightstand, uncovered, exposed to the elements. Resident #10's oxygen concentrator was observed in her room, set at the corner without tubing, appeared to not be in use. An attempt to interview Resident #10 was unsuccessful. A review of a document titled, Face sheet, showed Resident #10 was admitted to the facility on [DATE] with diagnoses to include pneumonia unspecified, COPD, encephalopathy, and unspecified dementia. An undated MDS for Resident #10 section C, showed a Brief Interview of Mental Status (BIMS) of 3, indicating severe mental impairment. Section D showed Resident #10 is dependent on staff for ADLs with one-person physical assist. A review of a document titled, Physician orders List dated 10/01/22 to 2/23/23, showed, administer oxygen at 2L/minute via nasal cannula, dated 10/23/22. The orders showed Albuterol Sul 2.5 MG/3ML solution administer vial via nebulizer 4 times daily, discontinued 11/15/22. On 02/23/23 at 01:21p.m., an interview was conducted with Staff D, LPN/UM. She stated she had reviewed Resident #10's oxygen orders and MAR which showed the resident was receiving Oxygen daily at 2L/min. Staff D was notified that during 3 of 3 days observations, resident was not observed on oxygen even though it was documented she was receiving continuous oxygen. Staff D confirmed the observation and stated that was why she updated the oxygen orders to PRN. Staff D stated said, I walked into the room and saw the concentrator on the corner of the room, I did not see any tubing or connection to power, to indicate it was in current use. I reviewed her current physician orders and saw she was supposed to be on oxygen 2L continuous. I have not seen her on oxygen. Staff D stated she got new tubing, set up the Oxygen, but the resident did not want it. Staff D said, I checked her O2 sats and reviewed the history of her saturations and noted no concerns with her room air oxygen levels. I called the doctor and received orders to change it to PRN. I do understand concerns related to documentation showing the resident was receiving oxygen 24 hours. I cannot speak of my co-workers observations and documentation, but I know the documentation is not accurate. She stated she and the DON would initiate education and will continue to monitor the resident's O2 saturations An interview was conducted on 02/23/23 at 01:31p.m. with Staff D. She stated she was doing rounds and saw Resident #10's nebulizer by bedside. She said, I saw it was not bagged, I went ahead and bagged it and dated it. I then reviewed the current orders and saw there were no orders for the nebulizer. I removed it from the room. Staff D confirmed the nebulizer should have been bagged or stored in the supply closet if not in current use. A follow up interview was conducted on 02/23/23 at 12:55 p.m. with the NHA and Staff P, NHA from a sister facility. Staff P stated she had reviewed the oxygen orders for Residents #10 and #62 and changed their orders to PRN (as needed) because these residents were not receiving oxygen continuously. She stated they have noted the documentation concern and they will be addressing it. Staff P stated respiratory equipment should be stored appropriately. On 02/20/23 at 10:08 a.m., an observation was made of Resident #62's concentrator was observed by her bedside, oxygen tubing on the floor, her nasal cannula resting on the floor. Photographic evidence was obtained. Resident #62 was observed in the resident lounge with her portable oxygen on, noted receiving oxygen via nasal cannula. A review of a document titled, Face Sheet, showed Resident #62 was admitted to the facility on [DATE] with diagnosis to include pneumonia unspecified. A review of a document titled, Physician Orders List, dated 7/22/22 to 7/23/23, showed resident #62 was to receive O2 at 2L/Min via NC, continuous diagnosis SOB/cyanosis as tolerated. During a facility tour on 02/20/23 at 12:38 p.m., an observation was made of Resident #73's CPAP (Continuous Positive Airway Pressure) machine resting on his bedside table on top of his bed covers. The CPAP face mask was exposed to the elements, and not stored in a bag. Photographic evidence was obtained. Resident #73 was admitted to the facility on [DATE] with diagnoses to include obstructive sleep apnea. A review of a document titled, Physician's Order List showed an order dated, 6/12/22, to apply CPAP mask at bedtime, and an order to remove CPAP and clean, 6/12/22. Resident #73 was not available for an interview. On 02/22/23 at 01:54 p.m., an interview was conducted with Staff D, LPN Unit Manager. Staff D confirmed all respiratory equipment should be stored in a bag after each use. She stated the tubing, masks and cannula's are changed weekly. Staff D said, They should not be on the floor or exposed to germs. On 02/22/23 at 04:59 p.m., an interview was conducted with the DON and the Nursing Home Administrator (NHA). The DON stated oxygen should be administered as ordered. She stated they initiated an audit the day before. She stated she was notified Resident #72's oxygen level was at 2.5L, it was adjusted to 2L should not have been 5.5L. The DON said, Her oxygen levels should not have been at 5.5L, absolutely not. The DON stated their policy is to follow physician orders. The DON stated respiratory equipment should be stored in a bag, nebulizer and oxygen cannula's should be stored in bags and changed out weekly and as needed. A review of a facility policy titled, Oxygen Administration - Nasal Cannula Clinical Practice Guideline, dated 7/25/22, indicated oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery and frequency. Humidification of oxygen is used for a flow rate of four liters per minute or greater or if requested by a patient. Guidelines showed to 1. check the resident's medical record to confirm the presence of a complete and appropriate physician's order. 2. Determine appropriate oxygen source and need for humidification. Under guidance for best practice 14. Replace the entire setup every 7 days. Date and store in treatment bag when not in use. A review of facility policy titled, Respiratory Muscle Trainer Clinical Practice Guideline, dated, 7/25/22, showed: 24. Rinse the nebulizer after the treatment and allow it to air dry. 25. Conclude treatment and store circuit in treatment bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A review of Resident #55's facesheet revealed he was admitted to the facility on [DATE] for long term nursing care. He was admitted with diagnoses that include but are not limited to dementia with agitation, vascular dementia with agitation, and Type 2 Diabetes Mellitus with hyperglycemia. A review of Resident #55's physician orders revealed an order to start on 2/3/23 for sliding scale: Level 2-Novolin N Subcutaneous Suspension 100unit/ML 0-150=No coverage 151-199=1 unit 200-249=2 units 250-299=3 units 300-349=4 units 350 or greater-5 units and call MD [medical doctor] A review of Resident #55's MAR for the month of February 2023 did not reveal the amount of Novolin administered according to the sliding scale for all administered doses and did not reveal the blood sugar reading which determines the amount the Novolin to be administered according to the sliding scale for all administered doses. A further review of the MAR and administration record notes revealed the following: 2/3/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/4/23 at 6:00 a.m. no documentation indicating the medication was administered or not. 2/4/23 at 8:00a.m. the medication was documented as not administered --> Review of the administration record note .scheduled for 2/4/23 8:00 AM was not administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/4/23 at 11:30 a.m. the medication was documented as administered. The administration record note revealed . scheduled for 2/4/23 11:30 AM was administered. BS [blood sugar] 155. No documentation of how much insulin was administered. 2/4/23 at 4:30 p.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/4/23 4:30 PM was not administered -other BS 159, awaiting arrival from pharmacy 2/4/23 at 9:00p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/5/23 at 6:00a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/5/23 at 8:00 a.m. there was no documentation for the medication. There was no evidence of the blood sugar reading. 2/5/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/5/23 at 4:30 p.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/5/23 4:30 PM was held There was no evidence of the blood sugar reading. 2/5/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/6/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/6/23 at 8:00 a.m. there was no documentation for the medication. There was no evidence of the blood sugar reading. 2/6/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/6/23 at 4:30 p.m. the medication was documented as not administered. There was no evidence of the blood sugar reading. 2/6/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/7/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/7/23 at 8:00 a.m. there was no documentation for the medication. There was no evidence of the blood sugar reading. 2/7/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/7/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/7/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/8/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/8/23 at 8:00 a.m. there was no documentation for the medication. There was no evidence of the blood sugar reading. 2/8/23 at 11:30 a.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/8/23 11:30 AM, 11:30 AM was held. There was no evidence of the blood sugar reading. 