Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as per physician order for 1 of 2 residents reviewed for respiratory services, Resident #33. Findings include: During an observation on 8/19/2024 at 9:58 AM, Resident #33 was lying in bed, receiving oxygen at 2 liters per minute via nasal cannula. During an observation on 8/20/2024 at 8:14 AM, Resident #33 was lying in bed, receiving oxygen at 2 liters per minute via nasal cannula. Review of Resident #33's physician orders revealed no order for oxygen administration. Review of Resident #33's Weights and Vitals Summary for oxygen saturation showed 94% (oxygen via nasal cannula) on 8/19/2024 at 10:12 AM and 99% (oxygen via nasal cannula) on 8/20/2024 at 8:52 AM. Review of Resident #33's care plan with an initiated date of 8/2/2024 read, Focus: The resident has altered respiratory status due to COPD [Chronic Obstructive Pulmonary Disease], acute respiratory failure with hypoxia and O2 [oxygen] use. During an interview on 8/21/2024 at 1:15 PM, the Director of Nursing (DON) stated, [Resident #33's name] did not have a current order in the facility for oxygen administration. We must have a doctor's order for all medications and interventions in order to know what rate the oxygen should be running at. Review of the facility policy and procedure titled Oxygen Administration with the last review date of 1/23/2024 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the facility policy and procedure titled Administering Medications with the last review date of 1/23/2024 read, Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 1 of 4 units. Findings include: 1) During an observation on 8/19/22024 at 9:52 AM, Resident #14 was lying in bed. On top of the resident's bedside table, there was a bottle of Magnesium Glycinate (Photographic evidence obtained). During an observation on 8/19/2024 at 11:02 AM with Staff G, Licensed Practical Nurse (LPN) Unit Manager, Resident #14 was lying in bed and there was a bottle of Magnesium Glycinate on top of the resident's bedside table. During an interview on 8/19/2204 at 11:02 AM, Resident #14 stated, I brought this Magnesium from home and the nurse will give it to me because the facility does not carry this type. 2) During an observation on 8/19/2024 at 9:43 AM, Resident #36 was not in his room. There was a bottle of Hydrogen Peroxide on top of the resident's drawer (Photographic evidence obtained). During an observation on 8/19/2024 at 11:00 AM with Staff G, LPN Unit Manager, there was a bottle of Hydrogen Peroxide on top of Resident #36's drawer. During an interview on 8/19/2024 at 11:05 AM, Staff G, LPN Unit Manager, stated, Those medications should not be there. Residents should not have medication at bedside. [Resident #36's name] does not even have orders for Hydrogen Peroxide. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing (DON) stated, Resident medication should be locked in a lock box inside the resident's drawer. Review of the facility policy and procedure titled Medication Labeling and Storage with the last review date of 1/23/2024 read, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on observation, interview, and record review, the facility failed to ensure staff sanitized the equipment while taking food temperatures in accordance with professional standards. Findings include: During an observation on 8/20/2024 at 7:40 AM, Staff C, Cook, picked up a towel that was sitting on the prep table and used the towel to wipe the temperature probe between taking temperatures of pureed foods including oatmeal, eggs, and waffles. Staff C did not use alcohol wipes after testing the first pureed food. During an interview on 8/20/2024 at 8:32 AM, Staff C, Cook, confirmed he used the towel to clean off the temp probe. During an interview on 8/20/2024 at 8:25 AM, the Certified Dietary Manager (CDM) stated they need to use alcohol wipes to clean the temperature probe and if they have to clean off the probe with another source, they would use a clean paper towel. During an interview on 8/21/2024 on 11:35 AM, the Registered Dietician stated that she expected the dietary staff to use alcohol wipes in between foods when using the temp probe. Review of the facility policy and procedure titled Food Temperatures with the last review date of 1/23/24 showed it read, Policy: Foods should be served at proper temperature to insure food safety and palatability. Procedure: 1. Wash, rinse and sanitize a dial face, metal probe-type thermometer with alcohol wipe. A practical range of 0-220 F [Fahrenheit] is recommended. Re-sanitize the thermometer after each use.

