**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dignity to one resident (#108) out of two sampled residents related to a catheter bag covering.Findings included:During an observation and interview on 08/18/2025 at 9:05 AM Resident #108's urinary catheter collection bag was hanging on the left side of the Resident's bed, uncovered, containing 300 milliliters (ML) of yellow fluid. There was a folded up white towel placed under the collection bag on the floor. Resident #108 stated, The urine bag has not been covered. Everyone can see it when they enter the room or even walk by, and it is embarrassing.Review of Resident #108's medical record revealed Resident #108 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, fracture of the right femur, subsequent encounter for closed fracture with routine healing, encounter for surgical aftercare following surgery on the digestive system, cholecystitis, and urinary retention.Review of Resident #108's physician order dated, 08/17/2025 revealed, indwelling urinary catheter: size 16 french (16fr) 30 milliliter (ml) for diagnosis of: urinary retention.An interview was conducted on 08/19/2025 at 2:00 PM with the DON who stated, All foley catheter bags should have a dignity cover over the bag.Review of facility's policy titled Catheter Care-Quality of Care, with an approval date of 01/28/2025 revealed, Procedure 3. Ensure the drainage spigot is not touching the floor, the tubing is free of kinks, the catheter is kept at an appropriate level to promote urine flow, and dignity is maintained. Catheter coverings are not required when drainage bags are out of sight from the public or per the resident's preference.Review of facility's policy titled Standards and Guidelines: Resident Rights, with a revision date of 1/2024 revealed, Procedure: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: a. a dignified existence; b. be treated with respect, kindness, and dignity;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment and implement their policy on securing smoking materials in a secure location for one resident (#3) out of three residents reviewed for accidents.Findings included:Review of Resident #3 medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of, but not limited to, trimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, unspecified fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing, asthma, chronic obstructive pulmonary disease (COPD), unspecified, type 2 diabetes mellitus with other oral complications, non-ST- elevation myocardial Infarction (heart attack), chronic diastolic (congestive) heart failure, and essential (primary) hypertension.Review of a list, provided by the Administrator titled, Residents who smoke revealed, the first and last name of Resident#3.An observation was conducted on 08/18/2025 at 09:00 AM, of Resident #3 reclining in bed. Attached to the bedside table, in a clear plastic bag, contained a light blue pack of cigarettes that was labeled 305's and two multicolored lighters. The bedside table is on the Resident #3's right side, perpendicular to the bed.An interview was conducted on 08/18/2025 at 09:01 AM with Resident #3 who stated I have kept my cigarettes and lighter in the room with me. They don't have a problem with that, and I don't want to give them one. I need assistance into the wheelchair but then I could go out when I want, no problems. An observation was conducted on 08/18/2025 at 11:00 AM of Resident #3 wheeling her wheelchair down the hall toward the main entrance doors asking staff who took cigarettes out of her room.An interview was conducted on 08/20/25 at 2:00 PM, the Nursing Home Administrator stated it is the facility's policy to have the cigarettes and the lighters locked up and removed during the scheduled smoking times. It is the responsibility of whoever takes them out to ensure they hand out and make sure they are returned after the smoking break is over.Review of the facility's policy and procedure titled Resident Smoking Supervised and Unsupervised-Use of Electronic Smoking/Vaping Devices with a revision date of 11/2022 revealed, Procedure: 11. Residents who have independent smoking privileges are not permitted to keep cigarettes, E cigarettes, pipes, tobacco, nicotine, and other smoking/vaping articles in their possession including all forms of lighters, matches, and electronic smoking/vaping device paraphernalia. 2. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including use of electronic smoking/vaping devices, designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences 12. Residents who have independent smoking privileges may request smoking/vaping materials from nursing personnel when desired, thus alerting nursing personnel of their intention to smoke at that time. Following use, lighters/matches, unused cigarettes, electronic cigarettes, vaping materials, etc. shall be returned to nursing personnel for safe storage. 13. Residents without independent smoking privileges may not have or keep any smoking/vaping materials, including cigarettes, E cigarettes, tobacco, nicotine, etc., except when they are under supervision. 14. Residents who require supervision with smoking privileges may be supervised by facility staff, volunteers, and family/legal representative during facility designated smoke times.