2/8/23 at 4:30 p.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/8/23 4:30 PM was held. There was no evidence of the blood sugar reading. 2/8/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/9/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/9/23 at 8:00 a.m. there was no documentation for the medication. There was no evidence of the blood sugar reading. 2/9/23 at 11:30 a.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/9/23 11:30 AM insulin coverage not needed There was no evidence of the blood sugar reading. 2/9/23 at 4:30 p.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/9/23 4:30 PM no insulin required 144 2/9/23 at 9:00 p.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/9/23 9:00 PM BS 121. No coverage needed. 2/10/23 at 6:00 a.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/10/23 6:00 AM was not administered- other Blood sugar 111. 2/10/23 at 8:00 a.m. there was no documentation for the medication. There was no evidence of the blood sugar reading. 2/10/23 at 11:30 a.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/10/23 11:30 AM was held. There was no evidence of the blood sugar reading. 2/10/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/10/23 at 9:00 p.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/10/23 9:00 PM BS 127 2/11/23 at 6:00 a.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/11/23 6:00 AM was refused by resident. There was no evidence the physician was notified of the refusal. 2/11/23 at 8:00 a.m. there was no documentation for the scheduled dose. 2/11/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/11/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/11/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/12/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/12/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/12/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/12/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/12/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/13/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/13/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/13/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/13/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/13/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/14/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/14/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/14/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/14/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/14/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/15/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/1/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/15/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/15/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/15/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/16/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/16/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/16/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/16/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/16/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/17/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/17/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/17/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/17/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/17/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/18/23 at 6:00 a.m. the medication was documented as administered. Review of the administration record note revealed .scheduled for 2/18/23 6:00 AM was held.' There was no evidence of the blood sugar reading. 2/18/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/18/23 at 11:30 a.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/18/23 11:30 AM was not administered- other BS 137, coverage not needed 2/18/23 at 4:30 p.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/18/23 4:30 PM BS 144, no coverage needed. 2/18/23 at 9:00 p.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/18/23 9:00 PM was held. There was no evidence of the blood sugar reading. 2/19/23 at 6:00 a.m. the medication was documented as not administered. There was no evidence of the blood sugar reading. 2/19/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/19/23 at 11:30 a.m. the medication was documented as not administered. Review of the administration record note revealed .scheduled for 2/19/23 11:30 AM was administered. BS 165. There was no indication of how many units were administered. 2/19/23 at 4:30 p.m. the medication was documented as administered. Review of the administration record note revealed .scheduled for 2/19/23 4:30 PM was administered. BS 157. There was no documentation on how much insulin was administered. 2/19/23 at 9:00 p.m. the medication was documented as not administered. There was no evidence of the blood sugar reading. 2/20/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/20/23 at 8:00 a.m. there was no documentation for the ordered medication. 2/20/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/20/23 at 4:30 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/20/23 at 9:00 p.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/21/23 at 6:00 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. 2/21/23 at 8:00 a.m. there was no documentation for the scheduled medication. 2/21/23 at 11:30 a.m. the medication was documented as administered. There was no evidence of the blood sugar reading or the amount of Novolin administered. On 2/23/23 at 2:23p.m. an interview was conducted with the Nursing Home Administrator (NHA) she confirmed the resident did not have a care plan related to his diabetes diagnosis and she stated the facility had not completed a February pharmacy review. On 2/23/23 at 2:31p.m. an interview was conducted with the facility's Consultant Pharmacist. He said, I have not done February reviews yet. Related to insulins, I make sure they are getting their blood glucose checked and that they are getting their Hemoglobin A1C's completed. I do not question the type of insulin they are on because insulin is so patient specific. and if I review a patient and they don't have blood glucose documented that is something I would write up and if I see 50 units being administered that is something I am going to write up. I mostly look at psychotropic's unless something jumps out at me. Based on record reviews, and interviews the facility failed to ensure insulin administration was adequately and appropriately monitored for two residents (#74 and #55) out of 7 resident reviewed for unnecessary medications and insulin administration. Findings included: 1) A review of Resident #74's facesheet identified the resident was admitted on [DATE]. The facesheet included diagnoses not limited to Type 2 Diabetes Mellitus. A review of Resident #74's physician orders for 2/2023 included an order for Insulin Lispro 100 unit/milliliter (mL) pen (interchange). Inject subcutaneously (sub-q) per sliding scale three times daily, 70-140=0 units, 141-180= 1 unit, 181-200= 2 units, 221-260= 3 units, 261-300= 4 units, greater than 400= call MD (Medical Doctor) . The order did not identify how much insulin Resident #74 should be administered for a blood glucose of 201-220 or if the residents blood glucose level was between 301 - 399. A review of Resident #74's Medication Administration Record (MAR) identified the residents blood sugar was not documented during the 6:30 a.m. monitoring on 2/3, 2/5-2/9, 2/15, 2/29, and 2/23/23 and during the 4:30 p.m. monitoring on 2/6/23. The MAR indicated the resident was administered insulin outside the parameters on 2/7 at 4:30 p.m. for a blood glucose of 103, on 2/11 at 11:30 a.m. for a blood glucose of 120, and on 2/13 at 4:30 p.m. for a blood glucose of 101. The MAR did not identify how much insulin had been administered twenty-seven out of twenty-seven administrations. The care plan for Resident #74 identified the resident had Diabetes Mellitus (Type 2): uncontrolled blood sugar levels and included interventions not limited to obtain blood sugars as ordered. A review of the policy titled Insulin Administration, copyrighted 2001 and revised September 2014, indicated the purpose was To provide guidelines for the safe administration of insulin to residents with diabetes. The policy identified the following: - The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. - The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin. The procedure portion of the policy instructed staff to Check blood glucose per physician order or facility protocol., Check the order for the amount of insulin., and Double check the order for the amount of insulin. The policy for documenting insulin administration include The resident's blood glucose result, as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure behavioral/side effect monitoring was conducted for psychotropic medications for one resident (#74) out of five residents sampled for unnecessary medications administration. Findings included: An observation, on 2/22/23 at 11:45 a.m., identified Resident #74 was lying in bed with eyes closed. A review of Resident #74's facesheet indicated the resident was admitted on [DATE] for short term skilled nursing and rehabilitative care. The facesheet identified diagnoses that included but not limited to Type 2 Diabetes Mellitus, unspecified anxiety disorder, other seizures, and unspecified single episode major depressive disorder. A review of the active Physician Orders for Resident #74 indicated the resident received the following psychotropic medication: - Lorazepam 0.5 milligram (mg) orally three times a day. - Venlafaxine extended release 225 mg orally daily - trazodone 50 mg at bedtime - Divalproex 250 mg every morning and bedtime Resident #74's Medication Administration Record (MAR) for February 2023 identified the resident received the above medications as ordered. The MAR did not include documentation the resident exhibited any behaviors or that staff had monitored the possible side effects related to the use of psychotropic medications. A review of Resident #74's care plan identified the resident was at risk for side effects (related to) psychotropic/seizure/supplement medication use and the goal was no injury related to medication usage/side effects. The interventions instructed staff to Monitor patterns of target behaviors (and) monitor ability to sleep and to Assess for adverse side effects, document, and report. The care plan for Resident #74, Behavior: verbally aggressive behavior, declines to get out of bed frequently, and declines showers at times indicated staff were to Monitor and document target behaviors. The policy, Use of Psychotropic Medication, copyrighted 2022, identified Residents are not given psychotropic drugs unless the medication is necessary to treat specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring, and documentation of the resident's response to the medication(s). The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis which identified In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. On 2/22/23 at 11:45 a.m., Staff M, Licensed Practical Nurse (LPN), stated behaviors are documented on the computer. Staff M reviewed Resident #74's orders and stated the behaviors had already been done this shift and was included with the MAR's. The staff member reviewed the MAR then asked another nurse sitting at the nursing station, Staff O, LPN to review the MAR. Staff N, Registered Nurse (RN) reviewed the orders and stated there was not an order for behavior monitoring for Resident #74 and confirmed if the resident was on psychotropic medications there should be an order for monitoring of Side Effects and Behaviors. The Director of Nursing (DON) stated on 2/22/23 at 1:17 p.m., behaviors and side effects should be monitored for residents with psychotropic medications ordered. On 2/23/23 at 2:36 p.m., the Consultant Pharmacist reported that a behavior monitoring record should be filled out, with an appropriate diagnosis, and if runs into more than one psychotic medication, a note is written.

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed with four errors identified for two residents (#51 and #17) of seven residents observed. These errors constituted a 14.29% medication error rate. Findings Include: 1. On 02/21/23 at 07:27 AM Staff F, Licensed Practical Nurse (LPN) was observed administering Tylenol 650 milligrams (mg) by mouth for pain to Resident #51. A review of the Medication Administration Record (MAR) did not show medication was administered. A follow up interview with Staff F was conducted on 02/21/23 at 11:48 AM. Staff F, LPN stated she didn't know why the medication was not documented. Staff F was not able to produce documentation of the medication from the morning but was able to provide a nursing note written at 11:15 AM assessing the effectiveness of the medication. Staff F stated, The original administration time may not show up except as medication follow up assessment. 2. Staff G, LPN prepared the following medications for administration to Resident #17 on 02/21/23 at 09:56 AM. Cranberry supplement 1 tablet Symbicort inhaler 160/4.5 mg Aspirin 81 mg chewable 1 tablet Wellbutrin SR 200 mg 1 tablet Bumex 0.5 mg 1 tablet On entering the room Staff G took vital signs for Resident #15, oxygen Saturation 92%, blood pressure 98/69 and pulse 113. Staff G did not administer Bumex because of low blood pressure. Staff G was observed administering the Cranberry tablet, Aspirin, Wellbutrin. Staff G then handed the resident the Symbicort inhaler who then took two puffs from the device. Medication reconciliation with the electronic medical record revealed the Bumex was held but no provider notification was present in the medical record. The order for Symbicort was for one puff and for the resident to rinse mouth with water after administration. A follow up interview was conducted with Staff G on 02/21/23 at 02:20 PM. Staff G confirmed Resident #17 likes to self-administer her inhaler and took two puffs. Staff G, LPN stated, The resident won't let anyone tell her what to do with it. She will not rinse after using it because she will not drink water. The only thing she drinks is soda and she will not rinse with water. When asked about holding the Bumex, Staff G stated she was trained blood pressure medications with a systolic under a hundred to hold the medications. She stated Resident #17 refuses to drink water and is tachycardic and hypotensive. She stated I am afraid that if I give her the medicine she will pass out getting up. We've been working on her BP medicine for a while and just last week we discontinued her metoprolol. The Director of Nursing (DON) was interviewed on 02/22/23 at 01:51 PM. The DON was informed of medication error observations and stated she expects nurses to use their judgement and hold medications when they feel is appropriate, but they should notify the provider when medications are held and she expects nurses to document medications at the time they are given. The DON said she expects nurses to follow medical orders and instruct residents on using medication devices like inhalers. The DON said she would ask to have the order to rinse after the inhaler changed by the provider or address the behavior in resident care plan. During an interview with Consultant Pharmacist on 02/23/23 at 02:55 PM the medication findings were shared. The Consultant Pharmacist confirmed the observations as medication administration errors. A review of facility policy Administering Medications (Revised April 2019) indicated the following: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs personnel who administer medication and/or have related functions. 3. Medications are administered in accordance with prescriber orders, including any required time frame. 15. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. 21. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of policy Documentation of Medication Administration (Revised April 2007) indicated the following: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the residents MAR. 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused (as applicable); f. Signature and title of the person administering the medication: and g. Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to 1) ensure a call light was functioning properly for Resident #315, and 2) ensure a call light was placed within reach for Resident #80 during two of four days of survey. Findings included: On 02/21/23 at 10:04 a.m., an interview was conducted with Resident #315. She stated her call light was not working and she had on-going issues. Resident #315 said, no one answers when I call, they say the call light was not ringing at the nurse's station. Resident #315 said, On 1/23/23, I waited for more than 4 hours to be assisted, when the aide responded, she stated the call light did not ring at the nurse's station, so they did not know I was calling. Resident #315 stated she was told a work order had been put in. She stated it still had not been fixed. Surveyor evaluated the call light with Resident #315. The call light lit up outside her door, but it did not light nor sound at the nurse's station. Resident #315 was admitted to the facility on [DATE] with a primary diagnosis of encephalopathy. An undated Minimum Data Set (MDS), printed on 2/22/23, showed Resident #315 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. In Section G-Functional Status, showed Resident #315 required extensive assistance for bed mobility and was totally dependent on staff for transfers. Resident #315 required extensive assistance for toileting. On 02/21/23 at 10:14 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN). The nurse evaluated Resident #315's call light and confirmed the call light did not light up at the nurses' station. Staff H stated the call light by bedside is supposed to light up outside the resident's door and then buzz and light up at the nurse's station. On 02/21/23 at 10:18 a.m., an interview was conducted with Staff D, LPN/UM (Unit Manager). She stated she did not know of any call lights that were not working on the second-floor hallway. She stated all resident's call lights should be working to ensure their safety. She stated the call light should light up outside the resident's door and then beep and light up at the nurse's station. She stated if there was a problem, they would notify the Director of Maintenance (DOM). On 02/21/23 at 12:53 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated they did not have any records of work orders related to call lights. She stated their previous DOM had quit about a month earlier and they were trying to establish a system for reporting work orders with the new DOM. She stated she did not know if there had been reports of call lights not working, or if they had any documented concerns. On 02/21/23 at 03:50 p.m., an interview was conducted with the Staff C, Social Services Director (SSD). Staff C, SSD confirmed Resident #315 had filed three grievances related to staff not responding