**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than five percent. A total of twelve medication administration opportunities were observed with four errors for two (#4 and #5) of four residents sampled for medication administration, which resulted in a medication administration error rate of 33.33%. Findings included: A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of hypertension and nontraumatic intracranial hemorrhage. A review of Resident #4's physician orders revealed the following orders: - An order dated 4/23/2024 for levetiracetam 1000 milligrams (mg) one tablet by mouth (PO) every 12 hours at 8:00 AM and 8:00 PM for seizures. - An order dated 5/10/2024 for metoprolol tartrate 50 mg one tablet PO two times a day at 8:00 AM and 9:00 PM for hypertension. An observation of medication administration was conducted on 9/3/2024 at 9:12 AM with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN prepared the following medications for administration to Resident #4: - levetiracetam 1000 mg, one tablet. - metoprolol tartrate 50 mg, one tablet. After preparing the medications Staff A, LPN entered Resident #4's room and administered the two medications. Staff A, LPN did not notify Resident #4 or Resident #4's physician prior to administering the two medications late. A review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, atherosclerotic heart disease of coronary artery, and depression. A review of Resident #5's physician orders revealed the following orders: - An order dated 6/26/2024 for aspirin delayed release 81 mg 1 tablet PO one time a day at 8:30 AM for coronary artery disease. - An order dated 6/26/2024 for amlodipine besylate 10 mg one tablet PO one time a day at 8:30 AM for hypertension. - An order dated 6/26/2024 for clopidogrel 75 mg one tablet PO one time a day at 8:30 AM for atrial fibrillation. - An order dated 6/26/2024 for indapamide 1.25 mg one tablet PO one time a day at 8:30 AM for fluid retention. - An order dated 6/26/2024 for paroxetine hydrochloride (HCl) 30 mg one tablet PO one time a day at 8:30 AM for depression. - An order dated 6/26/2024 for levetiracetam 500 mg one tablet PO two times a day at 8:30 AM and 9:00 PM for seizures. - An order dated 6/26/2024 for magnesium oxide 400 mg one tablet PO two times a day at 8:30 AM and 9:00 PM for supplementation. - An order dated 8/31/2024 for depakote sprinkles 125 mg 3 capsules PO three times a day at 8:30 AM, 4:30 PM, and 9:00 PM for mood disorder. An observation of medication administration was conducted on 9/3/2024 at 9:18 AM with Staff A, LPN. Staff A, LPN prepared the following medications for administration to Resident #5: - Aspirin 81 mg chewable 1 tablet. - Amlodipine besylate 10 mg one tablet. - Clopidogrel 75 mg one tablet. - Indapamide 1.25 mg one tablet . - Levetiracetam 500 mg one tablet. - Depakote sprinkles 125 mg 3 capsules. After removing the medications from the medication cart Staff A, LPN crushed each medication individually and placed the medication in a small amount of pudding per Resident #5's preference. After preparing the medications Staff A administered the six medications to Resident #5 and returned to the medication cart. Staff A, LPN accessed Resident #5's electronic medication administration record (eMAR) and signed off the six medications as administered. Staff A, LPN also signed off paroxetine HCl 30 mg one tablet as administered but did not pull the medication from the medication cart to administer to Resident #5. After saving the data, the order for magnesium oxide 400 mg one tablet appeared as not being administered. Staff A, LPN removed magnesium oxide 400 mg one tablet, crushed the tablet, added the crushed tablet to a small amount of pudding, and administered the medication to Resident #5. After administering the medication Staff A, LPN accessed Resident #5's eMAR and marked the magnesium oxide 400 mg one tablet as administered. Staff A, LPN did not administer paroxetine HCl 30 mg one tablet to Resident #5. Following the observation of medication administration, an interview was conducted with Staff A, LPN at 9:38 AM. Staff A, LPN accessed Resident #5's eMAR and reviewed the physician order for aspirin delayed release 81 mg. Staff A, LPN removed the bottle of aspirin 81 mg chewable tablets and stated she administered the chewable form of the medication to Resident #5 because he's a crush, I had to give the chewable. Staff A, LPN addressed Resident #5's physician order for aspirin 81 mg delayed release did not match what she removed from the medication cart and stated I'm not sure what to do after the fact. Staff A, LPN reviewed Resident #5's eMAR and observed the physician order for paroxetine HCl 30 mg. Staff A, LPN was not aware she did not remove the medication to administer to Resident #5 before signing the medication off as administered in the eMAR. During the interview with Staff A, LPN, Staff B, Registered Nurse (RN) and Unit Manager (UM) approached the medication cart and was interviewed. Staff B, RN UM stated Resident #5's physician order for aspirin 81 mg should be for the chewable form of the medication and not the extended release form. Staff B, RN UM also stated if a different form of a medication was administered and did not match the physician order, it would be considered a medication error. Staff B, RN UM stated medications should be administered between an hour before and an hour after the scheduled time and if a medication is going to be administered late, the nurse should notify the resident's physician before administering the medication. Staff A, LPN stated she was aware the resident's physician needed to be notified when a medication is administered late, but was not sure if the physician needed to be notified prior to administering the medication or after administering the medication. Staff A, LPN also stated, maybe I wouldn't have made the error if you weren't watching me. An interview was conducted on 9/3/2024 at 1:57 PM with the facility's Director of Nursing (DON). The DON stated facility nursing staff were educated at orientation and at skills fairs on the rights of medication administration, which included the right medication, right dose, right resident, right time, and right route. The DON also stated nursing staff should notify the resident's physician if a medication was going to be administered late and the notification should occur prior to the late administration. The DON stated medications should be administered between an hour before and an hour after the scheduled time. A review of the facility policy titled Medication Administration, last revised on 9/1/2023, revealed under the section titled Policy, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The policy also revealed the following steps under the section titled Policy Explanation and Compliance Guidelines: - Review MAR to identify medication to be administered. - Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. - Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. - Administer medications as ordered in accordance with manufacturer specifications. - If any medication is not available, or the possibility of late administration, the Nurse will contact the Attending Physician. - Sign MAR after administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to assess two residents (#73 and #178) out of twenty-eight sampled residents for the self-administration of medications and to ensure the self-administered medications were safely stored. Findings included: 1. On 5/18/24 at 12:14 p.m. Resident #73 was observed and interviewed in the resident's room. The observation revealed an allergy nasal spray bottle, 3 vials of an unknown type of eye drop and a medication bottle with a green top sitting on top of the bedside dresser underneath the resident's computer monitor. The resident reported having a lot of environmental allergies and the nasal spray was Fluticasone. Review of Resident #73's admission Record revealed the resident was admitted on [DATE]. The record revealed diagnoses not limited to sequela unspecified fracture of right femur, unspecified rheumatoid arthritis, and history of falling. The admission Record showed the resident suffered from almond, bread, tree, and shrub pollen allergies. Review of Resident #73's Order Summary Report, active as of 5/20/24 at 12:51 p.m., showed the resident did not have an order for Fluticasone nasal spray and an order had been received on 5/18/24 to start 5/19/24 for Artificial Tears Solution 1.4% (polyvinyl alcohol) - Instill 1 drop in both eyes one time a day for dry eyes, irritation. MAY KEEP AT BEDSIDE. The summary revealed an order received on 5/18/24 allowing the resident PER Advanced Registered Nurse Practitioner (ARNP) MAY KEEP EYE DROPS AT BEDSIDE. Review of Resident #73's May 2024 Medication Administration Record (MAR) showed an order for Artificial Tears solution, scheduled at 7 - 11 a.m., which started on 4/26/24 and discontinued at 4:54 p.m. on 5/14/24, an order which started on 5/15 and discontinued at 5/18/24 at 12:17 p.m. for Artificial Tears, and an order to start on 5/19/24 at 9:00 a.m. for Artificial Tears allowing for the resident to keep drops at bedside. The discontinued orders for Artificial Tears started on 4/26/24 and 5/14/24 did not reveal the resident was allowed to keep eye drops at bedside. Review of Resident #73's May MAR did not include an order for Fluticasone nasal spray. Review of Resident #73's Medication Self-Administration Safety Screen, dated 5/18/24 at 12:18 p.m., revealed the instructions were to complete this assessment prior to resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self-administer medications. Ongoing assessment should occur at a minimum of quarterly. Use clinical judgment with Section B to determine if or what level of self-administration will be allowed. The review revealed the list of medications being considered for resident self-administration as Tears One drop in each eye Once daily and storage was Bedside with resident. The screen did not reveal any other medication being considered for self-administration. The screening revealed, The resident can demonstrate secure storage of medications kept in room. Completely capable. The screening was completed by Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). Review of Resident #73's care plan did not reveal the resident was able to self-administer medications. During an interview on 5/20/24 at 11:08 a.m. Staff E, LPN/UM reported the physician had screened (for self-administration of medications) Resident #73 on Friday (May 17th) and the Regional Nurse Consultant (RNC) had to find the appropriate screening. The staff member stated the screening should have included all medications if at bedside and at admission. Staff E stated the facility does ask or tells residents not to bring medications from home. The staff member reported the resident should have been care planned for self-administration. 2. On 5/18/24 at 11:08 a.m. Resident #178 was observed and interviewed lying in bed with an over-bed table in a reachable distance to the resident. The observation showed an unopened box of 20 pain relief topical patches and an opened roll-on pain reliever lying on the over-bed table and a tube of 100% Leptospermum Scoparium honey gel lying on the vanity across from the resident's bed. The resident stated her [family member] brought them (patches) in, did not think the facility even noticed (the resident) had them, and used the roll-on on arms 1-2 times a day. The resident reported not using the roll-on as often since starting therapy. The resident admitted to having a butt wound and did not know what (the facility) was putting on it. On 5/19/24 at 1:48 p.m. Resident #178 was observed lying in bed, the pain relief topical patches and roll-on pain reliever was no longer lying on the over-bed table. The resident stated the girl who took the patches told the resident they had to take them. Review of Resident #178's admission Record showed the resident was admitted on [DATE] and diagnoses included but was not limited to sequela (of) unspecified injury to unspecified level of lumbar spinal cord, unspecified hemiplegia affecting right dominant side, and uncomplicated opioid dependence. Review of Resident #178's Admission/readmission Nursing Evaluation, effective 5/18/24 at 9:18 p.m., showed the resident was to receive wound care, the resident's skin integrity was impaired with dry skin to nose and forehead, boggy bilateral heels, and redness to coccyx, the resident was medicated for pain and routine or as needed (PRN) pain medication had been ordered. The resident had reported sharp left lower leg pain that was alleviated with pain medication. The evaluation revealed the resident had not requested to self-administer any medications. Review of Resident #178's Order Summary Report, active as of 1:05 p.m. on 5/20/24, did not reveal an order allowing for the resident to self-administer any medication. The report did not reveal an order for either pain relief topical patches or a roll-on pain reliever. The Order Report did reveal the following: - Wound Care: Sacrum Pressure Injury (PI) stage 2. Clean with normal saline (N/S), apply Honey Fiber and cover with border foam one time a day for treatment. Ordered 5/17/24. Review of Resident #178's Medication Administration Record (MAR) revealed the resident was receiving Oxycodone 10 milligram (mg) frequently as needed (PRN) for pain. The MAR did not reveal an order for pain relief patches, or a roll-on pain reliever was active or discontinued. Review of Resident #178's care plan showed the resident had mildly impaired cognitive function with short-term memory loss. The care plan showed the resident had acute/chronic pain related to (r/t) (blank). The interventions did not reveal the resident was allowed to self-administer pain medication. During an interview on 5/20/24 at 11:42 a.m. Staff E, LPN/UM reported Resident #178 should have been screened for self-administration for pain relief patches and/or roll-on pain reliever at bedside. The staff member stated in her opinion the resident did not have the capability to self-administer since staff had to do everything for the resident. Review of the policy titled, Resident Self-Administration of Medication, implemented 9/1/23, showed It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facilities interdisciplinary team has determined which medications may be self-administered safely. A review of the policies compliance guidelines revealed: 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facilities interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; b. The resident's physical capacity to: swallow without difficulty, open medication bottles, (and/or) administered injections; c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; d. The resident's capability to follow directions and tell time to know when the medications need to be taken; e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to the facility staff. f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs. g. The resident's ability to ensure that medication is stored safely and securely. 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medications. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. 8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families are the responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. 13. The care plan must reflect resident self-administration and storage arrangements for such medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure reasonable accommodations were made to ensure one resident (#29) of twenty four sampled residents was provided the right sized incontinent supplies. Findings included: An interview was conducted with Resident #29 on 5/18/24 at 11:52 a.m. in her room while she was in bed. She stated for the last two weeks she hasn't been able to get medium size pull ups. She said, That is what I always wear. Right now I'm wearing small youth and they are tight. I have severe diarrhea and these are so tight. She confirmed she has told staff members but could not recall their names. Review of the admission Record for Resident #29 revealed her most recent admission to the facility was 2/28/23 with diagnoses to include depression, anxiety, muscle wasting and atrophy, difficulty in walking, muscle weakness and need for assistance with personal care. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 3/27/24, revealed in Section C- Cognitive Patterns for the Brief Interview for Mental Status (BIMS) a score of 15, indicating the resident was cognitively intact. Section GG - Functional Abilities and Goals scored a 6 for independent for toileting hygiene. Section H - Bladder and Bowel shoed Resident #29 was always continent of bowel and bladder. A review of the active physician orders as of 5/20/24 revealed: Dicyclomine HCI Oral Capsule 10 MG (milligrams) - give 1 capsule by mouth two times a day for IBS (irritable bowel syndrome), start date of 5/10/24, Furosemide Oral Tablet 40 MG - give 1 tablet by mouth one time a day for edema, start date of 5/10/24, Loperamide HCI Capsule 2 MG - give 1 capsule by mouth as needed for loose stool after each loose stool, start date of 2/28/23. A review of the facility grievance log for May 2024 revealed no grievances for Resident #29. Review of Resident #29's current care plan revealed focus areas as: * The resident has bladder incontinence r/t (related to) dementia, impaired mobility, initiated 9/29/22. Interventions included: Brief use - the resident uses disposable briefs. Check and change prn (as needed), initiated 5/20/24. * The resident has bowel incontinence r/t immobility, initiated 9/29/22. Interventions included: check resident routinely and assist with toileting as needed, provide loose fitting, easy to remove clothing. * The resident has an ADL (activities of daily living) self-care performance deficit r/t activity intolerance, dementia, impaired balance, limited mobility. Interventions included: toilet use - the resident is independent for toileting. An interview was conducted on 5/20/24 at 10:32 a.m. with Staff H, Certified Nursing Assistant (CNA). Staff H stated the facility has a chart that tells them what size briefs a resident wears. For Resident #29, Staff H logged into the electronic medical record and looked at the [NAME]. Staff H stated she uses the restroom by herself so we wouldn't supply her any. A review of the [NAME] for Resident #29 revealed in the Bladder/Bowel section the following: * Brief use: The resident uses disposable briefs. Check and change prn (as needed). * Incontinent: Check and change as required for incontinence. Wash, rinse and dry perineum. Change clothing prn after incontinence episodes. The [NAME] was silent of what size disposable briefs Resident #29 wore. Resident #29 was interviewed on 5/19/24 at 10:30 a.m. and stated she had a shower and that her roommate went to the A Wing and got her some briefs. She now has four to use. An interview was conducted on 5/20/24 at 2:19 p.m. with Staff J, Central Supply. Staff J explained when a resident first comes into the facility she will measure them and if they gain weight they will remeasure if needed. She stated there was no list of residents and the sizes they wore for briefs or pull ups. She stated, No, I'm the only one who does this. She stated she knows everyone. She confirmed Resident #29 wore a medium. She said, She wears a medium pull up. She stated she thinks Resident #29 could fit in a small, but she prefers medium. She stated on Fridays she stocks the clean linen closet with a case of each size for residents. She stated residents will tell her if they need more. She stated, she leaves enough for the weekend. Staff J stated she doesn't order [NAME] because there is no one here who wears small. During an interview and observation on 5/20/24 at 2:24 p.m. with Staff J, Central Supply a 22 pack of youth small pull ups were observed to the side of Resident #29's bed. Staff J stated that maybe Resident #29's family member sent them because she only uses medium. At this time, Resident #29 confirmed another staff member gave them to her and stated, They really don't fit. On 5/20/24 at 2:36 p.m. two packages of youth extra small pull ups were found on the shelf in the supply shed behind the facility. (Photographic Evidence Obtained) In addition, multiple packages of medium briefs and medium pull ups were observed. Staff J, Central Supply clarified a resident wears briefs if incontinent and pull ups are a resident's choice. If they are care planned for briefs they can choose to wear pull ups. She stated she normally goes to each resident two times a week to see what they need. She confirmed she was not aware of Resident #29's current need for medium pull ups. On 5/20/24 at 6:53 p.m. the Director of Nursing stated a resident could ask staff for the size needed and staff can ask other staff if they are not sure of what size. She confirmed the [NAME] does not provide the size needed for a resident. She stated she hadn't heard anything about Resident #29's need for medium pull ups.