Based on observations, interviews, and record review, the facility failed to ensure midline catheter dressing changes were completed according to professional standards of practice for one resident (#111) of one resident reviewed with a midline catheter.Findings include:During an observation on 08/18/2025 at 9:45 AM Resident #111 was observed in bed with a left upper arm single lumen midline catheter, with a dressing date of 08/11/2025 with gauze under the transparent semi-permeable dressing.During an observation on 08/18/2025 at12:15 PM Resident #111 was observed in bed with a left upper arm single lumen midline catheter with date of 08/11/2025 with gauze under the semi-permeable transparent dressing. Review of Resident #111's admission record revealed an admission date of 08/09/2025 and diagnoses of encounter for surgical aftercare following surgery on the genitourinary system, generalized anxiety disorder, adjustment disorder with depressed mood, adjustment insomnia, acute cystitis with hematuria, metabolic encephalopathy, and sarcopenia.Review of Resident #111's physician order dated 08/11/2025 revealed, Mid Line left arm: Change dressing within 24 hours of admission, insertion, or reinsertion and Q [every]7 Days and PRN [as needed] thereafter using sterile technique. Measure arm circumference and external length of catheter. every day shift every 7 day(s) and as needed and one time only for 1 Day Change dressing within 24 hours of admission/insertion/reinsertion using sterile technique.During an interview on 08/18/2025 Staff F, Licensed Practical Nurse (LPN) stated, I don't know about when the dressing should be changed, its every seven days, I think. No, I don't think there are any other reasons it should be changed.During an interview on 08/20/2025 at 7:15 AM the Director of Nursing (DON) stated, It is my expectation that all dressings get changed per policy and for midlines. Any dressing with gauze would be a two-day dressing.During a phone interview on 08/20/25 at 5:19 PM, Resident #111's Advanced Practical Registered Nurse (APRN) said all dressings should be placed for central and midline catheters per the orders. And if the dressing had gauze under it, it should be changed every two days.A request for a midline catheter policy and procedure was made to the DON on 08/20/2025 at 7:20 AM. One was not provided at the time of the survey exit.Review of the Centers for Disease Control and Prevention (CDC) Summary of Recommended Frequency of Replacements for Catheters, Dressings, Administration Sets, and Fluids with a publication date of August 9, 2002, revealed Replacement of catheter site dressing for midline catheters was to Replace dressing when the catheter is removed or replaced, or when the dressing becomes damp, loosened, or soiled. Replace dressings more frequently in diaphoretic patients. In patients who have large bulky dressings that prevent palpitation or direct visualization of the catheter insertion site, remove the dressing and visually inspect the catheter at least daily and apply new dressing. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5132a9.htm.

Based on interview and record review, the facility failed to ensure pharmacy reviews were conducted monthly and the facility failed to ensure a physician provided a clinical rational for two residents (#11 and #51) out of five residents reviewed for medication regimen review (MRR). Findings included: 1. Review of Resident #11’s Consultant Pharmacist MRR’s for the months of August 2024 through July 2025 revealed the following: · There was no documentation a pharmacist performed an MRR for the month of September 2024 for Resident #11. · There was no documentation a pharmacist performed an MRR for the month of October 2024 for Resident #11. · There was no documentation a pharmacist performed an MRR for the month of April 2025 for Resident #11. · A pharmacy review for the month of June 2025 had a pharmacist recommendation for Resident #11 that revealed, the Resident received Eliquis 5mg (milligram) twice daily for “anticoagulation” and Phenytoin ER (extended release) 200mg every 12 hours for seizures. A recommendation was made to re-evaluate the continued use of the combination of Eliquis and Phenytoin because it may decrease the serum concentrations of Apixaban [Eliquis]. Per the manufacture, this combination should be avoided because of the interacting drugs effect of decreasing exposure to apixaban. There was a signature and a response from the physician dated 07/07/2025 to disagree, but there was no clinical rationale noted. A review of the “Census” for Resident #11 showed the date of admission was on 05/29/2024 with no in-active dates or discharges since the date of admission. An interview was conducted with the Director of Nursing (DON) on 08/21/25 at 7:45AM related to the pharmacy review for Resident #11. The DON confirmed that a rationale had not been provided by the physician for disagreeing with the recommendations by the pharmacy consultant for the month of June 2025. The DON also confirmed Resident #11 was not on the list of residents who had a medication regiment review but had no recommendations for September 2024, October 2024, and April 2025. The DON confirmed Resident #11 did not have a medication regimen review for September 2024, October 2024, and April 2025. 