to her call light. She stated if a resident had a concern either the resident, or staff can fill out the grievance form. On 02/21/23 at 03:59 p.m., an interview was conducted with Staff I, Certified Nursing Assistant (CNA) . She stated they used to have a maintenance book where they filed out work orders. This was with the previous DOM. She stated they have been without one for a while. She stated the new DOM has created work orders sheets placed at each nurse's unit. She stated that process just started today. She stated she did not know that there were any problems related to call lights on the second-floor hall. She stated the only call light issue was Resident #315's. staff I stated the resident's call light was not working properly. It would not light up at the nurse's station which meant they sometimes did not know she was calling. She stated she became aware of the issue sometime previous week and thought the call light was fixed. On 02/21/23 at 04:11 p.m., an interview was conducted with the DON. She stated she was not aware of any call lights not working and did not know Resident #315 had a problem with her call light. She stated she would expect nursing staff to notify someone right away if there was a problem with a call light. She stated they have a maintenance book in the nurse's station for work orders. She stated she would follow up with the DOM. On 02/22/23 at 09:15 a.m., an interview was conducted with Staff D, LPN/UM. She stated she was notified Resident #315's call light was not working the day before and she had put in a work order. Staff D stated the call light was working on the door, just not lighting and alarming at the nurse's unit. Staff D confirmed if staff were not outside the hall, they could not see the call light and they would not know if Resident #315 needed assistance. On 02/22/23 at 09:38 a.m., an interview was conducted with the DOM. He stated he was not aware there were call light issues until the day before. He stated he thought Resident #315's call light was not working because of an electric issue, and he would have to call a contractor to assess and repair. On 02/22/23 at 10:45 a.m., a follow -up interview was conducted with Staff C. she stated she had discussed with nursing staff Resident #315's on-[NAME] complaints related to staff not responding to her call light. She stated they had addressing the issue of staff answering call lights, making sure they are doing rounds and reporting call light issues. She stated the DON had initiated education. On 02/21/23 at 10:32 a.m., an interview was conducted with Resident #80 and his Representative. They reported his call light button has been missing for a couple months. Resident #80 stated he had reported it to staff. He stated a maintenance person had looked at it and he never came back. He stated if he needs staff's attention he waits until the staff conduct rounds or if they respond to his roommate's call light. He stated sometimes he asks his roommate to turn on the call light for him, but his roommate gets in trouble when staff responds because he is not the one that needs help. Resident #80 stated he wanted his call light to work. Resident #80 was admitted to the facility on [DATE] with the diagnosis to include bed confinement status. An undated Minimum Data Set (MDS), printed on 2/22/23, showed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Section G-Functional Status, showed Resident #80 required extensive assistance for bed mobility and was totally dependent on staff for transfers and toileting, personal hygiene, and bathing. On 02/22/23 at 09:18 a.m., an interview was conducted with Staff D, LPN/UM. She stated she did not know the resident's call light was not working. She looked around the resident's bed and could not locate the call light. Staff D stated it is wrapped behind the curtain on the other resident's side of the bed. Staff D confirmed the resident could not reach the call light. Resident #80 restated that he had not seen the call button in a long time, probably one month. Staff D repositioned the call light and handed it to Resident #80. The resident said, this is the first time I have seen this button in months. It has not been working. I couldn't call staff. Staff D stated she would in-service staff on ensuring proper placement of call lights and reporting any call lights that were not working. On 02/22/23 at 10:42 a.m., an interview was conducted with Staff C, SSD. She stated if a resident, family member or representative had expressed any concerns, they should immediately help them file a grievance if they needed help. She stated a resident's equipment should be in good working order. She stated the report should be documented and addressed. On 02/22/23 at 04:59 p.m., an interview was conducted with the DON and NHA. The DON stated the call light for Resident #315 was repaired and Resident #80's call light had been repositioned. The DON said, Staff should have reported these call light concerns sooner. The NHA said, The DOM has initiated a new system for reporting work order concerns, and we are training staff to document the work orders and also for the DOM to maintain a checklist. We are in-servicing staff on responding to call lights and ensuring they are within reach. Each time they position the resident, they should check the call light button placement. A review of a facility policy titled, Answering the Call Light, dated March 2021, showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs. Under general guidelines #4. Be sure that the call light is plugged in and functioning at all times. #5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. #6. Some residents may not be able to reach their call light. Be sure you check the residents frequently. #7. Report all defective call lights to the nurse supervisor promptly. Document any significant requests or complaints made by the resident and how the request or complaint was addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed 1) to ensure controlled substances were accurately documented for two residents (#74 and #51) out of four residents sampled for the documentation of narcotics, 2) to supply admission medications for one resident (#367) out of forty-three sampled residents, 3) to ensure a transdermal patch was provided for one resident (#45) out of forty-three sampled residents, 4) to provide eye drops for one resident (#39) out of forty-three sampled residents, and 5) to administer pancreatic enzymes for one resident (#94) out of forty-three sampled residents. Findings included: 1) On 2/20/23 at 10:43 a.m., Resident #74 was observed lying in bed and was interviewed at that time. On 2/22/23 at 11:45 a.m., the resident was observed lying flat in bed with eyes closed. A review of Resident #74's facesheet identified the resident was readmitted on [DATE]. The facesheet included diagnoses not limited to chronic pain syndrome, unspecified Diabetes Mellitus due to underlying condition with diabetic neuropathy, and unspecified anxiety disorder. A review of the active orders for February 2023 revealed an order for Oxycodone 5 milligram (mg) every 8 hours as needed for pain. The February 2023 Medication Administration Record (MAR) indicated Resident #74 was administered 5 milligrams (mg) of Oxycodone on: 2/1 at 9:47 p.m., 2/2 at 6:22 a.m., 2/3 at 11:22 a.m., 2/4 at 8:27 p.m., 2/5 at 4:54 a.m., 2/7 at 11:11 p.m., 2/9 at 12:17 p.m. and 7:31 p.m., 2/10 at 6:57 a.m., 2/12 at 6:46 a.m., 2/14 at 9:09 a.m. and 5:47 p.m.,2/15 at 2:28 p.m., 2/16 at 5:04 a.m. and 2:47 p.m., 2/17 at 6:16 a.m., 2/18 at 2:14 p.m. and 11:55 p.m., 2/19 at 2:26 p.m., and 2/21/23 at 6:33 a.m. and at 9:54 p.m. A review of Resident #74's Oxycodone Controlled Substance Record identified the resident received a dose of Oxycodone at the following times that were not documented on the February MAR: 2/1 at 1:13 p.m., 2/2 at 1:33 p.m. and at 9:00 p.m., 2/3 at 6:00 a.m. and 7:15 p.m., 2/4 at 4:25 p.m., 2/6 at 5:45 a.m. and 9:37 p.m., 2/7 at 2:41 p.m. and 9:00 p.m., 2/8 at 2:55 p.m. and 9:45 p.m., 2/11 at 7:00 p.m., 2/12 at 12:45 a.m. and 5:05 p.m. 2/13 at 12:04 p.m., 2/15 at 9:08 p.m., 2/19 at 10:30 p.m., 2/20 at 5:24 a.m. and 5:50 p.m., 2/21 at 5:30 p.m., and 2/22/23 at 1:30 a.m. The Controlled Substance Record identified the resident received twenty-two doses of Oxycodone that were not documented on the February MAR. Resident #51 was observed and interviewed at 1:02 p.m. on 2/20/23. The resident was lying in bed and answered question appropriately. A review of Resident #51's February Medication Administration Record (MAR) included an order for Percocet 5 mg/325mg orally every 6 hours as needed, started on 12/29/22. A review of the Controlled Substance Record for Resident #51's ordered Percocet 5 mg/325mg identified Resident #51 was administered the following doses that were not documented on the residents' MAR: 2/6 at 6:35 a.m., 2/9 at 10:45 p.m., 2/11 at 7:25 p.m., 2/14 at 7:15 p.m., 2/15 at a time of 12 p.m., 2/18 at 9:06 p.m., 2/19 at 9:10 p.m., and 2/20/23 at 7:00 p.m. The Controlled Substance Record identified the resident received eight doses of Percocet that were not documented on the February MAR. On 2/23/23 at 1:30 p.m., the Director of Nursing stated the expectation was controlled substances were to be signed off on the MAR and the Controlled Substances log book each time a narcotic medication was given. She reviewed Resident #74 and #51's narcotic log and stated this was an issues and she could see where it looked like narcotic diversion. The Consultant Pharmacist reported, on 2/23/23 at 2:36 p.m., doing spot checks with the MAR's and narcotic records and stated sometimes I pick up on things, sometimes I don't. The policy, Controlled Substances, copyrighted 2001 and revised August 2019, identified that The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. The policy indicated that if the count of controlled substances were correct, an individual resident-controlled substance record would be made for each resident who received a controlled substance and included the name of the resident, name and strength of the medication, quantity received, number on hand, name of physician, prescription number, name of issuing pharmacy, date and time received, time of administration, method of administration, signature of person receiving medication, and signature of nurse administering medication. 