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure a care plan had been developed and implemented for one resident (#70) out of one resident sampled for respiratory services. Findings included: On 5/18/24 at 12:31 p.m. Resident #70 was observed lying in bed with a Continuous Positive Airway Pressure (CPAP) machine on the bedside dresser next to the resident. The tubing and cannula attached to the machine were lying on top of it. The resident reported staff do not clean it, did not have anything to clean it with, and she would do it when she discharged to home. On 5/19/24 at 9:27 a.m. Resident #70 was observed lying in bed with the CPAP tubing and cannula sitting on top of the machine. Review of Resident #70's physician orders revealed an order for Bipap to be on every night at 129 setting, started on 3/19/24. The orders did not include an order to clean the equipment after resident use. Review of Resident #70's care plan, on 5/18/24 at 2:19 p.m., revealed no care plan related to the resident's respiratory status or use of respiratory equipment. (Photographic Evidence Obtained) Review of Resident #70's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to subsequent encounter (for) unspecified injury of head and subsequent encounter for fracture of nasal bones with routine healing. An interview was conducted with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM) on 5/20/24 at 10:08 a.m. Staff E stated yes there should be orders for staff to assist with cleaning the CPAP and Resident #70 was an exception, the resident did not want staff to assist with cleaning it and was alert and oriented. Staff E stated there should be a care plan regarding the resident not wanting staff to clean the CPAP. The staff reviewed the resident's care plan and confirmed there was no focus related to the resident having a CPAP. Staff E left the interview to ask the person responsible for developing the care plans to attend the interview. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 5/20/24 at 10:18 a.m. The staff member stated yes there should have been a care plan for Resident #70's use of a CPAP and reported there is now. Review of Resident #70's admission MDS assessment, dated 3/15/24, showed the resident did utilize non-specific oxygen therapy but did not reveal the resident used either CPAP or Bipap equipment. An additional review of Resident #70's Order Summary Report of active, as of 5/20/24 at 12:55 p.m., physician orders did not show staff were to clean or assist the resident with cleaning CPAP equipment. The review revealed active orders for: - BiPAP to be on every night at 129 settings at bedtime for BiPAP, start 3/19/24. - C-PAP to be on every night at 129 settings at bedtime for C-PAP, start on 5/20/24. An interview was conducted with the MDS Coordinator on 5/20/24 at 7:05 p.m. The MDS Coordinator reported reviewing Resident #70's care plan this morning with this writer and when later reviewing it, a care plan had been initiated for the resident's respiratory status on 3/10/24, but the MDS Coordinator had resolved it on 3/19/24 for an unknown reason. The MDS provided a revised care plan for Resident #70's respiratory status which showed the focus, goal, and interventions had been CANCELLED on 3/19/24. Review of the policy titled, Comprehensive Care Plans, implemented 9/1/23, showed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy definition of Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. The review of the compliance guidelines revealed: 1. The care planning process will include an assessment of the resident's strength and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care assessment areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident' exercise of his or her right to refuse treatment. 6. The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to revise the comprehensive care plan related to dialysis services for one resident (#45) of two residents sampled for dialysis. Findings included: Review of the admission Record for Resident #45 revealed he was admitted to the facility on [DATE]. The admission Record revealed diagnoses of end stage renal disease, and dependence on renal dialysis. Review of the active physician orders for May 2024 revealed and order for Dialysis - [Name of Dialysis Center, address and phone number] [name of transport company] transport chair time 0630 (a.m.)/PU (pick up) time 5:30-6a (a.m.) on Tuesday, Thursday and Saturday, 5/2/24 start. During an interview with Resident #45 on 5/18/24 at 12:54 p.m. he stated he goes to dialysis three times a week on Tuesday, Thursday and Saturdays. Review of the active care plan, initiated 2/22/23 and revised 11/20/23, revealed a Focus for renal failure with dialysis T/Th/S (Tuesday/Thursday/Saturday) at [name of dialysis center]. Interventions included: [name of dialysis center] on TU-TH-SA [name of transport company] pick up at 2:00 p.m., chair time is 2:30 p.m., revision 10/11/23. Review of the Dialysis List on the whiteboard in the nurses' station on the B Wing showed Resident #45's Chair time: 7:35 Leave: 12:10 .new time as of 4/24. (Photographic Evidence Obtained) An interview was conducted on 5/20/24 at 10:27 a.m. with Staff H, Certified Nursing Assistant (CNA). Staff H confirmed Resident #45 goes to dialysis. She reviewed the Dialysis List on the whiteboard in the B Wing nurses' station, at this time it was turned over, and stated his chair time is 7:35 (a.m.) so you would have him up at 6 (a.m.) for breakfast. She confirmed she would use this list as it tells staff who you should be expecting. During and interview on 5/20/24 at 11:00 a.m. the Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM) and Director of Nursing (DON) confirmed the physician's order for dialysis for Resident #45 showed a chair time of 6:30 a.m. and a pick up of 5:30 a.m. - 6:00 a.m., as of 5/2/24. They confirmed the care plan showed a chair time of 2:30 p.m. and a pick up time of 2:00 p.m. They confirmed the Dialysis List showed 7:35 a.m. (chair time). They confirmed the 12:10 p.m. time was the time Resident #45 left the dialysis center. The DON stated the 4/24/24 date might have been when he missed dialysis and that it should have been taken down. A care plan was provided for review on 5/20/24 for Resident #45 with a focus for Renal failure with dialysis T/Th/S at [name of dialysis center]. Interventions included: [name of dialysis center] on TU-TH-SA [name of transportation company] pick up at 5:30 a.m. Chair time is 6:30 a.m. During an interview on 5/20/24 shortly after the interview with Staff E, LPN/UM and the DON at 11:00 a.m., Staff I, Transportation confirmed Resident #45's chair time had changed and now the chair time is 7:35 a.m. on Tuesday, Thursday and Saturdays and he is picked up at 7:00 a.m. She stated the sheet at the nurses' station is correct. She confirmed that she ensures any new information was to be communicated to MDS (minimum data set staff) to update the care plan to make sure he gets to dialysis. She stated she forgot to notify MDS of the changes. Review of the policy titled, Comprehensive Care Plans, implemented 9/1/23, showed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The Policy Explanation and Compliance Guidelines revealed: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident' exercise of his or her right to refuse treatment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to assess altered skin conditions and provide wound care according to facility protocol, physician orders, and professional standards for two residents (#15 and #71) out of two residents sampled for non-pressure related skin conditions. Findings included: 1. On 5/18/24 at 10:30 a.m. Resident #15 was observed sitting in the hallway between the two units of the facility. An undated white 2x2 bordered dressing stained with a red substance was observed on the resident's right ankle and a whitish/gray 2x2 bordered dressing dated 5/16/24 was observed on the resident's left ankle. The resident allowed photographic evidence to be obtained. On 5/18/24 at 3:04 p.m. Resident #15 was observed with the same dressings on each lower extremity. On 5/19/24 at 9:01 a.m. Resident #15 was observed with an undated 2x2 white bordered dressing stained with reddish-brown drainage on the right ankle. The observation revealed a dated 2x2 grayish-white dressing on the left ankle. On 5/19/24 at 1:35 p.m. Resident #15 was observed with the same dressings. Review of Resident #15's admission Record showed the resident was admitted on [DATE] and re-admitted on [DATE]. The record revealed diagnoses not limited to unspecified chronic obstructive pulmonary disease, history of falling, other specified glaucoma, and need for assistance with personal care. Review of Resident #15's May 2024 Medication Administration Record (MAR) revealed no order regarding the treatment of the resident's bilateral lower extremity skin alterations. Review of the resident's May 2024 Treatment Administration Record (TAR) showed the following orders: - Clean Skin Tear to left lower extremity. Cleanse with normal saline, pat dry. Change dressing daily and as needed (prn). Every shift for skin impairment for 14 days, discontinue (DC) order after 14 days and leave of absence (LOA). Complete weekly non-pressure wound UDA. Start date: 5/3/24 and discontinued on 5/15/24 at 10:53 a.m. - Clean Skin Tear to left lower extremity. Cleanse with normal saline, pat dry. Change dressing daily and prn every day shift for skin impairment for 14 days. DC order after 14 days and LOA. Complete weekly non-pressure wound UDA. Start date 5/16/24 at 7:00 a.m. and discontinued on 5/20/24 at 9:20 a.m. - Weekly skin checks Saturday 7 a.m. - 3 p.m. every day shift every Saturday. Review of the TAR showed Staff D, Licensed Practical Nurse (LPN) had changed Resident #15's left lower extremity (LLE) skin tear dressing on 5/16/24, as the observed dressing had revealed. The TAR documentation showed Staff B, LPN, had documented changing the LLE dressing on 5/17 and Staff A, LPN, had documented changing the dressing on 5/18 and 5/19/24. Review of the TAR showed Staff A, LPN, had completed Resident #15's Weekly Skin Check on 5/18/24. Review of Resident #15's Weekly Skin Checks revealed the following: - 5/18/24 at 2:40 p.m., Resident #15 had no new injury or wound identified, the resident had no external devices such as casts, prosthetics, or braces. The evaluation revealed the resident had no previously noted or described skin injuries or wounds. - 5/11/24 at 11:11 a.m., Resident #15 had no new injury/wound identified and no external devices. The description of new skin injury/wound section showed the left lower leg (rear) had a skin tear under treatment. No previously skin injuries/wounds were noted. - 5/3/24 at 3:07 p.m., Resident #15 had a new injury/wound identified to two re-opened skin tears on left lower leg (rear). No other previously skin injuries or wounds were noted. Review of Resident #15's Certified Nursing Assistant (CNA) task history of Skin Observations, from 4/21/24 to 5/20/24 at 2:28 p.m. revealed the resident had no scratches, red areas, discolorations, skin tears or open areas. Review of Resident #15's progress notes revealed on 5/3/24 at 3:30 p.m., the resident was found on the floor in room and two LLE skin tears had reopened. Review of Resident #15's Progress notes revealed a Nurse's Note, dated 5/15/24 at 6:54 a.m. revealing the resident has two skin tears on left lower leg both are dry and healing, no open areas noted, redness or drainage noted. Review of Resident #15's progress notes did not show any further documentation between 5/15 and 5/19/24 related to the resident's bilateral lower extremity skin conditions. An interview and observation were conducted with the Regional Nurse Consultant (RNC), on 5/20/24 at 9:00 a.m. The RNC viewed Resident #15's bilateral lower extremity dressings. The resident raised her right leg revealing an undated 2x2 grayish-white bordered dressing stained with reddish-colored drainage and a dated gray left leg dressing stained with drainage. The RNC confirmed the left ankle dressing was dated 5/16/24 and the right ankle dressing was not dated. During an interview on 5/20/24 at 9:48 a.m., the RNC confirmed staff should have addressed the wounds. The Director of Clinical Operations (DCO) reviewed Resident #15's orders, confirming the orders were for the left leg and there was no wound care order for the right leg. The DCO confirmed the Weekly Skin Assessment done on 5/18/24 did not show any new or previous skin issues. The RNC stated there was a progress note on 5/15/24 revealing 2 skin tears. The mentioned note was reviewed with the RNC and DCO which they confirmed revealed 2 skin tears to the left leg and did not mention the right leg. Review of Resident #15's Treatment Administration Record (TAR) revealed an order, scheduled for 10:00 a.m. to start on 5/22/24 for Wound Care: Cleanse right outer lower leg skin tear with normal saline (NS), pat dry, apply Triple Antibiotic Ointment (TAO) every other day and as needed until healed in the morning, every other day for wound care. Review of a Change of Condition dated 5/20/24 at 9:45 a.m. revealed Resident #15's skin was assessed, resident treatment was changed to right lower leg skin tear, clean with normal saline (n/s) and apply Triple Antibiotic (AAA) ointment every other day (QOD) and PRN until resolved. Resident left lower leg have multiple old, scabbed areas. One scab is red on left inner calf area, treatment for skin prep daily to that area. Resident has no adverse effect. Resident missed treatments to lower legs, MD and Power of Attorney (POA) notified. Review of Skin Observation progress note dated 5/20/24 at 10:05 a.m., showed Resident #15 has skin tear on right lower leg and multiple scabbed areas on left lower leg, resident has one scabbed area with redness around it on left inner calf that area has new treatment for skin prep daily. The note showed the resident had an existing skin tear, scabbed areas resolved. Review of Resident #15's care plan revealed: - The resident had an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) Fatigue, Impaired balance, (and) Limited mobility. The interventions showed Skin Inspection: The resident requires SKIN inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. - The resident has potential/actual impairment to skin integrity r/t fragile skin, incontinence, and decline in function and mobility. The interventions instructed staff to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. 2. On 5/18/24 at 11:21 a.m. Resident #71 was observed sitting in wheelchair in between the bed of room. The observation revealed an undated 4x4 white bordered gauze dressing to the inner left elbow with drainage noted. During the observation, Staff C, Registered Nurse (RN) observed the dressing and confirmed it was undated. The staff member reported the family had allowed the resident to her drag arm across the bed yesterday and the dressing had been applied. Review of Resident #71's admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to unspecified cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, unspecified macular degeneration, and need for assistance with personal care. Review of a progress note dated 5/18/24 at 11:36 a.m. revealed the nurse was called by family to Resident #71's room and informed the resident bumped arm on bed resulting in a skin tear. The area was cleansed with normal saline (NS), steri-strips were applied, and covered with a dry sterile dressing (DSD). The note revealed the Nurse Practitioner had been notified. The note did not reveal any further details regarding the wound such as size or approximation of skin. Review of the Change In Condition Evaluation, dated 5/17/24 at 2:00 p.m. and locked on 5/18/24 at 12:00 p.m., revealed the physician had been notified on 5/17/24 at 3:00 p.m. and the spouse of Resident #71 had been notified on 5/18/24 at 1:30 p.m. Review of the Situation, Background, Appearance (and) Review (SBAR) revealed the situation was Resident #71 had suffered a skin tear and the resident condition or symptoms had stayed the same, no changes to the resident's mental and functional status had been observed, and the behavioral, respiratory, cardiovascular, abdominal/GI, GU/Urine, Pain, Neurological, and Skin evaluations were Not clinically applicable to the change in condition being reported. The Appearance portion of the report was left blank and did not include a summary of the nurse's observations or evaluation. The Review and Notify section revealed the physician had been notified at 3:00 p.m. on 5/17/24 and the spouse was notified at 1:30 p.m. on 5/18/24 (the day after the incident and 1.5 hours after the SBAR was locked). Review of Resident #71's May Medication Administration Record (MAR) did not show an order had been received for wound care related to the resident's skin tear to inner left elbow. Review of Resident #71's May Treatment Administration Record (TAR) did not reveal an order had been obtained for wound care to the resident's inner left elbows skin tear at the time of or prior to the observation made with Staff C, RN on 5/18/24. The TAR did show an order with a start date of 5/20/24 at 7:00 a.m. instructing staff to Apply DSD to left elbow daily. Monitor skin tear one time a day for skin tear. Review of Resident #71's Active Order Summary, dated 5/20/24, revealed and order to Apply DSD to left elbow daily. Monitor skin tear one time a day for skin tear had been received on 5/19/24 and was to start on 5/20/24 (three days after the incident). Review of Resident #71's care plan revealed the following: - ADL Care Plan: The resident has an ADL self-care performance deficit r/t decline in function and mobility related Cerebrovascular Accident (CVA). The interventions included SKIN INSPECTION: The resident requires SKIN inspection PRN. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. - Resident has pressure ulcer or potential for pressure ulcer development r/t decline in function and mobility. The interventions included Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, signs/symptoms (s/sx) of infection, wound size (length x width x depth), (and/or) stage. Review of the policy titled, Wound Treatment Management, implemented 9/1/23, revealed: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence- based treatments in accordance with current standards of practice and physician orders. The compliance guidelines showed: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations: a. feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise, or is wet. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing evaluation of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the care rustics of the wound (see above). c. Changes in the residence goals and preferences, such as at end-of-life or in accordance with his/her rights. Review of the policy titled, Change in Condition, dated 2024, revealed: To ensure the facility promptly notifies the resident, his or her provider, and legal representative of changes in the resident's medical/ mental condition and/ or status (e.g. Changes in level of care, billing/ payments, resident rights, etc.). The process revealed the nurse supervisor/ charge nurse will notify the resident's provider or on call provider when there has been: a. An accident or incident involving the resident. b. An injury of an unknown source 2. When a resident has a change in condition that requires notification of the provider, the nurse supervisor/ charge nurse will call the DON/designee for guidance prior to notifying the provider to ensure all necessary information will be provided to the provider in order for the provider to make an informed decision regarding care and treatment that minimizes the need for a transfer to a higher level of care. (In the event of an emergency where 911 is necessary do not delay care notify 911 for immediate transport). 6. The nurse supervisor/ charge nurse will record in the resident's electronic health record (EHR) information relative to changes in the resident's medical/ mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a pharmacy recommendation and physician order was implemented for one resident (#65) of two residents sampled for monthly drug regimen review. Findings included: Review of Resident #65's electronic medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included, but not limited to, major depressive disorder, recurrent, moderate, other specified persistent mood disorders, adjustment disorder with mixed anxiety and depressed mood. A review of the resident's physician orders revealed a current order, dated 4/7/2024, for Seroquel oral tablet 200 MG [milligram] (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for mood disorder. During a review of Resident #65's medical record, specifically the Consultant Pharmacist Medication Regimen Review, dated 4/25/20247, it revealed a recommendation suggesting adding an order to monitor for behaviors related to the use of Quetiapine (Seroquel). The Consultant Pharmacist Medication Regimen Review was signed by the Director of Nursing (DON), not dated, marked done, and agreed upon by checking AGREE: Please write order. No further action was taken. During an interview with the DON on 5/20/2024 at 9:07 p.m. she confirmed the Pharmacist Medication Regimen Review for Resident #65, dated 4/25/2024, was signed by the her (DON), not dated, and agreed with but no order was added as suggested. The DON stated, This one was missed but it will be added.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor side effects for one residents (#63) related to diuretic therapy and pain medication of seven sampled residents. Findings included: Review of Resident #63's admission Record revealed an original admission date of 11/23/23 and a readmission date of 4/23/24. The admission Record showed diagnoses to neuromuscular dysfunction of bladder, pain in right hip, obstructive and reflux uropathy, acute kidney failure, and chronic kidney disease stage 3B and osseous and subluxation stenosis of intervertebral foramina of lumbar region. During an interview and observation on 5/18/24 at 11:37 a.m. Resident #63 was in bed with a family member visiting. Resident #63 stated she doesn't get out of bed and was recently readmitted from the hospital. She confirmed she had wounds and receives all her medications. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Section N - Medications revealed Resident #63 received diuretic medication. Review of Resident #63's active physician orders as of 5/19/24 revealed: *Foley Catheter for DX (diagnosis) CKD (chronic kidney disease) Size 16f (ft)10 ml (milliliter), balloon, date 4/24/24. *Pain evaluation every shift for monitoring of patient's pain level, date 4/23/24. *Wound care: cleanse buttocks open area with wound cleaner or N/S then apply mycology cream mixed with hydrocortisone cream to peri-wound for pruritus and redness BID x 14 days every day and night shift for treatment, date 5/16/24; *Acetaminophen Oral Tablet 325 MG (milligrams) give 2 tablet by mouth every 6 hours as needed for pain 1-4, start 4/23/24; *Furosemide Oral Tablet 40 MG give 1 tablet by mouth one time a day for edema, date 5/10/24; *Oxycodone HCI Oral Tablet 5 MG give 1 tablet by mouth every 4 hours as needed for pain, start 4/27/24; *Tamsulosin HCI Oral Capsule 0.4 MG give 1 capsule by mouth at bedtime for overactive bladder, start 5/10/24. Review of the May 2024 Medication Administration Record (MAR) and Treatment Administration Record revealed the medications and treatments were administered as ordered for Resident #63. The MAR revealed Oxycodone HCI Oral Tablet was administered 35 times from 5/1/24 - 5/19/24. The MAR revealed the pain level was monitored. Review of the MAR and TAR revealed they were silent of monitoring for side effects of the pain medication and diuretic therapy. A review of the current care plan for Resident #63 revealed: * Focus - Pain Care Plan potential for alteration in comfort, initiated 3/4/24. Interventions included: notify MD (medical doctor) for new onset of pain, notify MD if pain medication is ineffective. *Focus - The resident is at risk for pain r/t (related to) declined function and mobility, initiated 11/30/23. The interventions included: Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function, monitor/document for side effects of pain medication. Observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls, monitor/record/report to nurse any s/sx (signs/symptoms) of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying , worried, scared, clenched teeth, grimacing), body (tense, rigid, rocking, curled up, thrashing). During an interview on 5/20/24 at 11:14 a.m. Staff E, Licensed Practical Nurse/Unit Manager confirmed there was no monitoring for side effects of the pain medication and diuretic therapy. She stated, No there isn't and there should be.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and four errors were identified for two residents (#78 and #3) of ten residents observed. These errors constituted a 16% medication error rate. Findings included: 1. On 5/19/24 at 2:09 p.m. an observation of medication administration with Staff C, Registered Nurse (RN) was conducted with Resident #78. Staff C dispensed the following medications: - Divalproex Delayed Release (DR) 250 milligram (mg) tablet - Magnesium Oxide 400 mg over the counter (otc) tablet On 5/19/24 at 2:09 p.m. the observation revealed the above medication profiles were colored red, showing the medications were late. Staff C, RN confirmed dispensing two tablets. Review of Resident #78 May Medication Administration Record (MAR) revealed the following medications and scheduled times to be administered: - Divalproex Sodium oral tablet Delayed Release 250 mg - Give 1 tablet by mouth three times a day for mood disorder. Scheduled for 1:00 p.m. with additional times of 9:00 a.m. and 9:00 p.m. - Magnesium Oxide oral tablet 400 mg - Give 1 tablet by mouth three times a day for low magnesium. Scheduled for 1:00 p.m. with additional times of 9:00 a.m. and 5:00 p.m. Review of the Medication Administration Audit Report for Resident #78 showed the above medications were dispensed at 2:10 p.m. and 2:11 p.m. 2. On 5/20/24 at 8:47 a.m., an observation of medication administration with Staff D, Licensed Practical Nurse (LPN), was conducted with Resident #3. Staff D dispensed the following medications: - Multi Vitamin with mineral otc tablet - Famotidine 10 mg otc tablet - Ferrous sulfate 5 grams/325 mg otc tablet - Gabapentin 600 mg tablet - Losartan 50 mg tablet - Memantine 10 mg tablet - Metformin 850 mg tablet - Metoprolol 25 mg tablet - Potassium chloride 20 milliequivalent (meq) Extended Release (ER) Staff D, LPN confirmed dispensing 9 tablets prior to the administration. Staff D administered the medications for Resident #3. Review of Resident #3's May Medication Administration Record (MAR) revealed the following medications were to be administered per physician orders: - Daily Multiple Vitamins oral tablet (Multi Vitamin) - Give 1 tablet by mouth one time a day for supplement. - Famotidine oral tablet 20 mg - Give 1 tablet by mouth two times a day for Acid reflux. The review revealed Staff D had dispensed and administered a Multi Vitamin with mineral despite the physician order did not include minerals and 10 mg of Famotidine was administered instead of the ordered 20 mg. Review of the policy titled, Medication Administration, reviewed/revised 9/1/23, revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy's compliance guidelines included the following: - 10. Review MAR to identify medication to be administered. - 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to adhering to transmission-based precautions for one resident (#69) out of one resident observed with Contact Precautions and providing eye drops to one resident (#58) out of one resident observed during the administration of eye drops. Findings included: 1. On 5/18/24 at 12:36 p.m. an observation revealed Resident #69's had a sign posted on their door that showed, Special Contact Precautions in addition to standard precautions. The sign advised for All family and visitors: Please report to nurses station or see staff BEFORE entering room. The posting instructed Before entering, everyone MUST: - Perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water. - Wear gown before entering and remove upon exiting. - Wear gloves before entering and remove upon exiting. - Before exiting, everyone MUST wash hands with soap and water. On 5/18/24 at 12:36 p.m., an observation was made of Staff C, Registered Nurse (RN) who knocked on the door to Resident #69's room and entered without donning a gown or gloving. Staff C exited the room and explained yes she should probably have put a gown on but was just seeing what the resident wanted (call light had been on). Staff C stated the resident was on contact precautions because of [chronic immune system disease] then reported Resident #69 had C-Diff. Review of Resident #69's physician orders revealed the resident was currently receiving Vancomycin 250 milligrams (mg) four times a day for C-Diff, dated 5/7 to 5/21/24. Review of the Centers of Disease Control and Prevention (CDC) Facts for Clinicians, located at https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html, revealed Clostridioides difficile (C.diff) was a common cause of antibiotic associated diarrhea (AAD). It accounts for 15 to 25% of all events of AAD. Prevent C. diff by appropriately using antibiotics and implementing infection control recommendations to prevent transmission. The CDC shows C. diff is a spore-forming, gram-positive anaerobic bacillus that produces 2 exotoxins: toxin A and toxin B. C. diff shades in faces. Any surface, device, or material that becomes contaminated with feces could serve as a reservoir for the C. diff spores. C. diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. The treatment and recovery of C. diff included instructions for clinicians to wear gloves any gown when treating patients with potential infectious diarrhea, including C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. In addition, hand washing alone may not be sufficient to eliminate all C. diff spores. During an interview on 5/20/24 at 1:36 p.m. Staff F, Registered Nurse/Infection Preventionist (RN/IP) stated Contact Precautions were used for any infection that was communicable say C. diff. Staff F explained for Contact Precautions, before entering, staff should wash hands with soap and water, don a gown, gloves, (and) mask depending on if splash-back may occur. Staff F reported hand hygiene was to be done with soap and water as alcohol did not kill spores. Staff F reported walking into Resident #69's room without Personal Protective Equipment (PPE) and not washing hands was not appropriate. The Director of Nursing stated they received Special Contact precaution signs from a local state department. 2. On 5/19/24 at 1:52 p.m. Staff A, Licensed Practical Nurse (LPN) was observed during the administration of medications with Resident #58. Staff A dispensed one tablet and removed one bottle of eye drops from the medication cart, sanitizing hands then entered the resident's room. The staff member administered, with bare hands, one drop in right eye, missing, then dropped another in the right eye, then administered one drop into the left eye. An interview was conducted with Staff A on 5/19/24 at 2:05 p.m. and confirmed she should have worn gloves to administer the eye drops. During an interview on 5/19/24 at 1:52 p.m., Staff F, RN/IP stated Staff A, LPN should have gloved, administered eye drop in one eye, complete hand hygiene preferably ABHR then glove and place another drop in the other eye. Review of the policy titled, Administration of Eye Drops or Ointments, implemented 9/1/23, revealed Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions. The review of explanation and compliance guidelines instructed: 1. Verify orders and labeling prior to administration. 2. Gather supplies: medication, gloves, and tissues/ gauze/ cotton balls. Prepare a clean, dry surface for placing medication caps. 3. Wash hands or utilize alcohol-based hand rub and apply gloves. 4. Position resident with head tilted back. 5. Administration: a. remove medication cap in place on clean, dry surface (i.e. Tissue or paper towel) to prevent contamination. b. Steady hand holding the medication, as needed, on residence forehead. c. With other hand pull down lower lid to form a pouch of the conjunctival sac, avoiding placement of drops directly on the eyeball. d. For eye drops: squeeze the prescribed number of drops into the conjunctival sac, avoiding placement of the drops directly on the eyeball. I. Replace the medication cap. Avoid touching the inside of the cap. Remove gloves and perform hand hygiene. 7. If administering medication to both eyes, use a different gloved finger to apply pressure to the inner tier duct. If the eye medication is an antibiotic or antiviral, change gloves in between. If an eye infected, treat that infected eye last.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I for three residents (#63, #56 and #30) of twenty four sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and later identified. Findings included: 1. Review of Resident #63's admission Record revealed an original admission date of 11/23/23 and a readmission date of 4/23/24. The admission Record showed diagnoses to include anxiety disorder as of 2/26/24 and depression as of 2/26/24. Review of Resident #63's medical record revealed a PASARR Level I, dated 11/23/23, and new one completed on 4/16/24. The PASARR Level 1 completed on 4/16/24 did not include the diagnoses of anxiety and depression in Section 1 A MI (mental illness) or suspected MI. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Section I - Active Diagnoses revealed anxiety and depression as checked. Review of Resident #63's active orders as of 5/20/24 revealed an order for Mirtazapine oral tablet 7.5 mg (milligrams)- give 1 tablet by mouth at bedtime for depression with weight loss, start date 5/1/24. The orders were silent of medication ordered for anxiety. An interview was conducted on 5/20/24 at 6:33 p.m. with the Social Services Director (SSD) and the Director of Nursing (DON). The DON confirmed the facility's PASARR process when a resident comes from the hospital was they reviewed the PASARRs and clinicals the next morning. If the resident has a diagnosis not on the PASARR or they notice medications; they would initiate a new one (PASARR). Then they would request a Level II based on [vendor name] recommendations. The SSD and DON confirmed a whole house audit is completed by the SSD on Fridays to ensure all PASARRs are complete and accurate and given to the DON for review. They confirmed Resident #63's PASARR Level I was not accurate. 2. Review of Resident #56's admission Record revealed an original admission date of 8/16/22 and a readmission date of 10/2/23. The admission Record showed diagnoses to include other stimulant abuse 8/16/22, generalized anxiety disorder as of 7/28/23, persistent mood (affective) disorder as of 3/11/24, and a binge eating disorder as of 3/11/24. Review of Resident #56's medical record revealed a PASARR Level I dated 7/30/23. The PASARR Level 1 did not include the diagnosis of substance abuse in Section 1 A MI (mental illness) or suspected MI. The medical record was silent of a revised PASARR Level I for the new diagnosis of persistent mood (affective) disorder. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section I - Active Diagnoses revealed anxiety, other stimulant abuse and binge eating disorder. Review of Resident #56's active orders as of 5/19/24 revealed: *Depakote Oral Tablet Delayed Release 250 MG - give 1 tablet by mouth three times a day related to persistent mood [affective] disorder, start date of 3/11/24, *Nortriptylie HCI Oral Capsule 25 MG - give 50 mg by mouth two times a day for depression, start date of 5/10/24, *Xanax Oral Tablet 1 MG - give 1 tablet by mouth at bedtime for anxiety, start date of 12/14/23. An interview was conducted on 05/20/24 at 6:44 p.m. with the Social Services Director (SSD) and Director of Nursing (DON). The SSD confirmed the PASARR dated 7/30/23 was the most recent PASARR for Resident #56. She confirmed the diagnosis of stimulant abuse should have been documented on the PASARR Level I and that Resident #56's PASARR Level I should have been redone. 