2. Review of Resident #51’s medical record revealed an admission date of 03/29/2023 with diagnoses including, but not limited to polyneuropathy, dementia, depression, anxiety and muscle weakness. Review of Resident #51's physician orders revealed an order dated 06/25/2024 for “Mirtazapine oral tablet 7.5 mg [milligram] -give 1 tablet by mouth at bedtime for depression with no end date.” Review of Resident #51’s Consultant Pharmacist MRR documents revealed a recommendation made on 05/31/2025 which read, Psychiatry recommendation: RE (regarding): Mirtazapine 7.5 mg at bedtime for depression started 11/21/24. Please consider a gradual dose reduction to Mirtazapine 7.5 mg every other night at bedtime x (for) 30 days, then discontinue. The Physician disagreed but did not provide a clinical rationale on the form or in a progress note. During an interview on 08/21/2025 at 12:06 PM, the DON confirmed the physician did not write a rationale for the disagreement with the recommendation made for Resident #51’s medication on 05/31/2025. Review of facility’s policy Medications Utilization and Prescribing- Clinical Protocol, with a revision date of 01/2024, revealed Guideline: The facility will comply with the requirements specified in accordance with State and Federal regulations as they pertain to Medications Utilization and Prescribing. Procedure: 2. The Physician and staff will identify situations in which a resident is taking medications associated with potentially significant medication- related problems such as allergies, drug- drug interactions, drug-food interactions and adverse drug reactions .4. The consultant pharmacist may help by reviewing facility medications usage patterns and trends and by medication reviews of individuals taking medications that present clinically significant risks .6. The consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs or symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received respiratory services consistent with professional standards of practice related to oxygen administration and respiratory equipment storage for four residents (#99, #78, #42 and #83) out of four sampled residents. Findings included: 1. Review of Resident #99’s admission record revealed an admission date of 02/08/2025 and diagnoses of chronic obstructive pulmonary disease unspecified (lung disease that blocks air flow in the lungs and makes it hard to breath), hyperlipidemia unspecified (high cholesterol), and essential primary hypertension (high blood pressure). Review of Resident #99's physician orders dated 07/23/2025 revealed, Respiratory-Oxygen: NC [nasal cannula]/Mask. Encourage and assist resident to use O2 [oxygen] @ 2 liters via NC as needed for SOB [shortness of breath]/DOE [dyspnea on exertion] as needed for O2 less than 93%. Review of Resident #99's comprehensive care plan revealed a focus of the resident is at risk for altered respiratory status/difficulty breathing r/t (related to) COPD (chronic obstructive pulmonary disease)/emphysema with an intervention of administer oxygen as ordered. During an interview on 08/18/2025 at 2:26 PM Resident #99 stated, I don't touch the oxygen, I need it, I have COPD. During an interview on 08/18/2025 at 2:30 PM Staff E, Licensed Practical Nurse (LPN) stated, I was not aware that the oxygen was wrong, maybe it got bumped when the aides were giving her care. During an interview on 08/20/2025 at 9:30 AM the Director of Nursing (DON) stated, I do expect all staff to have the oxygen running at the correct amount and to follow the orders. We do not have a specific policy for oxygen administration. 