2) A review of Resident #367's facesheet indicated the resident was admitted on [DATE]. The facesheet included diagnoses not limited to unspecified osteomyelitis, Type 2 Diabetes Mellitus with foot ulcer, and unspecified hereditary and idiopathic neuropathy. A progress note, on 10/1/22 at 6:59 p.m., indicated staff had verified Resident #367's medications with the physician. The Administration Record progress notes identified the following: - 10/2/22 at 1:33 a.m., Cephalexin 500 mg tablet, scheduled for 10/2/22 at 12:00 a.m. Medication not available. - 10/2/22 at 1:33 a.m., Xanax 0.5 mg tablet, scheduled for 10/1/22 at 9:00 p.m. Medication not available. - 10/2/22 at 5:05 a.m., Cephalexin 500 mg tablet, scheduled for 10/2/22 at 6:00 a.m. Not available. - 10/2/22 at 9:56 p.m., Temazepam 15 mg capsule, scheduled for 10/2/22 at 8:00 p.m., Not available. - 10/2/22 at 10:07 p.m., Temazepam 15 mg capsule, scheduled for 10/1/22 at 8:00 p.m., Not available. - 10/3/22 at 9:09 p.m., Temazepam 15 mg capsule, scheduled for 10/3/22 at 8:00 p.m., was not administered - Other. On order awaiting pharmacy delivery, MD notified okay to administer when available. - 10/5/22 at 1:43 a.m., Temazepam 15 mg capsule, scheduled for 10/4/22 at 8:00 p.m., was not administered - Other. On order awaiting pharmacy delivery, MD notified okay to administer when available. - 10/5/22 at 10:41 p.m., Temazepam 15 mg capsule, scheduled for 10/5/22 at 8:00 p.m., Not available. A review of the Emergency Drug Kit (EDK) content list identified the kit contained 5 tablets of Xanax 0.5 mg, 5 tablets of Temazepam 15 mg, and 10 capsules of 250 mg Cephalexin. During an interview, on 2/23/23 at 1:30 p.m., the Director of Nursing (DON) reviewed the Emergency Drug Kit (EDK) list and progress notes from the Medication Administration Record (MAR) which indicated Resident #367 had not received Temazepam, Xanax, and Cephalexin as ordered. She confirmed the medications were available in the EDK drug kits. The DON stated her expectation would be for the staff to have accessed the medications available in the EDK to administer to the resident until the pharmacy delivered. 3) On 2/20/2023 during an interview with Resident #45 she reported she had to remind the staff to provide her with her medications. A medical record review was conducted for Resident #45 which revealed she was admitted to the facility on [DATE] with multiple diagnosis but not limited to high blood pressure. Resident #45 had an active physician's order for Clonidine 0.2 mg/24 hour weekly transdermal patch. The patch was to be applied to the resident in the AM (morning) during medication pass time every Friday, for a diagnosis of hypertension with an order date of 10/1/2022. A review of the Medication Administration Record for the month of February 2023 indicated the resident did not receive her transdermal patch on 2/3/2023. An interview was conducted with Staff Q, Registered Nurse (RN) on 02/21/23 at 2:49 PM . She was asked to review Resident #45's medical record in regards to the reason the resident had not received her medication on 2/3/23. Staff Q confirmed the medical record showed no documentation for Resident #45 with the Clonidine 0.2 mg/24 hour weekly transdermal patch on 2/3/2023, and stated the physician was not notified of the missed medication. Staff Q stated she would expect to see documentation as to the reason why it was not provided and the physician had been notified. 4) A medical record review was conducted for Resident #39 who was admitted to the facility on [DATE] with multiple diagnosis but not limited to acute chronic systolic (congestive) heart failure, idiopathic neuropathy, muscle weakness and Type II Diabetes. A review of the Medication Administration Record for Resident #39 was conducted which revealed the resident was not provided with medications as follows: Prednisolone acetate 1% eye drops, suspension missed on 2/5, 2/14 and 2/18/2023. Vigamox 0.5% eye drops in both eyes four times daily for misses on 2/4 and 2/8/2023. Modafinil 100 mg tab not given on 2/9/2023. Venlafaxine Hcl 75 mg not given on 2/9/2023. Potassium CL ER 20 MEq every evening not given on 2/3 and 2/4/2023. Vitamin C 500 not given on 2/1, 2/2 and 2/3/2023. The facility omitted documentation about the reason Resident #39 did not receive his medication or that the physician had been notified of missed medications. On 02/22/23 at 1:07 PM an interview was conducted with the Director of Nursing who reported there should be documentation in the medical record as to the reason why the medication was not provided along with the physician being notified the order was not followed. She was asked to review the documentation and she confirmed there was no documented evidence as to the reason the medication was not provided. She reported she expects to see complete and accurate documentation. 5) A review of Resident #94's facesheet revealed she was admitted ot the facility on 9/15/22 and discharged on 9/21/22. The resident was admitted with exocrine pancreatic insufficiency, unspecified dementia without behavioral disturbance, and altered mental status. A review of Resident #94's physician orders revealed an order to start on 9/16/22 and was discontinued on 9/21/22 for Zenpep 40,000unit-126,000 unit-168,00-unit capsule, delayed release oral three times daily every day. A review of Resident #94's September Medication Administration Record (MAR) revealed the medication was not administered 4 out of 16 opportunities. A review of the Administration Record for the month of September 2022 revealed the following: On 9/17/22 8:00 p.m. dose the note indicated was not administered-other. On 9/16/22 2:00 p.m. dose the note indicated was not administered-other. not available On 9/16/22 8:00 a.m. dose the note indicated not available, waiting for approval. On 9/20/22 8:00 p.m. dose the note indicated was refused by resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a facility tour on [DATE] at 10:01 a.m., a round white tablet was found on the floor between Resident #50's bed and his roommate's. The tablet was found next to a clear plastic medicine cup, laying on the floor. Photographic evidence was obtained. On [DATE] at 10:06 a.m., an interview was conducted with Staff J, LPN. Staff J was notified there was a white, round tablet on the floor next to Resident #50's bed. Staff J looked at the tablet and stated it looked like a Magnesium tablet for Resident #50. Staff J retrieved the tablet from the floor, placed it in a plastic cup and stated she would follow-up with the nurse. She stated they would review to see when it was dropped. Staff J confirmed resident's medications should not be on the floor. On [DATE] at 09:49 a.m., an interview was conducted with Staff D, LPN/ UM (Unit Manager). She stated she followed up with the nurse on shift, and the nurse had stated the tablet belonged to Resident #50 but did not match his morning medications. Staff D said, it looked like it was from the night shift. The resident may have spit it out of his mouth. She stated she would educate the nurses on the expectation to supervise residents during medication administration. On [DATE] at 12:34 p.m. an observation was made of two bottles of medicated shampoo, Ketoconazole 2% in the bathroom shared by Resident #50 and his roommate. The two bottles were noted with prescription information and Resident's #50's name transcribed on them. In an interview with Resident #50, he stated the staff use the shampoo to wash his hair because he has a problem with dandruff. Photographic evidence was obtained. A review of a document titled, Face sheet, showed resident #50 was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus, mood disorder, Multiple Sclerosis, dermatitis, and vitamin deficiency. A review of a Minimum Data Set (MDS) printed [DATE], showed Resident #50 has a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Section G-Functional status showed Resident #50 was totally dependent on staff for bathing, with one-person physical assist. A review of an active physician orders list for Resident #50 showed the medicated shampoo was not listed. A review of a Medication Administration Record (MAR) for Resident #50 for the month of February 2023, showed an order for Ketoconazole 2% shampoo scalp, face, and ears. Shampoo and lather for minutes then rinse daily at night shift; diagnosis seborrheic dermatitis, order date [DATE], discontinued [DATE]. On [DATE] at 9:53 a.m., an observation was made of a prescription bottle labeled Nyamyc by Resident #10's bedside table. The small white bottle was noted with the resident's name, instructions for external use only, and an expiration date of [DATE]. An attempt to interview Resident #10 was unsuccessful. Photographic