3. Review of Resident #30's admission Record revealed the resident had been admitted on [DATE] and included diagnoses not limited to unspecified intractable epilepsy without status epilepticus (onset 1/23/24), personal history of traumatic brain injury (onset 1/23/24), unspecified anxiety disorder (onset 3/19/24, adjustment insomnia (onset 3/4/24), and mood disorder due to known physiological condition with mixed features (onset 5/14/24). Review of Resident #30's Preadmission Screening and Resident Review, dated 2/2/24 and completed by the facility's Director of Nursing (DON) showed the resident had a Mental Illness diagnosis of anxiety disorder and no Intellectual Disability related to condition, epilepsy or traumatic brain injury (TBI). The section for other indications did not reveal the resident had or may have had a disorder resulting in functional limitations in major life activities, serious difficulty interacting appropriately and communicating effectively, serious difficulty in sustaining focused attention for a long period to permit completion of tasks, or serious difficulty in adapting to typical changes in circumstances. The completion of the PASARR revealed the resident had no diagnosis or suspicion of a Serious Mental Illness or Intellectual Disability therefore a Level II was not required. Review of Resident #30's care plan included the following: - Activities of Daily Living (ADL) Care Plan: The resident has an ADL self-care performance deficit related to (r/t) decline in function and motility r/t TBI. - Resident at times makes complaints and upon investigating, complaints are found to be untrue. Resident has a tendency to fabricate stories (ex. missing items). The intervention instructed staff to Acknowledge resident's behaviors as an attempt to communicate needs. - Resident uses psychotropic medications r/t depression, anxiety, and insomnia. - Hypnotic Care Plan: The resident is on sedative/hypnotic therapy r/t Insomnia. - Anti-Anxiety Care Plan: Resident is at risk for adverse side effects related to use of anti-anxiety medication. - Antidepressant Care Plan: Resident is at risk for adverse side effects related to use of antidepressant medications. - Mood Care Plan: Potential for mood state issues related to anxiety. - Seizure Disorder Care Plan: Potential for injury or aspiration related to history of seizures. Review of the policy titled, Resident Assessment - Coordination with PASARR Program, implemented 9/1/23, revealed: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The compliance guidelines of the policy showed: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities, and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission. i. Negative Level 1 screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level 1 screen - Necessitates a PASARR level 2 evaluation prior to admission. b. PASARR Level 2 - a comprehensive evaluation by the appropriate state designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/ or rehabilitative services through individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or intellectual disability authority has determined as appropriate for admission. 6. The social services director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified in evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure behavior monitoring for psychotropic medication was in place for five residents (#32, #56, #59, #63 and #65) and failed to appropriately monitor the side effects for psychotropic medication for one resident (#56) of seven sampled residents. Findings included: 1. Review of Resident #56's admission Record revealed an original admission date of 8/16/22 and a readmission date of 10/2/23. The admission Record showed diagnoses to include other stimulant abuse, generalized anxiety disorder, persistent mood (affective) disorder, binge eating disorder, and chronic pain syndrome. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section E - Behaviors showed no behaviors were exhibited. Section N - Medications showed the resident was taking antianxiety antidepressant medications. Observation on 5/18/24 at 12:27 p.m. revealed Resident #56's room door was closed with a sign that showed Keep door closed. Resident did not answer to the knock on the door. Review of Resident #56's active physician orders as of 5/19/24 revealed: *Depakote Oral Tablet Delayed Release 250 MG (milligram) - give 1 tablet by mouth three times a day related to persistent mood [affective] disorder, start date of 3/11/24, * Xanax Oral Tablet 1 MG - give 1 tablet by mouth at bedtime for anxiety, start 12/14/23, *Nortriptyline HCI Oral Capsule 25 MG - give 50 mg by mouth two times a day for depression, start date of 5/10/24, *Monitor for antianxiety side effects every shift and report to MD if present: 0-None, 1-Drowsiness, 2-Slurred speech, 3-Dizziness, 4-Nausea, 5-Aggressive/impulse behavior, 6-Constipation, 7-Diarrhea, 8-Changes in appetite, hypertension, 9-other every shift for medication monitoring monitor for antianxiety medication side effects and place number corresponding with side effect. If other-document nurse's note., start 4/23/24. Review of the May 2024 Medication Administration Record (MAR) for Resident #56 showed medications were administered as ordered and there was no behavior monitoring for antidepressant medication until 5/19/24. In addition, the monitoring for the antidepressant side effects was documented as check marks for each administration and not a number which corresponded with the type of side effect. Review of Resident #56's active physician orders as of 5/19/24 revealed an order with a start date of 5/18/24 as: behavior monitoring - antidepressants behavior code: 0. None 1. Withdrawn 2. Anorexia 3. Crying 4. Social isolation 5. Apathy 6. Feeling of helplessness/worthlessness 7. Suicidal ideations 8. Insomnia 9. PN non pharmacological interventions code: 0, none 1. Activities 2. 1:1 3. Redirection 4. Repositioning 5. Food/fluids 6. Rest period 7. Quite [quiet] environment 8. Medication 9. PN Intervention outcome: I=improvement S= same W=Worsen N/A = not applicable every shift for antidepressant use codes applied to behavior; non pharmacological intervention, outcome. An interview with Staff K, Certified Nursing Assistant (CNA) on 5/20/24 at 10:21 a.m. revealed she has not had any issues with caring for Resident #56 but has heard others have. She stated he can tell you his needs and he watches the clock and puts his light on when he needs his pain pill. A review of the current care plan for Resident #56 revealed: * Focus - Antidepressant Care Plan resident is at risk for adverse side effects related to use of antidepressant medications, initiated 1/15/24. Interventions included: administer medications as ordered by physician. Observe/document side effects and effectiveness Q-shift (every shift). Observe/document/report PRN (as needed) adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living), continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo; fatigue, insomnia, appetite loss, wt (weight) loss, n/v (nausea and vomiting), dry mouth, dry eyes. *Focus - The resident has a mood problem r/t (related to) Admission, being in a nursing facility, his age and pain, initiated 7/13/23 and revised 10/12/23. Interventions included administer medications as ordered. Administer medications as ordered. Monitor/document for side effects and effectiveness; behavioral health consults as needed ; monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. *Focus - Behavior Care Plan potential for impaired or inappropriate behaviors related to refusing to wear nonskid socks nor shoes. Plays music with explicit language loudly in hallways. Inappropriate behavior towards other residents (asking for a kiss). Resident is non-compliant with his smoking contract, as he was vaping in dining room, initiated 1/12/23 and revised 8/28/23. Interventions included: if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. *Focus - The resident is verbally aggressive (cursing at staff, cursing in front of the other resident, in a loud manner when he is frustrated, does not get his way, and/or wants his pain meds) r/t ineffective coping skills, initiated 3/2/23. Interventions included: analyze of key times, places, circumstances, triggers, and what de-escalate behavior and document. In an interview on 5/20/24 starting at 11:17 a.m. Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM) confirmed there was no behavior monitoring for the antidepressants and the physician order for behavior monitoring for the antidepressants was not entered until 5/18/24. Staff E, LPN/UM stated the doctor discharged the monitoring for behavior and she wasn't sure why. She confirmed this was on 4/23/24 and the doctor discharged the monitoring for antipsychotics on 5/6/24 and wasn't sure why. She confirmed behaviors were not monitored from 4/23/24 - 5/18/24. Staff E confirmed the side effect monitoring for the antianxiety medication on the MAR was documented as check marks and not the required numbers. Staff E stated the check mark just means the nurse signed off on it and not that he did or did not have side effects. An observation and attempted interview was conducted on 5/20/24 at 2:53 p.m. with Resident #56. Resident #56 was observed on his electric wheelchair dressed for the day, clean and no behaviors exhibited. When addressed with a greeting he did not respond and continued to drive away on his electric wheelchair. 2. Review of Resident #59's admission Record revealed an original admission date of 10/18/22 and a readmission date of 11/11/22. The admission Record showed diagnoses to encephalopathy, and major depressive disorder. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section N - Medications showed the resident was taking an antidepressant medication. An observation from the hallway on 5/18/24 at 1:45 p.m. revealed Resident #59 in bed with bare chest and briefs exposed. At 2:10 p.m. Resident #59 was still in bed. An interview was attempted and the resident stated he didn't speak English. An observation was conducted on 5/19/24 at 10:05 a.m. and the privacy curtain was drawn for Resident #59 who was in bed. His roommate stated that Resident #59 never gets out of bed. Review of the May 2024 Medication Administration Record (MAR) for Resident #59 showed a physician order for Trazodone HCI Oral Tablet - give 100 mg by mouth at bedtime for depression, start 3/10/24. In review of the MAR this medication was administered as ordered. In review of the MAR and Treatment Administration Record (TAR) there was no behavior monitoring for the antidepressant medication. A review of the current care plan for Resident #59 revealed: * Focus - Antidepressant Care Plan resident is at risk for adverse side effects related to use of antidepressant medications, initiated 1/19/24. Interventions included: administer medications as ordered by physician. Observe/document side effects and effectiveness Q-shift. Observe/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo; fatigue, insomnia, appetite loss, wt, n/v, dry mouth, dry eyes. *Focus - Mood Care Plan Potential for mood state issues related to depressive disorder. Interventions included: consultation with psychological/psychiatric per order; encourage and allow open expression of feelings; report to the physician/psychiatrist changes in mood status. An observation on 5/20/24 at 10:05 a.m. revealed Resident #59 was in bed sleeping. During an interview on 5/20/24 at 10:23 a.m. Staff K, Certified Nursing Assistant (CNA) stated Resident #59 speaks a little English and that he is always in bed until you get him up. He would stay in bed 24/7. He doesn't get out of bed unless we get him out so he will go to lunch and then want to go right back to bed. An interview was conducted on 5/20/24 at 11:08 a.m. with Staff E, LPN/UM who confirmed Resident #59 was alert an oriented and he can sit on the edge of the bed by himself without assistance. She stated they try to encourage him to get up. She stated they do monitor for behaviors for Trazodone. She reviewed the orders and MAR and TAR for Resident #59 and confirmed there was not an order and there had been no monitoring for behaviors for Resident #59. She said there is supposed to be and she confirmed that excessive sleeping could be a behavior. 3. Review of Resident #63's admission Record revealed an original admission date of 11/23/23 and a readmission date of 4/23/24. The admission Record showed diagnoses to include anxiety disorder and depression. During an interview and observation on 5/18/24 at 11:37 a.m. Resident #63 was in bed with a family member visiting. Resident #63 stated she doesn't get out of bed and was recently readmitted from the hospital. She confirmed she had wounds and receives all her medications. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Review of Resident #63's active orders as of 5/19/24 revealed an order for Mirtazapine oral tablet 7.5 mg (milligrams)- give 1 tablet by mouth at bedtime for depression with weight loss, start date 5/1/24. The orders were silent of medication ordered for anxiety. The orders were silent of an order to monitor for behaviors. Review of the May 2024 MAR revealed the Mirtazapine was administered as ordered for Resident #63. A review of the current care plan for Resident #63 revealed: * Focus - Antidepressant Care Plan resident is at risk for adverse side effects related to use of antidepressant medications. Depression with weight loss, initiated 5/18/24. Interventions included: administer medications as ordered by physician. Observe/document side effects and effectiveness Q-shift. Observe/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo; fatigue, insomnia, appetite loss, wt, n/v, dry mouth, dry eyes. During an interview on 5/20/24 at 11:14 a.m. Staff E, LPN/UM confirmed there wasn't an order to monitor behaviors for the antidepressant. She stated, There isn't and there should be. 5. Review of Resident #32's admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to metabolic encephalopathy and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #32's care plan revealed: At risk for adverse side effects related to use of antidepressant medications, depression. The interventions instructed nursing staff to: - Administer medications as order by physician and observe/document side effects and effectiveness every (Q) shift. - Observe/document/report as needed (PRN) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; Decline in ADL ability, continents, no avoiding; Constipation, fecal impaction, diarrhea; Gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; Dizziness/ vertical; Fatigue, insomnia; Appetite loss, weight loss, nausea/vomiting (n/v), dry mouth, dry eyes. Mood Care Plan: Potential for mood state issues related to depression. The interventions instructed nursing staff to: - Observe for effectiveness/ side effects of medications as ordered - see physicians orders. - Report to the physician/ psychiatrist changes in mood status. Review of the new evaluation for psychiatry services, dated 4/11/24, revealed the resident was currently taking 15 milligram (mg) of Mirtazapine at bedtime for depression, No behaviors reported by staff, and as symptoms can exacerbate on periodic basis in the facility setting we will follow up with this patient intermittently. Review of Resident #32's Order Summary Report, active as of 6:53 p.m. on 5/20/24 included: - Mirtazapine 15 milligram (mg) - Give 1 tablet orally at bedtime for depression. - Behavior Monitoring - Antidepressants. Behavior code: 0. None, 1. Withdrawn, 2. Anorexia, 3. Crying, 4. Social isolation, 5. Apathy, 6. Feeling of helplessness/worthlessness, 7. Suicidal ideations, 8. Insomnia, 9. PN. NON-PHARMALOGICAL INTERVENTIONS CODE: 0. None, 1. Activities, 2. 1:1, 3. Redirection, 4. Repositioning, 5. Food/fluids, 6. Rest period, 7. Quiet environment, 8. Medication, 9. PN. Intervention Outcome: I=Improvement, S=Same, W=Worsen, N/A=Not applicable, every day and night shift for Antidepressant use. Use codes applied to Behavior, non-pharmalogical intervention, (and) outcome. Review of Resident #32's May Medication Administration Record (MAR) showed the resident had received 15 mg of Mirtazapine at bedtime nightly as ordered. The MAR showed staff were ordered to monitor behavior signs, non-pharmalogical interventions (NPI), and outcome on 4/6/24 to the discontinuation of the order on 5/18/24 at 12:02 p.m. The behavior monitoring was not completed during the day shift on 5/1, 5/13, and 5/18/24. Review of Resident #32's May MAR showed the order for behavior monitoring was to be completed with the documentation in accordance with the above-mentioned physician order however the MAR did not have any spaces to document the behavior signs, NPI, or outcomes as ordered, the order was written at 7:00 p.m. on 5/18/24. The MAR revealed no behavioral monitoring was completed during the day shift on 5/18/24. Review of the policy titled, Use of Psychotropic Medication, implemented on 9/1/23, revealed Residents are not given psychotropic drugs unless the medication is necessary to treat a 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 policy explanation and compliance guidelines revealed the following: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: and antipsychotics, antidepressants, anti-anxiety, and hypnotics. 3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/more representatives, other professionals, and the interdisciplinary team. 4. The indications for use of any psychotropic drug will be documented in the medical record. b. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. i. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. ii. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. 7. Residents who use psychotropic drugs shall receive non pharmaceutical interventions to facilitate reduction or discontinuation of the psychotropic drugs. 12. The effects of the psychotropic medications on a residence physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regimen review. c. During Minimum Data Set (MDS) review (quarterly, annually, significant change), and d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturers specifications, and the residence comprehensive plan of care. 13. The residents response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the residence medical record. 