4) During an observation on 8/20/2024 at 1:18 PM, Staff A, Registered Nurse (RN) Supervisor, and Staff B, Registered Nurse, were providing wound care to Resident #7. Staff B did not put down a protective barrier to protect the bed linen and other body sites before wound care. Staff B removed the dressing to the resident's right foot and then removed her gloves. Staff B did not perform hand hygiene before applying another set of gloves to clean the wound on the resident's right foot. Without performing hand hygiene, Staff B applied another set of gloves to dry the wound area. Staff B did not perform hand hygiene before applying dressing to the right foot. Staff B removed her gloves after completing the dressing change to the right foot and applied another set of gloves without performing hand hygiene and removed the dressing to the resident's left foot. Staff B applied a new set of gloves without performing hand hygiene to clean the left foot wound area. Staff B removed her gloves and applied another set of gloves for drying the left foot wound area without performing hand hygiene. Staff B removed her gloves and applied another set of gloves for applying dressing to the resident's right foot wound without performing hand hygiene. During an interview on 8/20/2024 at 2:45 PM, Staff A, RN Supervisor, stated, [Staff B's name] should have washed her hands between each procedure and placed a barrier between the resident and the bed. During an interview on 8/20/2024 at 2:45 PM, Staff B, RN, stated, I did the wound care just like I always do it. I should have washed my hands and should have laid a barrier down between the wound care and the bed before starting the procedure. During an interview on 8/22/2024 at 10:00 AM, the Director of Nursing stated, After removing the old dressing and removing gloves, they should wash hands before applying new gloves again. Review of the facility policy and procedure titled Dressings, Dry/Clean with the last review date of 1/23/2024 showed it read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressing . Steps in the Procedure . 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time, and initials, place on clean field. 11. Using a clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 12. Wash and dry your hands thoroughly. 13. Put on clean gloves. 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area usually from the center outward. 16. Use dry gauge to pat the wound dry. Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment while providing high contact care for the residents on enhanced barrier precautions for 2 of 6 residents observed, Residents #50 and #310, failed to ensure staff performed hand hygiene during medication administration for 1 of 6 residents observed, Resident #164, and failed to ensure staff followed infection control standard of practice while providing wound care for 1 of 2 residents reviewed for pressure wounds, Resident #7, to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 8/21/2024 at 5:38 AM, Staff F, Licensed Practical Nurse (LPN), entered Resident #50's room and donned gloves. Staff F did not don a gown. Resident #50's room door had an enhanced barrier precautions signage. Staff F administered IV (intravenous) medication and exited the room. While Staff F was standing outside of the room, Resident #50's IV pump started beeping and Staff F entered the resident's room and adjusted the IV pump. Staff F was wearing gloves and no gown. During an interview on 8/21/2024 at 5:54 AM, Staff F, LPN, stated, Wearing a gown is not something we regularly do only when the resident is on isolation. Enhanced barrier is more for infection. 2) During an observation on 8/21/2024 at 8:12 AM, Staff D, LPN, entered Resident #310's room. Resident #310's room door had an enhanced barrier precaution signage posted. Staff D entered Resident #310's room after pouring medication and donned gloves without donning a gown. Staff D administered the medication via Resident #310's gastric tube. During an interview on 8/21/2024 at 9:42 AM, Staff D, LPN, stated, I should have put on a gown since he [Resident #310] has a gastric tube and is under enhanced barrier precautions. 3) During an observation on 8/21/2024 at 8:57 AM, Staff E, LPN, was pouring medication for Resident #164. One Flomax capsule fell on top of the medication cart. Staff E proceeded to grab the capsule with her hands without wearing gloves and placed the capsule back into the medication cup. Staff E entered Resident #164's room and administered the medication. During an interview on 8/21/2024 at 9:05 AM, Staff E, LPN, stated, I should have discarded the medication once it fell onto the medication cart and poured a new medication onto the medication cup. During an interview on 8/21/2024 at 1:45 PM, the Infection Preventionist stated, Staff should wear gloves and gown when providing direct care to residents who are under enhanced barrier precautions and if they are at risk for a splash, they should wear a face shield. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing (DON) stated, Staff should follow full personal protective equipment when resident is under enhanced barrier precautions. The staff should wear gloves and gown when coming into direct contact with resident. Staff should discard medication and pour a new one if they fall. Medication should not be touched without gloves. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/23/2024 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi0frug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high-contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring use of gown and gloves for EBPs include . g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) Review of the facility policy and procedure titled Administering Medications with the last review date of 1/23/2024 read, Policy Interpretation and Implementation . 25. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the residents' health record showed the residents either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for 2 of 5 residents reviewed for immunization, Residents #3 and #7. Findings include: Review of Resident #3's admission record showed the resident was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, insomnia and chronic pain syndrome. Review of Resident #3's vaccination records showed a flu vaccine consent signed on 11/6/2023. Further review of the records showed the resident received the last flu vaccine on 10/25/2022, with no documentation of a flu vaccine administered after 11/6/2023. Review of Resident #7's admission record showed the resident was admitted on [DATE] with diagnoses including heart failure, atrial fibrillation, dementia and chronic kidney disease. Review of Resident #7's vaccination records showed a flu vaccine consent signed on 11/6/2023. Further review of the records showed the resident received the last flu vaccine on 10/25/2022, with no documentation of a flu vaccine administered after 11/6/2023. During an interview on 8/21/2024 at 10:02 AM, the Infection Preventionist confirmed Residents #3 and #7 had consented to having a flu vaccine administered and there was no documentation of the vaccine being administered after 11/6/2023. She stated, We got the consent on the unit, and it was the previous Infection Preventionist who was responsible for the administration. I cannot find documentation of administration for either resident. During an interview on 8/21/2024 at 2:45 PM, the Director of Nursing stated, It is my expectation that when a resident signs a consent for a vaccine, the staff obtain an order if there is not a standing order, administer it and document it in the record. Review of the facility policy and procedure titled Influenza, Prevention and Control of Seasonal with the last review date of 1/23/2024 showed it read, Policy Statement: This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. Policy Interpretation and Implementation . Vaccination: 1. The Infection Preventionist organizes and oversees an annual influenza vaccine campaign. 2. All residents and staff are offered the vaccine prior to the onset of the influenza season.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 2 of 5 residents reviewed for weight loss, Residents #12 and #14, received nutritional supplements. Findings include: 1) During an observation on 8/20/2024 at 12:18 PM, Resident #12 was sitting in a recliner, eating independently in her room. The resident's tray contained two cups of soup, apple juice, and coffee. There was no magic cup on the tray. During an observation on 8/21/2024 at 12:10 PM, Resident #12 was sitting in a recliner, eating independently in her room. The resident's tray contained tuna salad, curly fries, pie, and vanilla ice cream. There was no magic cup on the tray. Review of Resident #12's physician order dated 7/29/2024 read, Magic Cup (Formulary) two times a day for weight loss lunch and dinner. Review of Resident #12's weight record showed the weight of 136 lbs (pounds) on 7/21/2024, and 122.6 lbs on 8/18/2024, which is a -9.85% loss. Review of Resident #12's progress note dated 8/19/2024 read, Has orders for compression stockings to be worn daily d/t [due to] edema. Resident has order to be up daily for meals. Hx [history] of weight loss. Has intervention of magic cup offered at lunch and dinner (600 calories). accepts some of time. History of refusing oral supplements (Ensure, Boost). continue to follow. Review of Resident #12's Dietary/Nutrition Profile dated 7/19/2024 showed the resident was at risk for unintentional weight loss due to fair appetite and refusal of supplements under Section K. Nutritional Risk. During an interview on 8/21/2024 at 12:36 PM, the Registered Dietician stated, [Resident #12's name] has been a challenge for me. The first time I went to see her, she did not want to talk about her preferences and refused any supplements. She has been an ongoing challenge. [Resident #12's name] takes the magic cups some of the times. Her BMI [Body Mass Index] is 22.4 at this time. Anything above 21, I like. Ice cream does not have the same nutritional value as the magic cup. The ice cream has 200 to 250 calories and magic cup has more than 300 calories. Not having the magic cup can affect the weight but she will sometimes have half of it or sometimes will not. Resident #12 will rarely eat over 75%. It has been a challenge. Ensure would make her sick, so we decided to do the magic cups so if she eats at least 50% of her food plus the magic cup, she would have the minimum calories she needed. 