evidence was obtained. A review of active orders for Resident #10 showed there were no current orders for Nyamyc powder. A review of a document titled physician orders list', dated [DATE] to [DATE], showed an order for Nyamyc 100,000 unit/gm (gram) Apply to affected areas topically every morning, order date [DATE] and stop date [DATE]. On [DATE] at 01:38 p.m., an interview was conducted with Staff D. She stated Resident #10 did not have current orders for the Nyamyc powder. Staff D said, either way, it should not have been stored in the room. All medications should be secured. A review of a document titled, Face sheet, showed Resident #10 was admitted to the facility on [DATE] with diagnoses to include pneumonia unspecified, COPD, encephalopathy, and unspecified dementia. An undated MDS for Resident #10 section C, showed a BIMS of 3, indicating severe mental impairment. Section G showed Resident #10 is dependent on staff for ADLs with one-person physical assist. On [DATE] at 04:59 p.m., an interview was conducted with the DON and NHA. The DON stated if she found medication on the floor, she would identify what it is and then discard it. She stated the expectation is to not leave the resident alone during medication administration. The DON said, the nurse should always provide supervision, wait until the resident swallows. The DON stated anything that has a physician order should be considered a medication and should be secured. The DON confirmed a medicated shampoo should be secured and only brought out for use as ordered by the physician. Based on observations, record reviews, and interviews the facility failed to ensure 1) expired supplements and medications were discarded from three of the six medication carts, and 2) medications were stored appropriately for three residents (#50, #10, and #52) out of 43 sampled residents. Findings included: An observation was conducted, on [DATE] at 10:22 a.m., with Staff O, Licensed Practical Nurse (LPN) of the One Center medication cart. The observation revealed an opened bottle of Prostat Liquid Protein with 11/14 written on it. The staff member turned the bottle over and stated it was not expired until May. Staff O confirmed the manufacturer label instructed to discard the bottle 3 months after opening and it should have been discarded a few days ago. An observation on [DATE] at 10:32 a.m., was conducted with Staff M, LPN, of the One [NAME] medication cart. The observation revealed the following: - Levemir insulin pen, with no pharmacy label. A label was located under the pen on the bottom of the drawer which did not include a name of the one resident it was prescribed to. - An opened bottle of Novolog which did not identify an opened date. Staff M read the pharmacy label and stated that the bottle had been received on [DATE]. - One opened bottle, opened on [DATE], which was to be discard after 28 days. The bottle of insulin should have been discarded on [DATE]. - An open bottle of Semglee insulin, opened on 1/24 and to be discarded after 28 days. The bottle should have been discarded on [DATE]. - An Lispro insulin Kwikpen, opened on 1/24 and to discard after 28 days. The pen expired on [DATE]. - An opened bottle of ProStat Liquid Protein, labeled as opened on 11/14. Staff M confirmed that the bottle stated to discard after 60 days. A review of the policy titled Storage of Medications, copyrighted 2001 and revised [DATE], indicated the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy identified the following: - Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. - Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On [DATE] at 2:36 p.m., the Consultant Pharmacist was made aware of the concerns found with the medication carts. The consultant reported during a review of a facility medication carts 6 insulin pens were found without pharmacy labels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure privacy during personal care for one (#60) resident out of 46 residents sampled. Findings included: Resident #60 was observed from the hallway, on 6/3/21 at 6:11 a.m., standing up between an over-the-bed table and the bed, facing the door and not wearing any undergarments. Staff Member S, Certified Nursing Assistant (CNA), was observed standing to the side of the resident, bent over at the waist, and performing peri-care for the resident. As this writer introduced herself to the nurse who exited the resident room close to Resident #60's room, Staff S looked up, saw the writer standing in the hallway with the nurse, and exclaimed, oh no, reached over and shut the resident's door. Resident #60 was admitted on [DATE]. The Face Sheet included diagnoses not limited to Chronic Obstructive Pulmonary Disease (COPD) and Major Depressive Disorder (MDD). The Annual Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 6, indicative of severe cognitive impairment. The MDS revealed that the resident required an extensive assist from one-person for toileting, hygiene, and dressing and was frequently incontinent of bowel and bladder. The care plan for the resident included the problem that she does have episodes of incontinency and that staff should provide and utilize incontinence products as needed to provide dignity and protection. At 6:15 a.m., Staff S stated Resident #60 was upset and just wanted me to change her. The staff member stated she normally does provide residents with privacy. The policy, Quality of Life - Dignity, revised August 2009, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy indicated Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The policy also identified that Demeaning practices and standards of care that compromise dignity are prohibited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one (Resident #59) of three residents sampled for accidents had an accurate and current Minimum Data Set related to the use and placement of an elopement prevention alarm. Findings included: A review of Resident #59's Face Sheet, revealed a current admission date of 09/11/2015 with medical diagnoses of viral pneumonia, muscle weakness, unspecified mood affective disorder, and chronic obstructive pulmonary disease. Resident #59's MDS [Minimum Data Set] 3.0 Nursing Home Quarterly . dated 03/15/2021, revealed under Section C: Cognitive Patterns a Brief Interview for mental Status score of 14; indicating an intact cognition. Under Section G: Functional Status, it was revealed Resident #59 required extensive assistance with one-person for transfers, dressing, and personal hygiene. Resident #59 has a mobility device of a wheelchair. A review of Resident #59's Physician Order Report, revealed an active general order, dated 11/25/2019-Open Ended for wanderguard to Left ankle. A review of Resident #59's Progress Notes revealed a notation dated 11/25/2019 stating Resident found in w/c [wheelchair] in parking lot of facility. Resident easily redirected and brought back into facility. When asked why she had gone to parking lot, resident stated I was going to my son-in-laws, I have to make the rice, . New Order received for wanderguard and refer to pysch . Wanderguard placed to L. [left] ankle An observation and interview on 06/02/2021 at 1:23 p.m. with Resident #59 revealed no wanderguard placed on the Resident's person. Resident #59 was sitting in a wheelchair with a rolled-up towel held in her contracted left hand. Resident #59 stated she has had a contracted hand for a long time and her left leg was weak. During an interview on 06/03/2021 at 8:31 a.m. with Staff C, Registered Nurse/Unit Manager revealed if a resident is ordered an elopement alarm bracelet a physician order is placed into the online medical system and checked each shift for placement. If the elopement alarm bracelet is discontinued, then the active order is canceled after approval from the doctor. A progress note would be entered explaining why the elopement alarm bracelet was removed and an e-mail would be sent to the MDS/Care Planning department to have the information updated and reflected in the resident's online medical record. He stated currently there were no residents on his unit with an elopement alarm bracelet. A review of General Order, start date 11/25/2019 revealed an order to Check wanderguard to L. ankle for proper functioning daily . with a discontinue date of 11/20/2020 with a discontinue reason of Condition resolved. A review of the MDS dated [DATE] and the MDS dated [DATE] under Section P: Restraints and Alarms that Resident #59 revealed Resident #59 was coded for daily use of a Wander/elopement alarm. During an interview on 06/03/21 at 10:11 a.m. with Staff P, RN, Staff Q, RN and Staff R, LPN revealed all three staff members had duties of creating and coding for MDS and were considered MDS Coordinators. The procedure for MDS includes gathering information from the computer chart, staff, the resident regarding their activities of daily living to ensure an accurate and up to date MDS record. If a discrepancy is found during the review process, then the MDS Coordinators will go to the direct care staff. Additionally, one of the RNs (Staff P or Staff Q) must sign off for Staff R since she is an LPN upon completing an MDS. Staff Q, RN reviewed Resident #59's MDS record and confirmed the coding selection for an elopement alarm being used daily. A policy review of MDS Completion and Submission Timeframes, revised July 2017, revealed . Our facility will conduct and submit assessments in accordance with current federal and state submission timeframes . Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure that the behaviors, outcomes, and non-pharmaceutical interventions were monitored for one (#396) out of five residents sampled for unnecessary medications. Findings included: Resident #396 was admitted on [DATE]. The Face Sheet included diagnoses not limited to mild recurrent Major Depressive Disorder and a history of falling. An observation, on 6/1/21 at 10:52 a.m., Resident #396 was observed sitting in a chair next to the resident's bed. On 6/4/21 at 12:06 p.m., the resident was observed sitting up in bed watching television, and with a walker at the bedside. Resident #396's Medication Administration History for June 2021 indicated the resident was receiving the following psychotropic medications: - Aripiprazole (Abilify) 15 milligram (mg) tablet once a day for depression, started 5/28/21. - Sertraline (Zoloft) 50 mg tablet once a day for depression, started 5/28/21. The Medication History, printed on 6/2/21 at 2:04 p.m., for Resident #396 did not include monitoring for the resident's behaviors related to the administration of the antipsychotic medication, Aripiprazole and the antidepressant medication, Sertraline. A continued review of the history did not identify staff were monitoring for the side effects related to the above medications, non-pharmaceutical interventions utilized, or the outcome of the medications. The baseline care plan for Resident #396 indicated that the resident was alert and cognitively intact, had a history of falls, received psychotropic medications and did not have any behavior concerns. A revised care plan indicated that the resident was at risk for side effects related to the use of psychotropic medications, use of antipsychotics and antidepressants for the diagnosis of depression. The interventions related to the resident's use of psychotropic medications instructed staff to observe for signs and symptoms of side effects. A review of the observations and progress notes for Resident #396 did not indicate that the staff had noted any behaviors or side effects related to the administration of the resident's psychotropic medication. At 10:53 a.m. on 6/4/21, the Director of Nursing (DON) reviewed the physician orders for Resident #396 and confirmed that the target behaviors should be monitored and there should be an order for monitoring. He stated that the facility does a double-check of the chart and does not know why this resident's chart was missed. The policy, Behavioral Assessment, Intervention, and Monitoring, revised March 2019, indicated that behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment and that the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The policy Interpretation and Implementation identified that the nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: onset, duration, intensity, and frequency of behavioral symptoms. The management portion of the policy indicated that non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. The monitoring portion of the policy identified that if antipsychotic medications are used to treat behavioral symptoms, the Interdisciplinary team (ID) will monitor their indication and implement a gradual dose reduction, or document why this cannot or should not be done. The ID will monitor for side effects and complications related to psychoactive medications.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed, and twenty-six errors were identified for five (#398, #395, #70, #63, and #31) of five residents observed. These errors constituted an 83.87% medication error rate. Findings included: 1. On 6/2/21 at 10:11 a.m., an observation of medication administration with Staff Member T, Licensed Practical Nurse (LPN), was conducted with Resident #398. Staff T was observed administering the following medications: - Clopidogrel 75 milligram (mg) orally - Glipizide 5 mg orally A review of the Physician Orders for Resident #398 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Clopidogrel 75 mg orally once a day - Glipizide 5 mg orally once a day At 10:23 a.m. on 6/2/21, Staff T noted the medications, after the administration, as it was a late administration, then after a computer glitch she reentered the medication comment as charted late. 2. On 6/2/21 at 10:35 a.m., an observation of medication administration with Staff Member T, Licensed Practical Nurse (LPN), was conducted with Resident #395. Staff T was observed administering the following medications: - Vitamin B12 500 microgram (mcg) orally - Spiriva handihaler 2 inhalations - Losartan Potassium 2-50 mg tabs (100 mg) orally - Ferrous Gluconate 324 mg orally - Furosemide 40 mg orally - Dulera 100mcg/5mcg 1 inhalation A review of the Physician Orders for Resident #395 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Vitamin B12 500 mcg orally once a day - Spiriva Respimat 1.25 mg/actuation 2 puffs once a day - Losartan 100 mg orally once a day - Ferrous Gluconate 324 mg orally twice a day - Furosemide 40 mg orally once a day - Dulera 100-5 mcg/actuation 2 inhalations twice daily On 6/2/21 at 10:41 a.m., Staff Member T confirmed the medications for Resident #398 and #395 were late and it was due to the residents needing more attention, taking the vital signs for all the residents (COVID-19 monitoring), a resident with Alzheimer's was up and walking, and interruptions. At 3:42 p.m. on 6/2/21 the staff member stated technically charted late and administered late were the same thing. 3. On 6/2/21 at 5:22 p.m., an observation of medication administration with Staff Member T, Licensed Practical Nurse (LPN), was conducted with Resident #70. The staff member stated that the insulin was late and the time of administration needed to be adjusted as the meal trays did not arrive until now. After obtaining a blood glucose level of 160 from Resident #70, Staff T was observed dispensing the following medications: - Metformin 500 mg orally - Ondanasetron 4 mg as needed orally - Potassium Chloride 20 milliequivalent (mEq) orally - Furosemide 20 mg orally - Novolog FlexPen 100 unit/milliliter - 2 units subcutaneously Staff Member T was observed placing an insulin pen needle on the FlexPen, rolled the pen between her hands, she dialed the pen to 2 units, turned the pen upside down, and with the needle facing the facility floor the nurse depressed the injection knob. The LPN turned the injection knob to 2 units, entered the resident room and administered the dispensed medications at 5:40 p.m., as the resident was observed sitting in bed eating the evening meal. A review of the Physician Orders for Resident #70 revealed the following medication orders and the scheduled time of administration: - Metformin 500 mg orally twice a day, 9 a.m. and 5 p.m. - Ondansetron Hydrochloride (HCl) 4 mg orally every 6 hours as needed - Potassium Chloride extended release 20 mEq orally twice daily, scheduled 9 a.m. and 5 p.m. - Furosemide 20 mg orally twice a day, scheduled at 9 a.m. and 5 p.m. - Insulin Aspart U-100 solution; per sliding scale: If blood Sugar is 151 to 200 units give 2 units, scheduled before meals and at bedtime; 6 a.m., 11 a.m., 4 p.m., and 8 p.m. During the administration of the medication Staff Member T stated the purpose of priming the pen was to remove the air bubble from the pen. She confirmed that the air bubble moved away from the needle when the pen was turned upside down and was not removed when she had primed the pen. According to the NovoLog manufacturers instruction insert, located at https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen%20IFU%20PDF_LOCKED.pdf, instructed users in priming of the pen: - Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - E. Turn the dose selector to 2 units. - F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the needle pointing upwards, press the push button all the way in. The dose selector turns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. 4. On 6/3/21 at 10:42 a.m., an observation of medication administration with Staff Member U, Licensed Practical Nurse (LPN), was conducted with Resident #63. Staff U was observed dispensing the following medications: - Amlodipine 10 mg oral tablet - Buspirone 10 mg oral tablet - Divalproex Delayed Release 125 mg oral tablet - Aspirin Low Dose 81 mg chewable tablet - Ocular Vitamin 2 oral tablets The resident refused the medications. A review of the Physician Orders for Resident #63 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Amlodipine 10 mg orally once a day - Buspirone 10 mg orally twice a day - Depakote (Divalproex) Delayed Release 125 mg orally once a morning - Aspirin Delayed Release/Enteric coated 81 mg orally once a day - AREDS 2 orally twice a day 5. On 6/3/21 at 10:51 a.m., an observation of medication administration with Staff Member U, Licensed Practical Nurse (LPN), was conducted with Resident #31. Staff U was observed dispensing the following medications, following obtaining a blood glucose level of 272: - Aspirin Low Dose Chewable 81 mg orally - Carvedilol 3.125 mg orally - Bumetanide 1 mg orally - Gabapentin 300 mg orally - Nifedipine 30 mg Extended Release orally - Linzess 145 mcg orally - Magnesium Oxide 400 mg orally - MultiVitamin tablet orally - Ondansetron Disintegrating 4 mg orally - Bupropion 100 mg tab Sustained Release orally - Polyethylene Glycol 17 grams (gm) mixed with 4 ounces of water - Insulin Aspart, 100 unit/milliliter vial, 9 units subcutaneously A review of the Physician Orders for Resident #31 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Aspirin Delayed Release/Enteric Coated 81 mg oral once a day - Carvedilol 3.125 mg oral twice a day - Bumetanide 1 mg oral twice a day - Gabapentin 300 mg oral twice a day - Nifedipine Extended Release 30 mg oral twice a day - Linzess 145 mcg oral once a day - Magnesium Oxide 400 mg oral once a day - MultiVitamin oral once a day - Ondansetron Disintegrating 4 mg every 4 hours orally - Bupropion HCl Sustained Release 100 mg oral twice a day - Polyethylene Glycol 17 gm oral once a day - Novolog FlexPen U-100 (Insulin Aspart), scheduled at 11 a.m., per sliding scale before meals and at bedtime. - If blood sugar is 251 to 300 give 9 units. - Docusate Sodium 100 mg oral twice a day The observation indicated that Staff U did not dispense or administer Docusate Sodium 100 mg orally that was scheduled twice daily at 9 a.m. and 9 p.m. and had administered a chewable tablet of low-dose Aspirin versus the ordered enteric coated tablet. A review at 12:35 p.m. on 6/3/21 did not indicate that the physician/provider was notified prior to the administration of late medications for Resident #63 and/or #31. An interview was conducted, on 6/3/21 at 11:46 a.m., with Staff Member U, LPN. The staff member stated the reason the medications were late was that it was a heavy load, have 30 patients, and by the time I'm down to her (end of hallway) they're late. The Director of Nursing (DON) stated, on 6/4/21 at 10:53 a.m., that he was aware of some of the medication administration issues and that the facility was looking at implementing a liberalized medication pass. He acknowledged that priming a Novolog pen was to be done with the needle upwards. The policy titled Administering Medications, revised April 2019, identified that Medications are administered in a safe and timely manner, and as prescribed. The policy's Interpretation and Implementation indicated the following: - The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. - Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. - Medications are administered in accordance with prescriber orders, including any required time frame. - Medications are administered within one (1) hours of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observations, interviews and record review the facility failed to 1) maintain drugs and biologicals used in the facility in a safe, secure, and orderly manner for three medication carts (Second floor East and [NAME] medication carts, and First floor [NAME] cart) of five medication carts as evidenced by insulin pens and insulin vials without documented opened-on dates, and 2) the facility failed to secure the contents of two (first floor west, second floor east) of five medication carts observed during survey. Findings included: 1) On 6/4/21 at 12:18 p.m. an observation of the medication cart for the Second-Floor East hall was conducted. Staff L, Licensed Practical Nurse (LPN) was present during the observation. In the top left drawer of the cart, a Levemir FlexTouch pen was observed stored in a bag, with no open or expiration date documented. A Kwikpen of Lispro insulin was stored in a bag without an opened-on date. A Novolin 70/30 Flexpen was observed with no open date documented. An open Levemir multi-dose vial (MDV) was observed with an open date of 3/23/21, and a pharmacy label stating discard after 28 days. (Photographic Evidence Obtained). In the right bottom drawer of the cart a one-half white pill and four white loose pills were observed. In the third drawer of the cart two red round pills, one white round pill and one-half white pill, loose were observed. In the second drawer of the cart one white round pill, and two half white loose pills were observed. An interview was conducted with Staff L, LPN. Staff L stated that she had worked there for two months and did not know who should do the cart cleaning. Staff L, LPN left the cart during inspection, and Staff J, Unit Manager, replaced her and stated it was the expectation that all insulin pens and (MDV) were dated when they were removed from the refrigerator and that the carts were to be cleaned daily. On 6/4/21 at 12:42 p.m. an observation of the medication cart for the Second-floor [NAME] hall was conducted. Staff K, Registered Nurse (RN) was present during the observation. In the top drawer, a Novolog FlexPen was observed stored in a bag with no date as to when it was removed from the refrigerator. A variety of insulin pens were observed not stored in bags, two of the pens had open dates documented, but none of the pens had resident identifying information. A NovoLog Flexpen was observed with an open date of 4/19/21, the discard date was covered by a label. A Novolin 70/30 Flexpen was observed with no open date. A Levemir Flexpen was observed with no open date. An open Lantus multi-dose vial stored in a container was observed with an open date of 4/11/21. An open Lantus 100 unit multi-dose vial stored in a container was observed with no open date. An open Novolog multi-dose vial stored in a container was observed with an open date of 3/16/21 (Photographic Evidence Obtained). In the right third drawer of the cart one oblong white pill, one red pill, and one white oblong pill were observed loose in the drawer. In the left second drawer, one loose blue round pill was observed. In the left second drawer one loose white oblong pill, and one oval orange loose pill were observed. Staff K, RN, stated that all staff should keep the medication cart clean. She stated that she was not sure how long open multi-dose vials or insulin pens could be stored out of the refrigerator. Staff K also stated that she would check with the pharmacy regarding correct storage of insulin. On 6/4/21 1:15 p.m. an observation of the medication cart for the First-floor [NAME] hall was conducted. Staff C, RN/Unit Manager was present during the observation. An insulin pen was observed stored in a bag with no open date (Photographic Evidence Obtained). In the right second drawer one loose purple oblong pill and one loose round white pill were observed. An interview was conducted with Staff C, RN/Unit Manager who stated that this is wrong and confirmed that all insulin pens and multi-dose vials should be dated when removed from the refrigerator and opened. He also stated that he would follow up with the staff to ensure that the medication carts would be kept clean and tidy and the correct dating procedures would be followed. A review of the facility policy titled, Storage of Medications, effective date 2001 and revised April 2019, revealed: Policy Statement: The facility stores all medications and biologicals in a safe, secure, and orderly manner. Policy, Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. 3. Nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 10. Resident medications are stored separately from each other to prevent the possibility of mixing medications between Residents. 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Mediations are stored separately from food and labeled accordingly. Review of the manufacturer instructions related to the storage and use of Insulin multi-dose vials and pens revealed that when stored at room temperature, MDVs and pens should be discarded 28 days after opening. Levemir MDV and Flexpen should be discarded 42 days after opening. Humolog Kwickpens, https://www.humalog.com/taking-humalog/using-u100-u200-kwikpen#using-humalog-u-100-u-200 Levemir, https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/LevemirIFU.pdf Novolog insulin is a Novomed product, https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen%20IFU%20PDF_LOCKED.pdf Novolin 70/30 pens, https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLogMix7030IFU.pdf 2) An observation of the medication cart for the east hall of the second floor was conducted on 06/03/21 at 9:25 AM. The cart was unattended in the hallway in close proximity to the nursing station, several residents were observed self-propelling in the area. The DON confirmed that the cart could be opened and should be locked when unattended by the nurse. Staff A, LPN stated that she was responsible for the cart and had left it for a minute to care for a resident concern, she confirmed that the cart should not be left unlocked when unattended, and stated that it was not safe to do so especially when there were residents in close proximity. An observation later that morning, at 10:00 AM on the first floor revealed a similar occurrence with the west cart left unattended and unlocked. The nursing home administrator (NHA) confirmed that the cart was open. He confirmed that the cart should not be left unlocked when unattended. Staff B, LPN returned to the cart and confirmed that she was responsible for leaving it unlocked, she stated that she had recently received education related to making sure the cart was never left unlocked and when unattended. A review of the Facility's policy on medication storage with a revised date of April 2019 stated, paragraph 8. Compartments (including, but not limited to, drawers, . carts, and boxes) containing drugs and biologicals are locked when not in use. And paragraph 9. Unlocked medication carts are not left unattended. During observation of Medication Administration, on 6/3/21 at 10:51 a.m., Staff Member U, Licensed Practical Nurse (LPN), removed a Novolog vial from the medication cart for Resident #31. The Novolog vial was dated as opened on 4/8/21 and was to be discarded after 28 days. The staff member was unable to locate any other Insulin Aspart vial or FlexPen in either the medication cart or medication refrigerator. Staff U called the pharmacy for permission to remove Insulin Aspart from the emergency drug kit.