4. Review of Resident #65's admission Record revealed he was admitted on [DATE]. The record included diagnoses not limited to personal history of traumatic brain injury, major depressive disorder, recurrent, moderate, other specified persistent mood disorders, adjustment disorder with mixed anxiety and depressed mood. Review of Resident #65's care plan related to antidepressant, anti-psychotic and psychotropic medications revealed, Focus - Antidepressant Care Plan: Resident is at risk for adverse side effects related to the use of antidepressant medications. Interventions: Administer medications as ordered by the physician. Observe/document side effects and effectiveness Q-shift. Observe/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Focus - The resident uses psychotropic medications r/t depression Interventions: Administer medications as ordered by the physician. Observe for side effects Q-SHIFT. Observe/document/report PRN any adverse reactions of PSYCHOTROPIC medications Unsteady gait, tardive dyskinesia, EPS (shuffle gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Observe/record occurrence of for target behavior symptoms and document per facility protocol. Focus - Anti-psychotic Care Plan -The resident is at risk of adverse side effects related to use of antipsychotic medications. Interventions: Administer medications as ordered. Approach resident calmly. Attempt gradual dose reduction as indicated. Report results to physician as needed. Follow up with psych as indicated. Observe behavior. Observe for signs and symptoms, increase or decrease in behavior or adverse effects from the anti-psychotic medication. Redirect as needed. Report any adverse effects to MD. Review of Resident #65's MAR revealed the following medication orders, not limited to: Seroquel Oral Tablet 400 MG give 1 tablet by mouth at bedtime related to OTHER SPECIFIED PERSISTENT MOOD DISORDERS; Trazadone HCI Oral Tablet 100 MG give 2 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE; Zyprexa oral tablet 10 MG by mouth one time a day for depression; Seroquel Oral Tablet 200 MG give 1 tablet by mouth two times a day for mood disorder; and Lorazepam Oral tablet 0.5 MG give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days (start date, 5/18). Review of Resident #65's active physician orders as of 5/17/24 revealed an order with a start date of 5/17/24 as: behavior monitoring - antidepressants behavior code: Use behavior codes as noted on the order. Monitor every shift for possible side effects and notify MD if noted. Monitor for antidepressant medication side effects and place number corresponding with side effect. If other-document nurse's note. Review of Resident #65's active physician orders as of 5/17/24 revealed an order with a start date of 5/17/24 as: Behavior monitoring for-Anti-anxiety Behavior code: Use behavior codes as noted on the order. Review of Resident #65's active physician orders as of 5/17/24 revealed an order with a start date of 5/17/24 as: Behavior monitoring for-sedative/hypnotics Behavior code: Use behavior codes as noted on the order. Review of Resident #65's TAR for behavior monitoring for Anti-anxiety, Antidepressants and sedative/hypnotics revealed on 5/17, 5/18, 5/19 and 5/20 the box was checked and initialed but there was no place to document a behavior code for behavior monitoring as ordered. Review of Resident #65's TAR for monitoring of Antidepressant side effects: monitor every shift for possible side effects and notify MD if noted, revealed on 5/17, 5/18, 5/19 and 5/20 the box was checked and initialed, but there was no place to document a number corresponding with the side effect as ordered. During an interview on 5/20/2024 at 9:12 p.m. with Staff L, LPN, she stated she was not sure if they code for behaviors. She would look in document manager for behaviors, it would typically be in the progress notes or care plan. During an interview on 5/20/2024 at 9:16 p.m. with Staff M, LPN, he stated he would ask the previous nurse about behaviors, they would let him know to continue care. He was not sure on coding for behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 5/20/24 at 7:05 p.m. the Nursing Home Administrator (NHA) stated they do room rounds daily. The expectation is if staff see something they would report it. If it is something simple they would resolve it. During an interview on 5/20/24 at 7:16 p.m. the Housekeeping and Laundry Director stated they generally clean, mop and sweep each room everyday, once a day for each room. If there is a spill or something needs to be cleaned again they go back into rooms as needed. She confirmed there are a total of 11 staff members for housekeeping and laundry. She confirmed she hasn't been notified of items in resident rooms of concern or anything related to shower equipment or shower rooms. She stated CNAs (certified nursing assistants) are supposed to keep personal items bagged up in a plastic bag. Review of the policy titled, Safe and Homelike Environment, implemented 9/1/23, revealed the policy as: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Policy Explanation and Compliance guidelines: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Based on observation, record review, and interview the facility failed to provide an environment that was clean, safe, and sanitary for residents on one units (B Wing) of two units and two shower rooms (A Wing and B Wing) of two shower rooms. Findings included: On 5/20/24 starting at 3:00 p.m., observations were made of the resident rooms and shower rooms on the A Wing and B Wing. The following was observed: - A wheelchair in hallway across from the activity room with a ball of an unknown pink substance stuck to the seat of the chair and armrests that were ripped revealing foam interior. The was observed on 5/18/24, 5/19/24 and 5/20/24. - An observation of room [ROOM NUMBER] Bed A revealed a bottle of a name brand lotion, name brand dandruff shampoo, and another bottle of a name brand lotion sitting on the bedside dresser. The observation also revealed a bottle of an unknown green liquid in a basin sitting on top of a dresser. - An observation was made of a jar of name brand lotion on the bedside dresser of room [ROOM NUMBER] Bed B. - A bottle of body and hair cleanser was observed sitting on a dresser across from the beds in room [ROOM NUMBER]. - A can of name brand lubricant/degreaser sitting on the over-bed table in room [ROOM NUMBER]. The shower room on the 200 hall (B Wing) was observed at 3:42 p.m. and revealed an ant crawling in the shower, toilet was running with water and dark stain on inside of toilet bowl, and bowel movement swirling in the bowl, black bio growth was observed on the floor of the shower, the plastic ceiling light cover was cracked, and the shower chair had black bio growth on the blue chair back and leg rest, on the joints of the plastic frame, and under the seat. The continued environmental tour revealed the following observations: - at 3:49 p.m. from the hallway, an aerosol can of a brand disinfectant spray on the bedside table of room [ROOM NUMBER] bed B; - at 3:49 p.m. an aerosol can of a name brand deodorant/anti-perspirant was observed on the over-bed table of room [ROOM NUMBER] Bed B; - the wall next to the air conditioning unit of room [ROOM NUMBER] was bubbled and cracked; - room [ROOM NUMBER] had a bottle of a name brand diabetic lotion, a bottle of a name brand dry moisture lotion, a large bottle of non-alcohol mouthwash on the room's vanity, and a bottle of body mist without a diffuser on the window sill. In addition, at 4:01 p.m. the observation of the 100-hall shower room (A Wing) revealed a washcloth hanging from the handrail in the first shower stall, one washcloth hanging from the frame of the white plastic shower chair, a bottle of body wash, and a bottle of shampoo sitting on the hand rail of the shower. On 5/20/2024 at 3:38 p.m. an observation of room [ROOM NUMBER] B revealed a can of activICE (over the counter topical pain reliever) sitting on the table next to the bathroom door. The cap was missing. The resident in the room stated it was hers but she can't use it anymore because the spray top is missing due to falling on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain accurate and complete medical records by failing to fully document the occurrence of falls in the medical record for two (#3 and #4) of three residents sampled for documentation related to falls. Findings included: A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and dementia. A diagnosis of traumatic subdural hemorrhage without loss of consciousness was added on 12/23/2023. Resident #3 was discharged from the facility on 1/15/2024. A review of the facility's incident log for December 2023 revealed Resident #3 had an unwitnessed fall on 12/19/2023 at 4:34 PM. A review of Resident #3's progress notes dated 12/19/2023 at 9:00 PM revealed Resident #3 was transferred to the hospital and was diagnosed with a subdural hematoma. A review of Resident #3's progress notes did not reveal documentation related to Resident #3's fall on 12/19/2023 at 4:34 PM. Further review of Resident #3's medical record did not reveal documentation or assessments related to Resident #3's fall on 12/19/2023 at 4:34 PM. A review of a facility report dated 12/19/2023 at 4:34 PM revealed Resident #3 was observed sitting on the floor next to the toilet in his bathroom after a fall. The report also revealed Resident #3 had a small laceration to his nose and a small scraped area on his forehead with a yellow colored bruise on the left side of his nose. Resident #3 was assessed by the facility's Director of Nursing (DON) and sent to the hospital for evaluation. The facility report was not part of Resident #3's medical record. A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, dementia, and atrial fibrillation. A review of the facility's incident log for February 2024 revealed Resident #4 had an unwitnessed fall on 2/12/2024 at 2:13 PM. A review of Resident #4's progress notes did not reveal documentation related to Resident #4's fall on 2/12/2024 at 2:13 PM. Further review of Resident #4's medical record did not reveal documentation or assessments related to Resident #4's fall on 2/12/2024 at 2:13 PM. A review of a facility report dated 2/12/2024 at 2:13 PM revealed Resident #4 was observed sitting on the floor in his room with his head next to the wall beside the residents bed. Resident #4 was assessed by the DON and a lump was discovered on the back of Resident #4's head. Resident #4 was sent to the hospital for further evaluation. The facility report was not part of Resident #4's medical record. An interview was conducted on 2/13/2024 at 1:31 PM with the DON. The DON stated she was not able to find any documentation in Resident #3's medical record related to the resident's fall on 12/19/2023 at 4:34 PM. The DON also stated when a fall occurs in the facility, nursing staff should assess the resident for any injuries and document the call in a progress note and a change in condition assessment in the resident's medical record. The DON stated she was not able to find any documentation in Resident #4's medical record related to the resident's fall on 2/12/2024 at 2:13 PM. The DON stated the falls were documented in a facility record but she was unsure if the facility record was part of the resident's medical record. A review of the facility policy titled Documentation in Medical Record, last revised on 8/25/2022, revealed under the section titled Policy each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observations, record review, and interviews the facility failed to obtain wound care orders following the admission of one (#2) of one resident admitted with three (3) surgical wounds and one (1) unstageable pressure ulcer, and the facility failed to provide pressure ulcer care for one (#2) of one resident sampled for wound care. Findings included: Review of the admission Record identified that Resident #2 was admitted from an acute facility on 2/25/23. The admission Record included diagnoses not limited to fusion of spine - lumbar region, encounter for other orthopedic aftercare, site not specified urinary tract infection, occlusion and stenosis of right vertebral artery, and essential (primary) hypertension. Review of the hospital records did not identify the acute facility had ordered specific wound care procedures related to either the surgical wounds or the pressure ulcer for Resident #2. Resident #2's Admission/readmission Nursing Evaluation, dated 2/25/23, Section C identified the resident had a pressure wound and surgical wound. The Weekly pressure wound note, dated 2/27/23, identified that Staff Member A, Wound Care Nurse (WCN), had assessed the pressure ulcer, which indicated the wound was located on the coccyx and was unstageable. The wound bed had slough tissue present, with moderate amount of serous drainage, and no odor. The wound presented with no signs of infection and that new orders were received. The progress note did not identify the specifics of the orders received. The wound measured 3.8 centimeter (cm) x 0.7 cm x 0.2 cm. Review of Resident #2's February Treatment Administration Record (TAR) did not include any orders for the care of the residents pressure ulcer or the surgical wounds to the lumbar region. A review of the resident's February Medication Administration Record (MAR) did not include wound care orders for the pressure ulcer or the surgical wounds. The facility failed to provide the March Treatment Administration Record (TAR) as requested that did identify that wound care orders were obtained on 3/2/23 for Resident #2's coccyx pressure ulcer but did indcate that the facility failed to provide care to the area on Saturday 3/4/23 and Sunday 3/5/23. On 3/6/23 the Wound Care Specialist, from an outside provider, indicated an assessment and evaluation was performed on Resident #2's unstageable coccyx. The depth of the wound was unable to be measured due to necrosis. The evaluation indicated that staff were to apply alginate calcium daily for 30 days, Santyl apply daily with border (dressing). The evaluation indicated that a surgical excisional debridement was completed per the resident permission. On 3/13/23 the wound care specialist noted that the resident was not seen due to a non-wound related hospitalization. The Director of Nursing (DON) stated, on 3/23/23 at 2:50 p.m., that Resident #2 had one wound. The DON reviewed physician orders and confirmed the resident did not have surgical wound care orders and stated that the facility would find out what the surgeon wanted by looking at the notes, and ask the Wound Care Nurse (WCN) to contact the surgeon. She stated that if the WCN was at the facility they would assess the wound then or the next day, and if (resident admitted ) on weekend they would see them on Monday, the Wound Care physician comes on Mondays. The DON confirmed that wound care orders would be obtained by the Attending physician until the wound could be evaluated. The DON reviewed progress notes, again, and stated she believed the resident came in with 3 pressure ulcers. Staff A was interviewed, at 3:11 p.m. on 3/23/23, with the DON and Nursing Home Administrator (NHA). The staff member reported doing all wound care in the facility on Monday through Friday and that Resident #2 came in with 3 surgical wounds and an unstageable coccyx (pressure wound). Staff A stated that the resident did not come into the faciltiy with any dressing change orders, that the surgical wounds were open to air, and the coccyx wound did have a dressing on it but did not have wound care orders. The staff member reported calling the Wound Care physician and receiving orders for the coccyx. The DON reported that expectation was that if Staff A was not available that staff nurses do the wound care. The DON stated that the expectation was that staff would obtain wound care orders for the care of the coccyx wound on 2/25/23, when the resdient was admitted . The DON and Staff A reviewed the physicain orders and confirmed orders were not received on 2/25 or on 2/26/23. They did identify that no wound care orders were documented in February following Resident #2's admission and that wound care was not completed on 3/4 or 3/5/23. The DON confirmed if it was not documented it was not done. The policy - Provision of Physician Ordered Services, implemented and reviewed/revised on 8/25/22, indicated The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. The guidelines indicated that Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the resident centered care plan related to behaviors for one (#21) of 30 sampled residents. Findings included: On 5/09/22 at 10:45 a.m., Resident #21 was observed lying in bed. The resident did not respond to questions related to care and services. A review of the Physician Order Report from 4/12/22 to 5/12/22 revealed the following orders: Nortriptyline 50 mg oral once a day at night started on 12/9/21 for depression Nortriptyline 10 mg (milligrams) oral twice a day started on 1/25/22 for depression Wellbutrin SR 100 mg oral twice a day started on 2/4/22 for depression Paxil 10 mg oral once a day started on 4/18/22 for depression Trazadone 150 mg oral once a day at night started on 4/18/22 for depression A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section E--Behavior: indicated Resident #21 exhibited verbal behavioral symptoms directed toward others that occurred 1 to 3 days. Section N-Medications: indicated Resident #21 received antidepressant medications. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 4/1/22 through 4/30/22 indicated Resident #21 had a pattern of refusing medications and treatments documented by nursing. Some medications ordered for the resident were refused from 10 to 25 days of the 30 days in the month. The resident was also refusing treatments and meals. A review of the Resident Progress Notes dated 3/1/2022 to 5/12/2022 revealed the following: 5/3/22 12:31 a.m. ARNP (Advanced Registered Nurse Practitioner) notified of resident's on-going refusal to take medications. 4/23/22 8:50 a.m. Continues to refuse all medications. NP (Nurse Practitioner) notified. 4/22/22 8:47 a.m. Patient refuses all medications this AM when asked why she was refusing meds she stated very loudly its none of your business, but if you need to know they are making me sick. 4/7/22 11:33 p.m. Resident refused skin check X 2. Stated that her skin is fine. A review of the Comprehensive Care Plan for Resident #21 revealed the following: Problem: Behavioral: Resident has unrealistic goals (edited 5/10/2022) Goal: Adjustment to new baseline with her ADLs (Activities of Daily Living) Approach: Psych (Psychiatric) consult The care plan did not indicate a behavioral concern related to refusal of medications, treatments, or nursing care for the resident. On 5/12/22 at 12:32 p.m., Staff H, Certified Nurse Aide (CNA) stated Resident #21 refuses care and medications often. She stated the resident was having a good day and had been cooperative, but some days the resident is very uncooperative and will not let the nurse aides do anything. Staff H stated she has to be patient with Resident #21 and give her time to adjust to what needs to be done. Staff H stated when the resident becomes combative, she lets the nurse know so they can assess the resident. On 5/12/22 at 12:44 p.m., Staff C, Licensed Practical Nurse (LPN) stated Resident #21 refuses her medications a lot and this has been going on for the last month or so. She stated Resident #21 is touch and go, and today she is pretty good. She stated when a resident refuses medications they document it on the MAR and notify the provider. She stated the NP was very familiar with the resident and was at the facility at least 3 to 4 days a week. She stated the MDS department was responsible for updates to the care plan. She confirmed there was no problem listed for the refusal of medications and treatments for Resident #21 on the current care plan. On 5/12/22 at 12:52 p.m., the MDS Coordinator, RN (Registered Nurse) stated if a resident has behaviors like refusal of medications and treatments this should be on the plan of care for the resident. She stated behavior care plans were driven by social services. After reviewing the most recent assessment for Resident #21, she confirmed the nursing notes are reflective of refusal of care and medications and stated it did not trigger in the assessment, but it should have. She confirmed the care plan should have a behavior problem area addressing the refusal of medications and treatment. A review of the policy titled Care Plans, Comprehensive Person-Centered with a revised date of December 2016 indicated the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. g. Incorporate identified problem areas. h. Incorporate risk factors associated with identified problems. m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, interviews and record review, the facility failed to provide dressing changes to an intravenous (IV) catheter site in accordance with physician orders for one (#5) of four residents in the facility receiving IV therapy. Findings included: During a facility tour conducted on 05/09/22 at 10:01 AM, Resident #5 was observed laying on bed. Resident #5 was noted with a peripherally inserted central catheter (PICC) line with a gauze dressing dated 04/01/22 14:00 hours (2:00 PM) on the left arm. An attempt to interview Resident #5 was unsuccessful. (Photographic evidence was obtained.) A minimum data set (MDS) assessment for Resident #5 dated 03/30/22, section C cognitive patterns showed Resident #5 was not able to complete the brief interview for mental status interview, indicating severe cognitive impairment. Section G functional status showed Resident #5 required extensive assistance and dependency on staff for activities of daily living (ADLs). Additional observations on 05/10/22 at 09:03 AM and 05/11/22 at 8:44 AM, revealed the dressing dated 04/01/22 was still in place. Review of physician orders for Resident #5 dated 04/01/22 to 05/11/22 showed orders as follows: • Meropenem reconstitute solution; 1 gram; amount: 1 gram; intravenous [Diagnosis: Klebsiella pneumoniae as the cause of diseases classified elsewhere- Urine; wounds] Every 8 hours: 06:00, 14:00 (2:00 PM), 22:00 (10:00 PM) • Midline extension, connector and dressing change weekly. (Special instructions; date and time dressing for change and readjust standing Midline change before meals every Wednesday; 07:00-01:00.) • Midline