2) During an observation on 8/20/2024 at 12:21 PM, Resident #14 was sitting up in the bed, eating independently. The resident's lunch tray had soup, coffee, sandwich, and beets. There was no magic cup on the tray. During an observation on 8/21/2024 at 12:11 PM, Resident #14 was sitting up in the bed, eating independently. The resident's lunch tray had curly fries, sandwich, and strawberry ice cream. There was no magic cup on the tray. Review of Resident #14's physician order dated 8/19/2024 read, Magic Cup (Formulary) two times a day for give [Sic.] at lunch and dinner. Review of Resident #14's weight record showed the weight of 127 lbs on 8/1/2024, and 117.4 lbs on 8/18/2024, which is a -7.56% loss. Review of Resident #14's Dietary/Nutrition Profile dated 8/5/2024 showed the resident was at risk for unintentional weight loss due to eating fair, over [AGE] years of age under Section K. Nutritional Risk, with discharge goal of weight remaining more than 120 under Section L. Comments. During an interview on 8/21/2024 at 12:43 PM, the Registered Dietician stated, [Resident #14's name] came in on Ensure twice a day and her weight had decreased, so we boosted it to 3 times a day. On August 18, 2024, I saw she came down almost another pound and the nurses noted she hated the taste of ensure, so we recently changed her to the magic cup, which was ordered on the 19th [8/19/2024]. This was a recent change. During an interview on 8/21/2024 at 12:21 PM, the Certified Dietary Manager (CDM) stated, Ice cream and magic cups do not have the same nutritional value. We have magic cups at hand in the facility. The server makes sure they are on the tray when they are sent out to the resident. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing stated, Nursing staff should be checking the trays and if they are missing a magic cup, they are able to get it from the dinning area. Review of the facility policy and procedure titled Nutrition Risk-Weight Loss Management with the last review date of 1/23/2024 read, Policy: Goal: To implement a nutritional risk-weight loss management program that will emphasize implementation of services that minimize episodes of preventable weight loss and promote nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure care and services were provided for a PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 (Resident #222) of 7 residents reviewed. Photographic evidence obtained. Findings include: During an observation on 4/10/2023 at 11:36 AM Resident #222 was sitting in a bed side chair, PICC observed on left upper arm. A transparent dressing was over top of gauze securing the PICC. The dressing was dated 3/30/2023. During an interview on 4/10/2023 at 11:36 AM Resident #222 stated that he came into the facility with the catheter and the dressing has not been changed since he was admitted . During an observation on 4/10/2023 at 1:18 PM Resident #222 a PICC was on left upper arm with a transparent dressing was over top of gauze securing the PICC. The dressing was dated 3/30/2023. During an interview on 4/10/2023 at 2:52 PM Staff B, Licensed Practical Nurse (LPN), confirmed that the dressing was dated 3/30/2023 and should have been changed within 7 days. Review of the admission record for Resident #222 documented the resident was admitted on [DATE] with diagnosis that included but not limited to osteomyelitis of ankle and foot. Review of physician orders for Resident #222, dated 4/3/2023, read: Change PICC dressing and end caps every day shift every 7 days for infectional [sic] control and as needed for soiled or not intact. During an interview on 4/11/2023 at 8:17 AM the Director of Nursing (DON) stated Dressing changes for PICC's are to be changed on admission if gauze is under the Tegaderm (clear dressing). If no gauze is under the Tegaderm and we can see the site and there is no issue, then the dressing on the PICC is changed in 7 days. Review of the policy titled Central Venous Catheter Dressing Changes, last reviewed 2/28/2023, read The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines. 4. After original insertion of CVAD ( Central Venous Catheter Dressing), the dressing will consist of gauze and TSM (Transparent semi-permeable membrane). This must be changed within 24 hours. 5. Change transparent semi-permeable membrane dressing at least every 5-7 days and PRN (as needed when wet, soiled, or not intact). 6. If gauze is used, it must be changed every 2 days.

Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided for 2 of 2 sampled residents out of 10 residents receiving respiratory services (Resident #22 and #223). Photographic evidence obtained. Findings include: During an observation on 4/10/2023 at 10:19 AM, Resident #223 was sitting in a bedside recliner. The oxygen tubing was hanging on the regulator on the wall and the tubing was not dated. During an interview on 4/10/2023 at 10:19 AM, Resident #223 stated I only use oxygen when I have sinus issues and the oxygen will clear it up, the oxygen rate is 2 and I never change it. The tubing has not been changed since I've been here. During an observation on 4/10/2023 at 1:49 PM Resident #223's oxygen tubing was not dated. During an observation on 4/11/2023 at 8:37 AM Resident #223 was sitting in his bedside recliner with his nasal cannula lying over the bedside table. There was no water observed in the bottle for the humidifier. Review of the admission record for Resident #223 documented an admission date of 3/22/2023 with diagnosis that included but not limited to atherosclerosis heart disease, pleural effusion, hypoxia, and encounter for surgical aftercare following surgery on the circulatory system. Review of physician orders for Resident #233 dated 3/23/2023 read O2: Oxygen at 2 liters per nasal cannula as needed for shortness of breath, low oxygen saturation. Review of physician orders for Resident #233 dated 3/29/2023 read O2 (oxygen): Change oxygen tubing and date with securement bag . Every night shift every Wed (Wednesday). During an observation on 4/10/2023 at 9:47 AM Resident #22 was sitting in a recliner beside her bed. Resident #22's oxygen tubing was not dated and the plastic bag hanging on the regulator was dated 3/22. During an interview on 4/10/2023 at 9:47 AM Resident #22 stated I use oxygen at night. During an observation on 4/10/2023 at 1:34 PM Resident #22 was lying in bed. Resident #22's oxygen tubing was not dated. During an interview on 4/11/2023 at 8:27 AM the Director of Nursing confirmed that Resident #22's oxygen tubing was not dated prior to her having the night shift go in and date the tubing the previous night. All tubing is supposed to be dated and changed on Wednesday nights, it was not changed and dated as ordered. Review of the physician orders for Resident #22 dated 3/15/2023 read O2: Oxygen tubing (must be dated) every night shift every Wed [Wednesday] for infection control. Review of the facility policy title Oxygen Administration, last reviewed 2/28/2023, read Purpose. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the Procedure. 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a drug regimen review recommendation from the pharmacist was acted upon for 1 resident (Resident #6) of 5 residents reviewed. Findings include: Review of the admission record for Resident #6 documented the resident was admitted to the facility on [DATE] with diagnosis that included but not limited to heart failure, muscle weakness, and abnormalities of gait and mobility. Review of physician orders for Resident #6 dated 11/1/2022 read: Voltaren Gel 1 % (Diclofenac Sodium) Apply to Bilat shoulders topically every 8 hours as needed (PRN) for shoulder pain. Review of physician orders for Resident #6 dated 12/31/2022 read: Diclofenac Sodium Gel 1% Apply to Both shoulders topically every 12 hours as needed for shoulder pain. Review of pharmacist consultation report dated 12/08/2022 read Recommendation: Please update the direction for topical diclofenac 1% gel to 'Apply 2 grams to bilateral shoulders every 8 hours as needed.' Physician Response: Diclofenac 1% gel Apply 1 gm to both shoulders every 12 hours prn for pain. Physician dated document 12/29/2023. Review of pharmacist consultation report dated 1/20/2023 read Recommendation: Please update the directions for topical diclofenac 1% gel to Apply 2 grams to bilateral shoulders every 8 hours as needed. (Clarify dosing - have duplicate orders). Physician Response: I accept the recommendations, please implement as written. Physician dated document 2/8/2023. Review of pharmacist consultation report dated 3/13/2023 read Recommendation: Please update the directions for topical diclofenac 1% gel to 'Apply 2 grams to bilateral shoulders every 8 hours as needed.' (Clarify dosing - have duplicate orders). Physician Response: I accept the recommendations, please implement as written. Physician dated document 3/23/23. Review of Resident #6's clinical records failed to document the facility acted upon the pharmacist recommendations. During an interview on 4/12/2023 at 1:44 PM, the Director of Nursing stated that the physician had agreed with the pharmacists' recommendation but the recommendations had not been acted upon. Review of policy titled Interim Medication Regimen Review (MMR), last reviewed 2/28/2023, showed the policy read: The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician / Prescriber to either accept and act upon the recommendations contained within the MRR ( Medication Regimen Review) or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner.

Based on observation and interview the facility failed to ensure that all drugs and biologicals used in the facility were properly labeled and stored in accordance with professional standards in 2 of 4 medications carts and two resident's rooms, Resident # 222 and Resident #326. Photographic evidence obtained. Findings include: 1). During an observation on 4/10/2023 at 2:52 PM of the west wing medication cart #2 with Staff B, Licensed Practical Nurse (LPN), two opened insulin pens, Toujeo Solostar and Insulin Glargine, were not dated with date opened. During an interview on 4/10/2023 at 2:55 PM, Staff B, LPN, confirmed the insulin pens in the west wing medication cart #2 were not dated with an open date or expiration date when removed from the refrigerator. Staff B stated, When insulin pens are removed from the refrigerator, we are supposed to date them with the open date and the expiration date. During the observation on 4/10/2023 at 3:18 PM of the west wing medication cart #2 with the east wing Nurse Manager, one Novolog insulin pen was lying in the cart, opened with no resident's name on the pen and one Lispro insulin pen with no opened date labeled on the pen. During an interview on 4/10/2023 at 3:18 PM the east wing Nurse Manager confirmed the Novolog insulin was opened with no resident's name on the pen and one Lispro insulin pen with no opened date labeled on the pen. During an interview on 4/10/2023 at 3:22 PM, the East Wing Nurse Manager confirmed the insulin pens were not dated when opened and no expiration dates were entered on Insulin pens. She stated, When the insulin pens are removed from the refrigerator the open date and the expiration date must be written on the insulin pen. These insulin pens expire within 28 days, but some insulin pens vary on the expiration days after opening. 2). An observation on 4/10/2023 at 8:30 AM of Residents #222's room revealed a syringe of Normal Saline and a syringe of Heparin lying on a bookshelf unsecured. An observation on 4/11/2023 at 7:51 AM of Residents #222's room revealed a syringe of Heparin lying on bookshelf unsecured. During an interview on 4/11/2023 at 8:05 AM, Staff C, LPN, confirmed the Heparin syringe was lying on the bookshelf in Resident #222's room. Staff C confirmed that Heparin syringe was at the bedside and stated, this is to be locked up on the med cart, it should not be in here. During an interview on 4/10/2023 at 3:58 PM, the Director of Nursing (DON) stated that her expectation was that no medications were to be left at the bedside and that all insulin pens when removed from the refrigerator were dated with the date and an expiration date when the insulin pen was removed. 3). An observation on 04/10/2023 at 10:05 AM, Resident #326 was observed at bedside taking medications from a medication cup. Two pills remained in the med cup. During an interview on 4/10/23 at 10:05 AM Resident #326 stated, I'm not even sure what the meds are but one taste like iron or something. During an interview on 4/11/23 at 10:52 AM Staff A, Registered Nurse (RN) stated that the nurse on the medication cart should prepare the medications for a resident, take it to the resident, administer the medications and then chart that the medications were given. Medications should not be left at bedside. When asked why Resident #326 had medication at bedside, Staff A stated, Oh no, I guess I forgot to go back when I went to get him something to drink. During an interview on 4/11/23 at 11:15 AM the DON stated that the nurse on the medication cart should follow the protocol when passing medications. The DON confirmed that Staff A, RN was the nurse on the medication cart for Resident #326.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents received information related to the right to formulate an advance directive upon admission for 8 (Resident #26, #58, #123, #173, #174, #222, #224, and #325) of 18 residents sampled for advance directives review. Findings include: Record review of Resident #26's admission record documented Resident #26 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, chronic obstructive pulmonary disease, end stage renal disease and hyperlipidemia. Record review of Resident #26's Advance Directives Policy and Record on 4/12/2023 documented Resident #26 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #58's admission record documented Resident #58 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, chronic obstructive pulmonary disease, chronic kidney disease and anemia. Record review of Resident #58's Advance Directives Policy and Record on 4/12/2023 documented Resident #58 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #123's admission record documented Resident #123 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, essential hypertension, personal history of pulmonary embolism, and gout. Record review of Resident #123's Advance Directives Policy and Record on 4/12/2023 documented Resident #123 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #173's admission record documented Resident #173 was admitted to the facility on [DATE] with