extension, connector and dressing change as needed (PRN) due to soiling or dislodgement. • Check Midline site for signs and symptoms of infection every shift. An interview was conducted on 05/11/22 at 09:06 AM with Staff E, licensed practical nurse (LPN). Staff E observed the PICC line dressing with the date 04/01/22. Staff E stated she thought the PICC line dressing should be changed every 30 days. Staff E stated she would review the physician orders to see when it should have been changed. Staff E stated, either way it was past 30 days. Staff E stated she was assigned to care for Resident #5 and had not reviewed the orders yet. Staff E stated she would talk to the Director of Nursing (DON) and will get back with the surveyor. Staff E did not return. On 05/11/22 at 03:35 PM, an interview was conducted with Staff F, LPN. Staff F stated the expectation for PICC line dressing was to change them weekly. Staff F said, That is the protocol. On 05/11/22 at 03:38 PM, an interview was conducted with Staff G, LPN. Staff G stated she does not change PICC line dressings. Staff G stated if she would have to change one, she would follow physician orders. Staff G stated she thought orders were in place to change the dressing weekly. A follow- up interview was conducted on 05/11/22 at 3:45 PM with the Director of Nursing (DON). The DON stated the expectation was standard practice, change the PICC line dressing every week. The DON stated physician orders were in place, and she did not know why Resident #5's PICC line dressing had not been changed. The DON said, I expect the nurses to complete dressing changes weekly or as ordered. Review of a facility policy titled, Midline dressing changes', revised April 2016, showed the purpose is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter site dressings. Under general guidelines (1) Change Midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Review of a job description titled, Licensed practical nurse, dated 09/04/20, showed an expectation to provide quality care to patients and perform technical skilled care in compliance with nursing standards, federal, state, local government regulations and company policies. Under essential functions provide direct and individualized nursing care to assigned patients. Ensures quality and safe delivery of nursing services to patients / clients. Change bandages, dressings and change catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure medications were stored and secured appropriately in one (A Wing) of two treatment carts and three (B-North, A-North, A-South) of four medication carts. Findings included: 1. On [DATE] at 3:29 PM, observation with Staff O, Registered Nurse (RN) of the A wing Treatment Cart revealed: • Nyst Ointment 100,000 USP opened, no date, no resident identifier, no pharmacy label • SSD Silver Sulfadiazine Cream opened, resident label not identifiable, no open date • Latanoprost Opthalmic Solution 125 mcg located in treatment cart • Muprocin Ointment 2% with no resident identifier or Pharmacy label, open date not observed • Calamine Lotion manufacturer expiration date on bottle 03/2022 An interview with Staff O at the time of the observation confirmed the Nyst ointment, SSD Silver Sulfadiazine Cream, and Mupirocin ointment was not labeled for pharmacy, resident or identified with a date opened. Staff O stated, The Latanoprost Opthalmic Solution 125 mcg should be secured in the medication cart, not treatment cart. Staff O confirmed the Calamine Lotion was expired, needed to be discarded, and reordered if needed for resident care. A phone interview conducted on [DATE] at 12:05 PM with the facility Pharmacist confirmed the Nyst 100,000 ointment required a prescription for a resident and needs to be coordinated through the pharmacy with a label, and the date should be 1 year from the date dispensed. The SSD Silver Sulfadiazine Cream also required a prescription for an individual resident. The Pharmacist stated if there is not a resident specifically on the label, it should be pulled off the cart, and the pharmacist notified. The Latanoprost Opthalmic Solution 125 mcg should be stored in the top drawer of the medication cart with medication stock not the treatment cart. The pharmacy expectation for the Muprocin ointment 2% is that it is utilized for a single resident with a prescription required and should go through pharmacy services. Review of the facility policy titled, Storage of Medications revised [DATE] revealed: - 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. 2. On [DATE] at 11:25 AM, the Medication Cart B North was observed unlocked, open in hallway, drawers able to open with medication access for residents, staff and visitors. On [DATE] at 11:35, Staff K, Licensed Practice Nurse (LPN) confirmed the medication cart was unlocked. Staff K reported that he was assigned to this medication cart and it was a mistake to leave it unlocked. An interview with the Pharmacist on [DATE] at 12:50 PM revealed he has brought unlocked medication carts to the facility's attention during his audits and confirmed that this was a security concern. A review of the facility policy titled, Storage of Medications, revised [DATE] revealed: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 3. On [DATE] at 8:59 AM, Medication Cart A-North was observed with 4 medication cards on top of the cart with no staff in attendance. Residents were observed passing the cart in the hallway as medications remained on top of the cart observable and with no staff present. On [DATE] at 9:01 AM, the Director of Nursing (DON) approached the cart. The DON called over Staff J, LPN to review the medication cards and inquire as to why they were placed on the top of the medication cart. The prescription Venlafaxine Tab 75 mg was identified as the medication card which was filled on top of the medication cart. An interview was conducted on [DATE] at 9:05 AM with the DON. The DON stated, The only medication card that has medication in it is the first medication card on the bottom, which is not appropriate. The other medication cards are empty and might be in the process of being discarded. The DON stated to Staff J, LPN that this needs to be corrected, and it is a priority. An interview with Staff J, LPN on [DATE] at 9:10 AM confirmed she had left the medication cards on top of the medication cart and the medication card with Venlafaxine 75 mg tab should be with another resident in another medication cart. A phone interview conducted on [DATE] at 12:50 PM with the facility Pharmacist confirmed medications should not be stored on top of an unattended medication cart at any time, and this was a security issue. 4. On [DATE] at 10:34 AM, observation with Staff E, LPN of Medication Cart A-South revealed: 3 Insulin pens contained in a plastic bag for 1 Resident. The expiration dates of [DATE] were written in marker and the pharmacy label noted refrigerate until opened for 1 pen. A second insulin pen had a handwritten note on it open on [DATE] and a third insulin pen had a handwritten note on it Date Opened [DATE]. Interview with Staff E, LPN at the time of the observation revealed, Insulin pens should have label on it that says day opened, not date expired from Pharmacy. There are 3 insulin pens with expiration date on it rather than date opened, and the expiration dates are not supposed to be on the pen. On [DATE] at 12:15 PM a phone interview with the facility Pharmacist's revealed Insulin pens should be in the refrigerator until use. The manufacturer guidelines need to be followed. If observing 3 pens for 1 resident in the medication cart in a bag, the date opened should be the date removed from the refrigerator. The expiration tag dated [DATE] needs to be clarified with the nurse. The date the insulin pen is removed from the refrigerator is the date it is opened, not the date expired. The Pharmacist reported that he would not expect to see all 3 pens for this resident in the medication cart. A review of the facility Medication Cart Reference Sheet titled, Expiration Dating of Common Pharmaceuticals dated [DATE] revealed: Insulin Pen Injector Cartridges see Manufacturer recommendations, refrigerate and remove only one pen at a time. Photographic evidence was obtained.

Based on observation, record review, and interview, the facility failed to ensure proper storage of respiratory equipment for five (Resident #3, #28, #45 #48, #49) of 17 facility residents receiving respiratory therapy during three (5/9/2022, 5/10/2022, and 5/11/2022) of four days observed. Findings included: 1. On 05/09/2022 at 10:07 a.m. and 12:13 p.m., Resident #49's nebulizer mask was observed on top of the nebulizer machine. Additionally, the oxygen nasal cannula and tubing were observed hanging over the oxygen concentrator. On 05/10/2022 at 08:50 a.m., observation revealed Resident #49's nebulizer facemask was not stored in the plastic storage bag, and the oxygen nasal cannula and tubing were hanging over the oxygen concentrator. On 05/11/2022 at 08:49 a.m., Resident #49's oxygen tubing was observed hanging over the oxygen concentrator, and the unbagged nebulizer facemask was on top of the bedside table. An observation was conducted with the Director of Nursing (DON) on 05/11/2022 at 10:15 a.m. During the observation, the DON confirmed Resident #49's nebulizer facemask was not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. Clinical Record review of Resident #49's Physician Order dated 12/13/2021 revealed the resident was to receive oxygen therapy via nasal cannula (NC) at 2 liters per minute continuous, and Ipratropium-albuterol solution for nebulization 0.5mg-3mg (2.5 mg base)/3ml inhalation every 4 hours (06:00, 10:00, 14:00, 1800, 2200, 0200). 2. On 05/09/2022 at 10:20 a.m., Resident #45's nebulizer facemask was observed in the top drawer of the bedside table, and the oxygen tubing was on the floor of the resident's room. The oxygen plastic storage bag dated 2/14/2022 was located on top of the oxygen concentrator. Interview with Resident #45 at the time of the observation revealed she did not know how her respiratory equipment should be stored. On 5/11/2022 at 08:38 a.m., an observation was made of Resident #45's unbagged oxygen cannula on the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:35 a.m. During the observation, the DON confirmed Resident #45's nebulizer facemask and oxygen nasal cannula were not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. A review of Resident #45's Physician Order dated 02/11/2021 revealed the resident was to receive Oxygen Therapy via Nasal cannula (NC) at 2 liters per minute as needed, and an order dated 12/09/2021 for Ipratropium-albuterol solution for nebulization 0.5mg-3mg (2.5 mg base)/3ml inhalation three times a day as needed. 3. On 05/09/2022 at 10:30 a.m., Resident #48 was observed to be lying in bed sleeping. The resident was not wearing respiratory/using respiratory equipment at the time of the observation. The resident's oxygen nasal cannula was observed unbagged on the bedside table. On 05/10/2022 at 08:30 a.m., Resident #48 was observed in his room. His unbagged oxygen nasal cannula was observed hanging over the left side bedrail. On 5/11/2022 at 08:09 a.m., Resident #48's nebulizer facemask was observed to be unbagged on the bedside table. Interview with Resident #48 at the time of observation revealed the facemask was always stored in this manner on top of the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:00 a.m. of Resident #48's room. During the observation, the nebulizer facemask was on top of the bedside table, and the oxygen nasal cannula was hanging over the bedrail. The DON confirmed both respiratory devices were not stored appropriately. The DON immediately removed both respiratory devices and placed them in the garbage receptacle. Clinical Record review of Resident #48's Physician Order dated 12/13/2021 revealed the resident was to received oxygen therapy via nasal cannula (NC) at 2 liters per minute as needed, and Budesonide suspension for nebulization 0.5mg-2ml inhalation twice a day. 4. On 05/09/2022 at 11:00 a.m., Resident #28's room was observed with an unbagged nebulizer facemask on top of the bedside table. On 05/10/22 at 9:21 a.m. and 05/11/22 at 08:45 a.m., Resident #28's oxygen nasal cannula was observed on the floor of the room in front of the oxygen concentrator, and the unbagged nebulizer facemask was located on top of the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:20 a.m. During the observation, the DON confirmed Resident #28's nebulizer facemask, and oxygen nasal cannula were not stored appropriately. The DON removed the facemask from the bedside table, and indicated the resident was not receiving nebulizer treatments. She then removed the oxygen cannula and placed both items into the garbage receptacle near the resident's bed. Clinical record review of Resident #28's Physician Order dated 04/22/2021 revealed Oxygen Therapy via Nasal cannula (NC) at 3 liters per minute as needed. 5. On 05/10/2022 at 08:45 a.m., an observation was made of Resident #3's room. During the observation, a nebulizer facemask was observed next to the plastic storage bag. On 05/11/2022 at 08:41 a.m., Resident #3's nebulizer facemask was stored on top of the bedside table near the plastic storage bag. An observation was conducted with the DON on 05/11/2022 at 10:24 a.m. During the observation, the DON confirmed Resident #3's nebulizer facemask was not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. On 5/11/2022 at 10:30 a.m., the DON confirmed all respiratory devices for Residents #3, #28, #45, #48, and #49 were not stored appropriately. The DON stated, This needs to be addressed promptly. There will be staff education and monitoring. A follow-up interview with the DON on 5/11/2022 at 11:40 a.m., revealed all respiratory equipment for residents observed was removed and replaced with new respiratory devices to include nebulizer facemasks and oxygen nasal cannulas. A review of the facility policy titled Administering Medications through a Small Volume (Handheld) Nebulizer, with revision date of October 2010, revealed: Purpose: The purpose of this procedure is to administer aerosolized particles of medication safely and aseptically into the resident's airway. 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Photographic evidence was obtained.

Based on observations, interviews and policy review, the facility did not ensure the kitchen was maintained in a sanitary manner during 3 of 4 days of survey. Findings included: An initial tour of the facility's kitchen was conducted on 05/09/22 at 09:48 AM. The tour was facilitated by the assistant certified dietary manager/CDM2 The kitchen tour revealed concerns with dirty vents located above food prep areas and clean dish storage areas. The vents were noted with dust, debris, and bio-growth. The CDM2 stated maintenance is supposed to clean the vents once a month. Concerns with Bio growth on the edge of the sink in dishwashing area were identified. The CDM2 stated they would clean it up. The CDM2 said, that is not sanitary. The CDM2 stated they have had that problem before. Photographic evidence was obtained. On 05/11/22 at 11:15 AM, a kitchen tour was conducted with the Registered Dietician (RD). An observation was made of ceiling vents in dish storage area and food service areas with dirt, debris, and bio growth. An interview was conducted on 05/11/22 at 11:35 AM with the RD. The RD stated she thought maintenance had cleaned all the vents. RD stated it will be done right after food service. An interview was conducted on 05/11/22 at 01:14 PM with the CDM2. The CDM2 stated they had scrubbed the sink area and removed the bio growth. The CDM2 stated they had scrapped off the old caulking in the sink area and applied new caulking. The CDM2 stated maintenance staff cleaned some vents, but they forgot the other two. A second interview was conducted with the RD on 05/11/22 at 1:11 PM. The RD stated the vents had now been cleaned and the CDM and maintenance will ensure surfaces are maintained in clean manner. When asked what the expectation was, the RD said, The vents will be cleaned weekly and then monthly after that. The RD stated dirty vents with debris over clean dishes and food service areas were of concern due to cross contamination. The RD said, We will make sure cleaning is done. On 05/11/22 at 1:39 PM, a telephonic interview was conducted with the CDM1. The CDM1 stated she had conducted an inspection a few weeks earlier and had identified the vents in the kitchen needed to be cleaned. The CDM1 stated the list was given to maintenance director. The CDM1 said, I forgot to follow-up. It was on my list 3 weeks ago. The CDM1 stated the expectation is to clean vents once a month. The CDM1 stated she would conduct inspections on an on-going basis. The CDM1 stated they did not have the vents on the checklist. The CDM1 said, I can understand the concern with dust flowing on food or food serving dishes. It is not sanitary. An interview was conducted with the Director of Maintenance (DOM) on 05/11/22 at 4:20 PM. The DOM stated he did not know the cleanliness and maintenance was on his list. The DOM said, I will make sure it is done going forward. It is on my list to make sure we dust them every week. The DOM stated the black stuff looked like bio growth. The DOM stated cleaning should be done more often. On 05/11/22 at 5:11 PM, the nursing home administrator (NHA) reviewed photographic evidence and stated the staff are always cleaning. It should not look like that. The NHA said, No, bio growth in the kitchen and near food surfaces is not good. I will follow-up and make sure they take care of it. Review of a facility policy titled sanitation revised October 2008, showed food service areas shall be maintained in a clean and sanitary manner. Review of a facility policy titled, cleaning and disinfection of environmental surfaces revised August 2019 showed environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standards. Review of a facility policy titled, maintenance service revised December 2009, showed maintenance service will be provided to all areas of the building, grounds, and equipment. (2) Functions of maintenance personnel include maintaining the building in compliance with current federal. State, and local laws, regulations, and guidelines. Buildings will be maintained in good repair and free from hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 5/12/2022 at 9:29 a.m., an interview was conducted with the Director of Nursing (DON) and Assistant Nursing Director (ADON)/Infection Preventionist (IP), related to infection control procedures for hand hygiene. The DON revealed that her expectation for all staff is that they perform hand hygiene before between and after resident care. She further indicated that all staff must use Personal Protective Equipment (PPE) appropriately based on the signage posted on each resident isolation precaution room. The ADON indicated the facility does in-service training and stated The education is working; we are finding that the staff is telling other staff to wash their hands and don PPE. We are following the Centers for Disease Control (CDC) guidance (as a main source), pulling up the website continuously. On 5/12/2022 at 11:00 a.m., an observation was conducted with the DON of the Laundry area. Personal items of a large cup and two bags were on top of the folding table. These items were right next to many clean and folded resident gowns, that were placed on top of each other in a pile. Staff P, Laundry Aide, confirmed that her personal items were on the table, and stated, the facility does not provide a locker, there is no place to