diagnoses that included hypokalemia, peripheral vascular disease and essential hypertension. Record review of Resident #173's Advance Directives Policy and Record on 4/12/2023 documented Resident #173 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #174's admission record documented Resident #174 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications and pruritus. Record review of Resident #174's Advance Directives Policy and Record on 4/12/2023 documented Resident #174 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #222's admission record documented Resident #222 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, [NAME] macroglobulinemia, and hypo-osmolality and hyponatremia. Record review of Resident #222's Advance Directives Policy and Record on 4/12/2023 documented Resident #222 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #224's admission record documented Resident #224 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of bone and articular cartilage, intrahepatic bile duct carcinoma, and essential hypertension. Record review of Resident #224's Advance Directives Policy and Record on 4/12/2023 documented Resident #224 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #325's record documented Resident #325 was admitted to the facility on [DATE] with diagnoses that included hypertensive crisis, dysphagia, heart failure, chronic kidney disease and atherosclerotic heart disease. Record review of Resident #325's Advance Directives Policy and Record on 4/12/2023 documented Resident #325 had not been provided information related to the right to formulate an advance directive until 4/11/2023. During an interview on 4/12/2023 at 11:02 AM, the Administrator confirmed the facility had not consistently provided residents with information related to the right to formulate advance directives upon admission. Record review of the facility policy titled Advance Directives, last reviewed 2/28/2023, read 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen coolers and freezers, and failed to ensure equipment was cleaned and sanitized before use (Photographic evidence obtained). Findings include: During an observation at the time of initial walk-through tour of the kitchen on 4/10/2023 at 9:16 AM with the Certified Dietary Manager (CDM), there were a large container with what appeared to be approximately 20 pieces of fresh raw chicken with red bloody fluids surrounding the bottom of the container in the walk-in cooler, a container of food that had a product with Fresh Sliced Mushrooms label by the [NAME], with no received or expiration date, and a partial box of frozen raw beef patties located on the bottom shelf with the lid open and the product exposed in the reach-in freezer. During an interview on 4/10/2023 at 9:45 AM, the CDM verified that the fresh raw chicken was stored in a container with blood pooling on the bottom of the container and should have been on an ice bed, that the fresh sliced mushrooms did not have a received, opened, or a use by date, and that the raw frozen beef patties should have been stored in a closed container that did not expose the product to freezer burn. The CDM stated that the products should be labeled according to the policy, and all products should be closed or covered when stored. Review of the facility policy and procedure titled Food Storage revised on 3/9/2020 and last reviewed on 2/28/2023, reads, Procedure . Raw Meat . 4. Hamburger and fresh chicken should be cooked within one to two days of purchase. Fresh Chicken should be stored on ice to maintain an optimal temperature of 28 to 32 degrees F [Fahrenheit] . Food Storage Frozen Meat/Poultry and Foods . 3. Storage: Store items promptly to 0 degrees F or less or at a temperature maintains the food frozen. Foods should be stored in their original containers if designed for freezing. Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items. During an observation at the time of follow-up tour of the kitchen on 4/11/2023 at 7:28 AM with the CDM, the can opener had a buildup of food residue and rust. The sanitation test strips being used had an expiration date of December 15, 2022. During an interview on 4/11/2023 at 7:28 AM, the CDM confirmed the can opener had food residue and that the test strips currently being used were expired. Review of the facility policy and procedure titled Can Opener, revised on 8/31/2018 and last reviewed on 2/28/2023, reads, Sanitation of Equipment. Frequency: After each meal; more frequently if needed. 1. Remove shank to pot and pan sink, or to the dish machine area. 2. Scrub shank, paying attention to blade and moving parts. Use sanitizing solution and brush, or run through dish machine. 4. Air dry on clean surface. Review of the facility policy and procedure titled Recording of Dish Machine Temperatures revised on 1/31/2023 and last reviewed on 2/28/2023 reads, 6. The concentration of the sanitary solution during the rinse cycle is 50-100 ppm with Chlorine sanitizer. This is used on low temperature dish machines. Assure that test strips are within the Use-By-date and not outdated.

Based on observation, record review, and interview, the facility failed to ensure the residents who were incontinent of bladder received appropriate treatment and services for indwelling urinary catheters for 2 of 4 residents, Residents #95 and #96, in a total sample of 20 residents. Findings: 1. During an observation of Resident #95 on 11/1/2021 at 9:15 AM with Staff B, Registered Nurse (RN), Unit Manager, the resident's catheter bag was laying on the floor, folded in half, with no privacy bag. There was about 40 milliliters of dark yellow liquid in the bag. The bag was off the hook on the bottom frame of the bed. The tubing and the connector were on the floor. Review of the medical record dated 10/29/2021 for Resident #95 revealed the diagnosis to include prostatectomy. During an interview on 11/1/2021 at approximately 9:20 AM, Resident #95 stated, I don't know who put it on the ground. I want it in the right place, so I can get well and return home. During an interview on 11/1/2021 at 9:20 AM, Staff B, RN, Unit Manager, verified the catheter bag was not attached to the bed frame. She verified it was laying on the floor, folded in half, with about 40 milliliters of urine in it. 2. During an observation of Resident #96 on 11/1/2021 at 9:30 AM with Staff A, Certified Nursing Assistant (CNA), the resident's catheter bag was facing the doorway with the curtains pulled toward the head of the bed. The catheter bag and urine were visible from the doorway. The tubing had a yellow-colored liquid, which was backed up in the tubing. The tubing draped off the bed, dropped lower than the drainage bag, preventing the urine draining into the connector located at the top of the bag (Photographic evidence obtained). During an interview on 11/1/2021 at approximately 9:35 AM, Staff A, CNA, stated she was assigned to Resident #96, and she had no further information regarding catheter care and techniques. During an interview on 11/1/2021 at 9:50 AM, Resident #96 stated, I prefer having a privacy bag. I do not want the bag in view for others if the door is open. I want the door open today. Review of the policy and procedure titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing revised in September 2017 reads, . Steps in the Procedure: . 6. Maintain unobstructed urine flow. a. Keep the catheter and tubing free of kinks. b. Secure catheter after insertion to prevent movement, c. Keep drainage bag below the level of the bladder at all times. Do not place the drainage bag on the floor. Review of the policy and procedure titled, Quality of Life - Dignity revised in August 2009 reads, . Policy Interpretation and Implementation: . 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: 1. Helping the resident to keep urinary catheter bags covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. Findings: During an initial tour of the kitchen on 11/1/2021 at 9:06 AM with the Certified Dietary Manager (CDM), a walk-through of the walk-in cooler showed a large clear container with leftover hotdogs with no label or date, a container of food labeled as brussel sprouts by the [NAME] with a fuzzy substance on the product, a container of food labeled as lemons by the [NAME] with a fuzzy substance on the product, and an approximate 1/4 open container of food labeled as pesto with no opened date. A walk-through of the reach-in cooler showed an open container of food labeled as liquid eggs, which was on the second open shelf placed directly over bottles of assorted condiments. A walk-through of the reach-in freezer showed a partial box of frozen beef steaks located on the top shelf with the lid open and the product exposed, a partial bag of frozen ravioli located on the second shelf with the bag open and the product exposed and no label or opened date, a partial bag of frozen pasta located on the third shelf with the bag open and the product exposed and no label or opened date, and a partial bag of tortilla or wraps located on the second shelf with the bag open and the product exposed and no label or date. During a second tour of the kitchen on 11/2/2021 at 9:33 AM with the CDM, a walk-through of the reach-in cooler showed a small plate on the second shelf containing two raw shell eggs that were not wrapped or with any sides to prevent the eggs from rolling off the plate and were placed directly over multiple food items. A walk-through of the dry storage room showed an opened container of peanut butter on the top shelf, with peanut butter residue build-up on two sides of the container with no opened date, and an opened package of hamburger buns on the bread rack containing three buns remaining in the bag and fully exposed. A walk-through of the reach-in freezer showed a partial box of beef steak remaining open with the product exposed. During an interview on 11/1/2021 at 10:28 AM, the CDM verified that he observed the products with the fuzzy substance, the products without a label or date and identified the products as leftover hotdogs and pesto in the walk-in cooler, in the reach-in freezer as frozen beef steak, ravioli, pasta and wraps, and that he observed the cartons of liquid eggs on the second open shelf of the reach-in cooler. The CDM stated that the products should be labeled according to the policy, all products should be closed or covered when stored and, that raw eggs should never be over other food products. During an interview on 11/2/2021 at 11:28 AM, the CDM stated, I discussed the dating, labeling, and closing of products with my staff and I am very disappointed to find the same or even more items the second time around. Review of the policy and procedure titled, Refrigerated Leftover Storage revised on 12/8/2018 and reviewed on 2/24/2021 reads, Policy: Leftover foods should not be saved and re-used for human consumption if there is any doubt of wholesome quality. A leftover is a product that has been on the meal service line at one time. For items that have been cooked or opened but have not been on meal service line, refer to the Dry, Refrigerated and Freezer Storage Charts (POLs 154a, 154b, 154c). These timeframes are not only used to control sanitation but the quality of the food also. Refer to corporate policy for stricter guidelines. Procedure: 1. Cover with non-absorbent lid or material. 2. Date container with use by date (lids may be misplaced). 3. Label unless easily identifiable without removing cover - such as sliced peaches in glass jar.