put items. Immediately after the interview a bottle of (Cleanser and Disinfectant) was seen on the other side of the folding table with no kill time on the label. Staff P confirmed she uses the product to clean the folding table and did not know the product kill or dwell time when she uses the product on the table. She stated, I do not know, I put it on and let it dry and do it once when I come into work. Further observations revealed that Staff P, Laundry Aide was wearing her own gown and surgical gloves while sorting dirty clothes on the dirty side of the laundry area. Staff P was observed wearing the same gown while transferring clean clothes into the dryers on the clean side of the laundry area. Staff was not using the facility provided PPE items of gown, goggles, and black gloves. Staff P was asked about her gown and stated, I refuse to use that [expletive]. She further indicated that she brings three gowns from home and changes them when necessary. On 05/12/2022 at 12:00 p.m. an interview with the DON and ADON (IP) was conducted. The ADON provided a copy of education and in-service training given to Staff P on 3/19/2022, held by the Housekeeping Director. Staff P signed and acknowledged she understood product kill and dwell time for the of (Cleanser and Disinfectant). The ADON also provided the product information, which showed that the product has a 10-minute kill time in order to be effective. She further revealed that all staff in the laundry room must wear the appropriate PPE which is hanging on hooks in the laundry room. The ADON stated Staff P cannot bring in her own personal gowns from home, and she cannot wear gloves that we use to take care of patients while sorting laundry. The DON reported that following the observation of the laundry area at 11:00 a.m. on 5/12/22 with the surveyor, all laundry on the folding table was being rewashed and the folding table was re-cleaned. The DON reported that maintenance was going to install a locker for staff to place all personal items in to avoid having personal items in the laundry area. 2. On 5/9/2022 at 11:23 a.m. a lunch meal tray service was observed in the hallway of the facility serving rooms 119 to 128. Staff A, CNA was observed getting a tray from an open metal dining cart and taking the tray into room [ROOM NUMBER]. Staff A was observed proceeding to get another tray from the cart without conducting hand hygiene and taking the tray into room [ROOM NUMBER]. Staff A could be seen setting up the food tray for the resident in room [ROOM NUMBER] without performing hand hygiene. Staff A proceeded to exit the room and was not observed to perform hand hygiene. Staff A then put on a gown and gloves, took another tray from the dining cart, and entered room [ROOM NUMBER]. room [ROOM NUMBER] was marked with a sign indicating Droplet/Contact Isolation. Staff A came to the doorway and was handed another tray for room [ROOM NUMBER] by another staff member. Staff A could be seen setting up the tray for each resident in the room. Staff A exited the room, removed the gown and gloves in the hallway, and placed them in a small metal receptacle. Staff A was not observed conducting hand hygiene after removal of her gown and gloves. Staff A was observed putting on another gown and gloves and taking another tray from the dining cart and taking the tray into room [ROOM NUMBER]. room [ROOM NUMBER] was marked with a sign indicating Droplet/Contact Isolation. Staff A set the tray on an overbed table and reached out into the hallway, while still wearing the same gown and gloves, to take another tray from the cart for room [ROOM NUMBER]. Staff A did not perform hand hygiene, and did not change her gown and gloves prior to serving the second resident in the room. Staff A proceeded to exit room [ROOM NUMBER], take off her gown and gloves in the hallway, and place them into a small metal receptacle. Staff A, CNA was not observed to perform hand hygiene after removal of her gown and gloves. Staff A then removed another tray from the dining cart and took the tray into room [ROOM NUMBER]. Staff A could be seen setting up the tray for the resident. Staff A returned to the hallway and without performing hand hygiene, she left the hallway and brought back a box of gowns to restock the supply in the hallway. Staff A , without performing any hand hygiene, proceeded to put on another gown and gloves and get another tray from the dining cart. Staff A was observed taking the tray into the room for Resident #21. Resident #21's room was not marked as being in isolation of any kind. Staff A was observed setting up the tray for the resident. Staff A exited Resident #21's room, took off her gown and gloves in the hallway and placed the items in a small metal receptacle. Staff A was not observed performing hand hygiene after removal of the gown and gloves. Staff A then assisted another employee to put on a gown, and she left the hallway pushing the dining cart as she left. On 5/09/22 at 11:45 a.m., a visitor was observed approaching Resident #21's room with a mask and shield on. The visitor was observed putting on gloves and a gown to enter the room. The visitor stated Resident #21 was on isolation due to being exposed to COVID. No signage was observed on the door indicating the resident was on isolation or providing any direction to visitors for Personal Protective Equipment (PPE) usage. Photographic evidence was obtained. A review of facility policy entitled Handwashing/Hand Hygiene with a revision date of August 2019 revealed the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1 All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in prevention 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 and water for the following situations: .b before and after direct contact with residents .f before donning sterile gloves .l after contact with objects in the immediate vicinity of the resident m after removing gloves n before and after entering isolation precaution settings o before and after eating or handling food p before and after assisting a resident with meals .8 Hand hygiene is the final step after removing and disposing of personal protective equipment 9 The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10 Single-use disposable gloves should be used .c when in contact with a resident or the equipment or environment of a resident, who is on contact precautions. A review of the facility policy entitled Isolation-Categories of Transmission-Based Precautions with a revision date of October 2018 indicated 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. .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 (Centers for Disease Control) precautions, instructions for use of PPE, and/or instructions to see a nurse before entering the room. 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. .4 Staff and visitors will wear gloves when entering the room .b Gloves will be removed and hand hygiene performed before leaving the room 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. Droplet Precautions 1 Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets , larger than 5 microns in size, that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). .4 Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. Based on observations, interviews, record review and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 and other infections on two (101-110 and 119-128) of six hallways and one of one laundry area. Findings included: 1. On 5/9/22 beginning at 11:30 AM, Staff I, Certified Nursing Assistant (CNA) was observed delivering and setting up lunch trays for residents in rooms 101 through 108. No hand hygiene by Staff I was observed between each tray delivered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility did not ensure that care was provided in a dignified manner for one resident (#28) of one resident sampled for dignity. Findings included: A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, hemiplegia, and acute pyelonephritis. A review of Resident #28's care plan revealed a problem, revised on 12/03/2020, that Resident #28 had impaired cognitive skills as evidence by decision making problems, short term memory problems, long term memory problems, and problems understanding others. Interventions included promote dignity by conversing with the resident and ensuring privacy while providing care. A review of Resident #28's Physician Order Report from 1/11/21 to 2/11/21 revealed an order, dated 12/24/2020, for an indwelling catheter size 18 french with 10 cubic centimeter balloon to straight drainage. Special instructions: privacy bag at all times. A wound care observation was made on 02/11/2021 at 9:00 a.m. for Resident #28 with Staff E, Licensed Practical Nurse (LPN) performing the wound care, and Staff F, LPN assisting in the procedure. During the observation, Resident #28 was observed to have an indwelling catheter and a urine drainage bag, which was hanging from Resident #28's bed. The urine drainage bag was observed to not have a privacy cover at the time. Staff E, LPN stated that Resident #28's urinary collection bag should be kept inside of a privacy bag and was not able to state why the urine collection bag was not placed inside of a privacy bag. Staff F, LPN then placed Resident #28's urine collection bag inside of a privacy bag and hung the bag from Resident #28's bed. An observation was made on 02/12/2021 at 10:06 a.m. during medication administration for Resident #28 with Staff E, LPN. Resident #28's urinary collection bag was observed hanging from the side of her bed and was not in a privacy bag. A folded up privacy bag was observed on Resident #28's bedside table. Staff E, LPN addressed that Resident #28's urinary collection bag should have been stored inside of a privacy bag and was not able to explain why another staff member brought the bag into the room and did not use it. A review of the faciltiy policy titled Catheter Care Procedure, last reviewed on 05/23/2018, revealed under the section titled Guideline Steps, that staff should routinely check to ensure that a drainage bag is covered with a privacy bag unless resident requests otherwise.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure self-administration of medications was clinically appropriate for one resident (#28) of four residents sampled for medication administration. Findings included: A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). A review of Resident #28's care plan revealed a problem, revised on 12/03/2020, that Resident #28 utilized oxygen therapy secondary to COPD. Interventions included medications, nebulizers, and puffers as ordered. A review of Resident #28's Physician Order Report from 1/11/21 to 2/11/21 revealed an order, dated 12/23/2020, for ipratropium-albuterol solution for nebulization, 0.5 milligrams (mg) - 3 mg per 3 milliliter (ml) solution; 1 dose inhalation three times a day for a diagnosis of COPD. An observation was made on 02/10/2021 at 11:03 a.m. of Resident #28 resting in bed in her room. Resident #28 had a nebulizer mask on her face, which was attached to the running nebulizer machine on her nightstand. No staff were observed in the resident's room at the time of the observation. An interview was conducted on 02/10/2021 at 11:06 a.m. with Staff Q, Registered Nurse (RN), who was at the nurse's station. Staff Q, RN stated that Resident #28 had not been assessed for self-administration of medications and that the resident was totally dependent on staff for her care. An interview was conducted on 02/11/2021 at 03:57 p.m. with the facility's Director of Nursing (DON). The DON stated that residents may administer their own nebulizer treatments if a self-administration assessment is conducted, and if it is within the resident's plan of care. The DON also stated that it would not be acceptable to leave a nebulizer treatment and walk out of the room if the resident is not able to self-administer the medication. An observation of medication administration was conducted on 02/12/2021 at 09:32 a.m. with Staff E, Licensed Practical Nurse (LPN) for Resident #28. Staff E, LPN was observed preparing ipratropium-albuterol 0.5 mg - 3 mg per 3 ml solution for administration via nebulizer mask for Resident #28. Staff E, LPN was observed pouring the medication into the chamber of the nebulizer mask, applying the mask to Resident #28's face, and turning on the nebulizer. Staff E, LPN then explained to Resident #28 that she would be back in about 15 minutes to take the mask off and exited the room. An interview was conducted with Staff E, LPN following the observation at 10:12 a.m. Staff E, LPN stated that Resident #28 had not been assessed for self-administration of medications, but that she would normally stay near the resident's room and monitor the administration until it was completed. A telephone interview was conducted on 02/19/2021 at 02:24 p.m. with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that staff at the facility were educated on proper administration of nebulizer treatments to residents and that nurses should be in the room and available to the resident during the administration unless the resident is able to self-administer the medication. If a resident is able to put on and take off the nebulizer mask themselves, then an order would be obtained, and an assessment would be conducted for self-administration of medications. A review of the facility policy titled, Medication Administration - Nebulizers, dated 09/2010, revealed under the section titled Procedures, that staff were to remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to make prompt efforts to resolve a grievance for one resident (#9) of one resident sampled for grievances. Findings included: A review of Resident #9's medical record revealed that Resident #9 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit and need for assistance with personal care. An interview was conducted on 02/10/2021 at 11:03 a.m. with Resident #9. Resident #9 stated that her dentures were missing for two days. Resident #9 also stated that she wrapped her dentures in a brown paper napkin and placed them on her bedside table. When she woke up the next morning, they were gone from her bedside table. Resident #9 stated that she was not sure what the facility was doing regarding her missing dentures and she reported that they were missing to the nursing staff. A review of Resident #9's Progress Notes revealed a note, dated 02/03/2021 at 11:22 a.m., that a Certified Nursing Assistant (CNA) reported to the nurse that Resident #9's dentures were reported missing. Resident #9 told the CNA that she wrapped the dentures in a brown paper napkin on the night of 02/02/2021 and left them on her bedside table. The note revealed that the nurse reported the lost dentures to the Director of Nursing (DON) and administration. A review of the facility's Grievance Log revealed a grievance, dated 02/03/2021, that Resident #9 had a grievance related to missing dentures. No documentation was revealed under the sections titled Follow-Up Investigation or Resolution. An interview was conducted on 02/11/2021 at 11:58 a.m. with the facility's Nursing Home Administrator (NHA). The NHA stated that he was informed of Resident #9's missing dentures on 02/08/2021. The NHA was not able to state why the concern was not reported sooner than 02/08/2021. The NHA stated that his initial goal was to close out the investigation on 02/08/2021 but the grievance was not investigated by then. Typically, the goal would be to resolve a grievance within three days of the grievance being reported and to strive toward resolving grievances as quickly as possible. The NHA stated that staff were aware that Resident #9's dentures were missing and that efforts were being made to locate them. An interview was conducted on 02/11/2021 at 12:45 p.m. with Staff G, CNA. Staff G was assigned to Resident #9's care for the 7:00 a.m. to 3:00 p.m. shift. Staff G, CNA stated that she was not aware that Resident #9's dentures were missing. Staff G, CNA spoke with Resident #9 and confirmed with her that the dentures were missing. A review of the facility policy titled, Investigate Complaint/Grievance, revised on 07/19/2018, revealed that all grievance and complaint reports must be resolved and reviewed by the NHA within 3 working days of the receipt of the grievance or complaint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a baseline care plan that included minimum healthcare information necessary to properly care for two residents (#2 and #276) of nine residents with an indwelling urine catheter. Findings included: On 02/11/2021 at 10:10 a.m. an observation of Resident #276 revealed the resident had an indwelling urine catheter. The indwelling catheter bag was observed in a vanity cover and laying flat on the floor under the bed. On 02/11/2021 at 10:23 a.m. an observation of Resident #2 revealed the resident had an indwelling urine catheter. The indwelling catheter bag was observed in a vanity cover and laying flat on the floor. Review of the clinical record for Resident #276 showed an admission date of 01/11/2021 and admitting diagnoses that included, but not limited to muscle weakness, COVID-19, pneumonia, hypertension and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed the resident had an indwelling urinary catheter. Further review of the clinical record on 02/10/2021 at 8:00 a.m. revealed no documentation of the indwelling urinary catheter on the care plan, as well as no interventions or goals for the catheter and care. A subsequent review of the clinical record on 02/11/2021 at 8:38 a.m. showed a problem of indwelling catheter added to the care plan, with a problem start date of 02/10/2021 and a revised date of 02/11/2021. Interventions included provide catheter care as ordered. Further review of the Physician Order Report 1/11/21 - 2/11/21 showed no physician's order for the indwelling urinary catheter or care modalities. A review of CMS Form 3008 dated 01/11/2021 showed the indwelling urinary catheter was inserted on 01/9/2021 at 13:00 (1:00 p.m.) in the hospital for urine retention. Review of the clinical record for Resident #2 revealed an admission date of 07/04/2019, a readmission date of 01/21/2021 and admitting diagnoses that included, but not limited to hydronephrosis with renal and ureteral calculi obstruction, pyelonephritis, and COVID-19. The Physician Order Report dated 1/11/21 - 2/11/21 showed physician orders for: Flush/irrigate catheter with 60ml [milliliters] NS [Normal Saline] for leakage/blockage, catheter to straight drainage for obstructive uropathy, change catheter PRN [as needed] for leakage/blockage/dislodgement; contact doctor if balloon size changed is required, record output every shift, and catheter care every shift. The record also indicated the resident was on Contact Precautions for colonized ESBL (Extended Spectrum beta-lactamases) in the urine. The 5-day MDS dated [DATE] revealed the resident had a urinary catheter. The active care plan was reviewed and did not indicate any listed problems, goals, or interventions related to the indwelling urinary catheter. On 02/11/2021 at 10:26 a.m. an interview was conducted with Resident #2. He stated he had been at the facility for several years and just recently came back after a trip to the hospital. He said he had a catheter as he had an infection in his urine, and it was put in at the hospital. On 02/11/2021 at 10:32 a.m., an interview with Staff A, Registered Nurse (RN) confirmed the resident had an indwelling urine catheter and was on contact precautions for ESBL in his urine. An interview with Staff B, MDS RN was conducted on 02/11/2021 at 2:51 p.m. Staff B, MDS RN stated care plans are updated by the resident's nurse as well as the multi-disciplinary team and discussed each morning at the team meetings. She stated the care plan for Resident #276 was updated yesterday; however, she confirmed the indwelling urine catheter should have been added to the care plan upon the resident's admission. Staff B, MDS RN also said she was unaware that the care plan for Resident #2 did not include his indwelling urinary catheter, and further stated it should have been added upon his re-admission. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 02/11/2021 at 2:59 p.m., the DON stated it was her expectation that indwelling urinary catheters would be included in the resident's care plan upon admission or readmission. A review of a facility-provided policy titled, Comprehensive Care Plans, and dated 07/19/2018 revealed: 2. The Comprehensive Care Plan is based on a thorough assessment that includes, but is not limited to, the Resident Assessment Instrument. 9. Care Plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident's goals. 13. Care Plans are ongoing and revised as information about the resident and the resident's condition change. 14. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition. The policy did not address baseline care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the medical record for Resident #35 revealed that Resident #35 was admitted to the facility on [DATE] for diagnoses that included COVID-19, viral pneumonia, and anxiety. A review of Resident #35's active physician orders included: Oxygen therapy: oxygen via NC (nasal cannula) @ (at) 2 liters per minute continuously dated 12/14/2020 with no end date, and oxygen therapy: verify that tubing is changed weekly once a day on Wednesday dated 12/14/2020. A review of the care plan initiated on 10/23/19 and edited on 12/21/20 revealed that Resident #35 had a problem documented as, [Resident #35] has a pulmonary condition/DX [diagnosis] and has the potential for difficulty breathing . Interventions included: Administer O2 (oxygen) as ordered. On 02/09/21 at 11:50 a.m., it was noticed that Resident #35 had an oxygen concentrator next to her bed. The concentrator was off, and the resident was not wearing a nasal cannula. The oxygen tubing was lying over the top of the concentrator undated and unbagged. On 02/10/21 at 10:37 a.m. Resident #35 was observed lying in bed with no oxygen on. The oxygen concentrator was against the wall next to her roommate's bed with the tubing lying over the top of it without being bagged or dated. (Photographic evidence obtained.) On 02/10/21 at 03:05 p.m. Resident #35 was lying in bed without oxygen on, the tubing was lying over the top of the concentrator, unbagged and undated. On 02/11/21 at 08:35 a.m. the resident was observed lying in bed with no oxygen on. The tubing was lying over the top of the concentrator, unbagged and undated. On 02/11/21 at 12:45 p.m. an interview was conducted with Staff M, Registered Nurse (RN) Consultant and the Interim Director of Nursing (DON). They both said that the tubing on all oxygen should be changed weekly, and there should be a bag for the nasal cannula for when the tubing is not in use. The tubing should be dated. Based on observations, interviews, and review of facility policy, the facility failed to store respiratory equipment in accordance with professional standards of practice for two residents (#28 and #35) of three residents sampled for respiratory care. Findings included: 1. A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). A review of Resident #28's care plan revealed a problem, revised on 12/03/2020, that Resident #28 utilized oxygen therapy secondary to COPD. Interventions included medications, nebulizers, and puffers as ordered. A review of Resident #28's Physician Order Report dated 1/11/21 - 2/11/21 revealed a physician's order, dated 12/23/2020, for ipratropium-albuterol solution for nebulization, 0.5 milligrams (mg) - 3 mg per 3 milliliter (ml) solution; 1 dose inhalation three times a day for a diagnosis of COPD. An observation was made on 02/10/2021 at 11:06 a.m. of Staff Q, Registered Nurse (RN) removing a nebulizer mask from Resident #28 following a nebulizer treatment. Staff Q, RN was observed removing the mask from Resident #28 and placing the mask on the nebulizer machine on Resident #28's nightstand. Staff Q, RN stated that she would normally wipe off the nebulizer mask and place the mask upright next to the machine. Staff Q, RN also stated that she did not store the nebulizer mask inside of a storage bag after nebulizer treatments. An observation was made on 02/11/2021 at 09:16 a.m. in Resident #28's room. Resident #28's nebulizer mask was observed laying on top of the nebulizer machine on Resident #28's night stand. An interview was conducted with Staff E, Licensed Practical Nurse (LPN) following the observation. Staff E, LPN stated that Resident #28's nebulizer mask should not be laying on the night stand and that the nebulizer mask should have been stored inside of a plastic bag with the resident's name and date. Staff E, LPN was not able to state why Resident #28's nebulizer mask was not stored properly. A interview was conducted on 02/11/2021 at 03:57 p.m. with the facility's Director of Nursing (DON). The DON stated that respiratory equipment was replaced on a weekly basis, including oxygen tubing and nebulizer equipment. All oxygen tubing and nebulizer equipment should be dated and have a bag included with the date on it for storage purposes. The DON stated that respiratory equipment should be stored in a plastic bag when it was not in use and that it would not be acceptable to store a nebulizer mask on the resident's night stand because it could get dirty. A review of a facility policy titled, Nebulizers, dated 09/2010, revealed that after treatment nursing staff rinse and disinfect the nebulizer equipment according to manufacturer's recommendations and facility policy. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Change equipment and tubing per nursing facility policy. A review of the facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, revealed under the section titled, Infection Control Considerations Related to Oxygen Administration, to change the oxygen cannula and tubing every 7 days, or as needed and to keep the oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use. The policy also revealed, under the section titled, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol, to remove the nebulizer container, rinse the container with fresh tap water, and dry on a clean paper towel or gauze sponge after use. Reconnect to the administration set-up when air dried and store the circuit in a plastic bag marked with the date and the resident's name between uses. (Photographic evidence obtained.)

Based on observations, interviews, and record reviews, the facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with professional standards in one medication room (100 unit) of two medication storage rooms in the facility and two (100 unit and 200 unit) of six medication carts in the facility. Findings included: A medication cart inspection on the 100 unit was completed on 02/12/2021 at 11:42 a.m. with Staff E, Licensed Practical Nurse (LPN). A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. An observation of the label revealed text that read Use within 90 days (3 months) of first opening. Staff E, LPN stated that they were never told that they needed to date blood glucose test strips once they were opened and observed that label. Staff E, LPN addressed that the blood glucose test strips should be dated per the label instructions. A medication storage room inspection on the 100 unit was completed on 02/12/2021 at 12:01 p.m. with Staff E, LPN. An inspection of a medication storage refrigerator revealed a temperature log, last completed on 02/09/2021. No entries were observed for 02/10/2021 or 02/11/2021. An inspection of a narcotics storage refrigerator also revealed a temperature log, last completed on 02/09/2021. No entries were observed for 02/10/2021 or 02/11/2021. Staff E, LPN stated that the 11 PM to 7 AM staff were responsible for completing the temperature logs and that it should be completed daily. Two large boxes of various medications were observed on the counter in the medication storage room. Staff E, LPN stated that the 11 PM to 7 AM shift was also responsible for documenting and completing the return of medications to the pharmacy and was not sure why so many were being kept in the medication storage room. An interview was conducted on 02/12/2021 at 12:27 p.m. with the facility's Director of Nursing (DON). The DON stated that the temperature log for the medication refrigerators should have been completed daily by the 11 PM to 7 AM shift. The DON also stated that the 11 PM to 7 AM shift returned medications to the pharmacy by putting the medications in bags and conducting an inventory of the medications. The DON addressed that the medications were not inventoried, and stated that the medications should not accumulate in large quantities in the medication storage room. The DON also stated that blood glucose monitoring strips should be dated upon opening in accordance with the label instructions. A medication cart inspection on the 200 unit was completed on 02/12/2021 at 12:31 p.m. with Staff F, LPN. A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. An observation of the label revealed text that read Use within 90 days (3 months) of first opening. Staff F, LPN stated that they did not date blood glucose test strips upon opening and asked for what reason?. A vial of Levemir insulin was observed in the medication cart, with a label that read Discard after 42 days. The label had two sections, which read, Date Vial Opened and Date Vial Expires which were not dated. The manufacturer's box that the Levemir insulin was stored in also had a label that read Date Opened, which was not dated. A vial of Lantus insulin was observed in the medication cart, with a label that read Discard unused portion 28 days after opening, and a section that read, Date Opened, which was not dated. The manufacturer's box that the Lantus insulin was stored in also had a label that read Date Opened, which was not dated. Staff F, LPN stated that the insulins should have been dated when they were opened and was not able to state why the insulins were not dated. A telephone interview was conducted on 02/19/2021 at 02:24 p.m. with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that she conducted monthly visits to the facility and conducted spot checks of the medication carts and the medication rooms. Expiration dates of medications, dating of medications, dating of glucose test strips, temperature logs, and medication storage and stock were all things that she checked during visits to the facility. The Consultant Pharmacist stated that the nursing staff dropping off medications to go back to the pharmacy had been a challenge because the nursing staff often forget to bring the boxes to the front of the facility for pickup, so there may be a few more than usual. The Consultant Pharmacist stated that blood glucose monitoring strips and insulins should be dated once they are opened. A review of the facility policy titled, Medications and Medication Labels, dated on 05/2016, revealed that multi-dose vials shall be labeled to assure product integrity, considering the manufacturers' specifications. Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label. A review of the facility policy titled, Storage of Medication, dated 09/2018, revealed that medications requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify temperature has remained within accepted limits. (Photographic evidence obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of the medical record for Resident #35 revealed that Resident #35 was readmitted to the facility on [DATE] with an original admission date of 7/07/2014. Resident #35's diagnoses included COVID-19, and anxiety. In a quarterly MDS (minimum data set) assessment dated [DATE], the resident was assessed to have a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 02/09/21 at 11:50 a.m. Resident #35's belongings were observed in bags in the wheelchair that was next to her bed, and on top of her dresser near the door. On 02/10/21 at 10:37 a.m. the resident's belongings were observed in bags in the wheelchair and on top of the dresser. On 02/10/21 at 03:05 p.m. the resident's belongings were observed in bags in the wheelchair and on top of the dresser. On 02/11/21 at 08:35 a.m. the resident's belongings were observed in bags in the wheelchair and on top of the dresser. 5. A review of Resident #41's medical record revealed that Resident #41 was admitted to the facility on [DATE] with the most recent readmission date being 1/21/2021 for diagnoses that included but not limited to chronic pain, fever, insomnia, cough, nausea with vomiting and depressive episodes. On 02/09/21 at 11:15 a.m., Resident #41 said that when she was moved to the COVID unit, they (the facility) packed up her personal items and that since moving back to her original room, she has yet to get it back. She said that she has asked, but whoever she asks, doesn't know where it is. She said it's getting old that no one knows where her stuff is. On 02/11/21 at 02:55 p.m. Resident #41 said that someone brought her personal items back to her last night (02/10/21). The staff member did not put it away, but instead left it sitting in multiple boxes on top of her bedside dresser, and she said that a box was sitting in her closet unpacked. Based on observations, record review and interviews, the facility failed to provide a clean and homelike environment by leaving resident personal belongings in bags and boxes for five residents (#8, #10, #28, #35, and #41) of 26 sampled residents for four of four days. Findings included: 1. A review of Resident #8's medical record revealed that Resident #8 was admitted to the facility on [DATE] with diagnoses of dementia, COVID-19, cognitive communication deficit, and need for assistance with personal care. An observation was made on 02/10/2021 at 11:45 a.m. of Resident #8 eating lunch in his room. A large box was observed in the corner of Resident #8's room containing several belongings. An interview was conducted with Staff H, Certified Nursing Assistant (CNA) following the observation. Staff H, CNA stated that the large box in Resident #8's room contained his personal belongings from his previous room and they had not yet been put away. Staff H, CNA also stated that Resident #8's belongings were not unpacked and put away because he was not staying in the room for very long and he would be returning to his previous room. Staff H, CNA stated that Resident #8 also had a television out in the storage shed and that it was not brought to his room because he would be moving out of the room soon. An interview was conducted on 02/10/2021 at 11:50 a.m. with Staff I, Licensed Practical Nurse (LPN). Staff I, LPN stated that Resident #8 was staying on the unit temporarily and that all of his belongings were not brought over to his current room. Staff I, LPN was not able to state why Resident #8's belongings were not put away when he moved into the room and was not able to state how long Resident #8 would remain on the unit for. Staff H, CNA stated during the interview that Resident #8 refused to have his belongings put away, which is why they were still in a box in his room. Staff H, CNA was not able to state where Resident #8's refusal was documented. 2. A review of Resident #10's medical record revealed that Resident #10 was admitted to the facility on [DATE] with diagnoses of dementia and COVID-19. An observation was made on 02/11/2021 at 09:54 a.m. in Resident #10's room. A large, clear bag was observed in the corner of Resident #10's room on the floor. The bag appeared to contain several blankets and other resident belongings. An interview was conducted following the observation with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN was not able to explain why the bag was on the floor of Resident #10's room and was not able to state who the bag belonged to. 3. A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with a diagnosis of hemiplegia. An observation was made on 02/11/2021 at 09:37 a.m. of Resident #28's room. A large, clear bag of belongings was observed on the floor of Resident #28's room underneath the sink. An interview was conducted following the observation with Staff F, LPN. Staff F, LPN stated that the bag of belongings should not be stored underneath of the resident's sink and was not able to state why the belongings were put there. Staff F, LPN also stated that she had concerns with resident belongings being kept in bags and boxes and placed on the floor and that the concerns were mentioned to administrative staff, but nothing was done about it. An interview was conducted on 02/11/2021 at 12:57 p.m. with Staff G, CNA. Staff G, CNA stated that Resident #28's bag of belongings were placed in the MDS (Minimum Data Set) office. Staff G, CNA was not able to state why the belongings were not put away but stated that someone told her to put them there. An observation was made following the interview of the MDS office. The clear bag of Resident #28's belongings were observed on the floor of the office next to Staff J, MDS Nurse. An interview was conducted with Staff J, MDS Nurse, who was not able to state why the belongings were placed in the MDS office. A tour was conducted at 02/11/2021 at 01:01 p.m. with the facility's Director of Nursing (DON). The DON observed Resident #28's belongings in the MDS office and was not able to state why the belongings were brought to the office and not put away in Resident #28's room. The DON also observed the bag of belongings on the floor of Resident #10's room and stated that the belongings should not be kept in bags and boxes or placed on the floor. The DON stated that the items should have been put away. An interview was conducted on 02/11/2021 at 01:08 p.m. with the facility's Assistance Director of Nursing (ADON). The ADON stated that when a resident was diagnosed with COVID-19, belongings were boxed up and stored in the storage shed with the exception of five outfits for the resident. Once the resident is off of the COVID-19, the belongings should be returned to the resident. The ADON stated that CNAs bring the resident's belongings back to the resident's room and should put them away. Resident belongings should not be left laying on the floor and should be stored in the resident's dresser or closet. An interview was conducted on 02/11/2021 at 01:16 p.m. with Staff B, MDS Nurse. Staff B, MDS Nurse stated that Resident #28's belongings were placed in the MDS office because they had not had a chance to go through the bag to determine what Resident #28 needed. Staff B, MDS Nurse addressed that resident belongings should be put away when a resident returned to their room and should not be placed on the floor of the room. An interview was conducted on 02/11/2021 at 01:20 p.m. with Staff D, Supply in the facility's storage shed. Staff D, Supply stated that when a resident is transferred to the COVID-19 unit, all belongings get packed up and stored in the storage shed except for five outfits. Belongings are returned to residents once they are able to leave the COVID-19 unit. Several boxes with labels and signs that read Who's Stuff? was observed on the top shelf of the storage shed. Staff D, Supply stated that sometimes belongings were not labeled correctly by staff before storing them, so they had several unclaimed belongings in those boxes. (Photographic evidence obtained)