2. Review of Resident #78's admission record documented diagnosis that include Parkinson's disease without dyskinesia without mention of fluctuations, unspecified diastolic congestive heart failure, unspecified atrial fibrillation (an irregular heartbeat), and peripheral vascular disease unspecified. During an observation on 08/18/2025 Resident #78 was observed sitting at bedside in a wheelchair. Resident #78 was sitting on the left side of the bed, and the oxygen concentrator was on the right side of the bed out of the residents’ reach. The oxygen concentrator was set at four liters per minute. Review of Resident #78's physician orders dated 06/11/2025 revealed, “Respiratory-Oxygen: NC [nasal cannula] Continuous. Encourage and assist resident to use O2 @ 2 Liters via NC continuously CHF [congestive heart failure] Patient may apply/remove device adlib every shift for SOB [shortness of breath] related to UNSPECIFIED DIASTOLIC (CONGESTIVE) FAILURE.” During an interview on 08/18/2025 at 2:38 PM, Staff E, LPN stated, That oxygen should be at two liters. I usually check it when I give meds and make sure it’s correct then. I do need to follow the doctors’ orders. 3. An observation was conducted on 08/18/2025 at 9:40 AM of Resident #42 ambulating in the room from the bathroom to sit on the edge of the bed. A nebulizer mask is located on the bedside table to the right of the Resident’s bed unbagged and not labeled. Review of Resident #42’s medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of, but not limited to, chronic obstructive pulmonary disease (COPD), chronic systolic (congestive) heart failure, pre-excitation syndrome, and paroxysmal atrial fibrillation. Review of Resident #42’s physician order dated 07/06/2025, revealed, Arformoterol Tartrate 15 Micrograms (MCG)/2 milliliters (ML) Nebulization solution, 1 vial inhale orally via nebulizer two times a day for COPD. And a physician order dated 07/08/2025, revealed, Budesonide Suspension 0.5 MG (milligrams)/2ML, 2 ml inhale orally via nebulizer two times a day for COPD. Review of Resident #42’s medication administration record (MAR) documentation revealed Arformoterol Tartrate was delivered via nebulizer at 0900 (09:00 AM) and 1700 (5:00 PM) daily, beginning on 07/06/2025. Budesonide Suspension was delivered via nebulizer at 0900 (09:00 AM) and 1700 (5:00 PM) daily, beginning on 07/08/2025. 4. An observation was conducted on 08/18/2025 at 09:50 AM, Resident #83 was lying in bed with his eyes closed. The nebulizer mask attached to the nebulizer machine was laying on top of a blanket rolled up on the chair to the right side of Resident #83. Review of Resident #83’s medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses of, but not limited to, chronic diastolic (congestive) heart failure, other malformations of cerebral vessels, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), unspecified, and unspecified asthma, uncomplicated. Review for Resident #83’s physician order, dated 07/28/2025, revealed, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath (SOB). Review of Resident #83’s medication administration record (MAR) for Resident #83 revealed the medication was administered on 08/19/25 at 09:00 AM. An interview was conducted on 08/19/2025 at 11:25 AM, with the DON, who stated, “Once the nebulizer is complete the mask should be bagged and labeled”. Review of the facility’s policy and procedure titled “Standards and Guidelines: Nebulizers” with a revision date of 12/2023 revealed, “General Guidelines 4. Store nebulizer in [sic] tubing in a hygienic manner when not in use (i.e. labeling bag with date tubing was changed”. Review of the policy and procedure titled, Oxygen Administration, revised 12/2023, revealed, Standard: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: 1. Review the physician's order for oxygen administration. General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device, per physicians’ orders.

Based on interview and record review, the facility failed to administer insulin according to physician orders for one resident (#65) out of two residents reviewed for insulin administration.Findings included:Review of Resident #65's admission record revealed a diagnosis of type 2 diabetes mellitus without complications.Review of Resident #65's physician order dated 04/17/2025 revealed, Insulin Glargine-yfgn 100 UNIT/ML(milliliter) Solution pen-injector. Inject 50 unit subcutaneously at bedtime for diabetes and inject 5 unit subcutaneously in the morning for DM [diabetes mellitus].Review of Resident #65's August medication administration record revealed documentation on 08/02/2025 at 6:00 AM of a chart code of 4. Review of the Chart Codes/ Follow Up Codes revealed 4=Pulse below 60/min [minute] Ineffective.Review of Resident #65's July medication administration record revealed documentation on 07/16/2025 at 6:00 AM, on 07/25/2025 at 6:00 AM, on 07/28/2025 at 6:00 AM and on 07/30/2025 at 6:00 AM a chart code of 4.During an interview on 08/20/2025 at 6:30 AM Staff G, Licensed Practical Nurse (LPN) stated, I did hold the insulin in the morning, it [blood sugar] was low and her parameters on the other insulin so I held it. I guess I should have let the doctor know.During an interview on 08/20/2025 at 6:54 AM the Director of Nursing (DON) stated, I would expect all staff to follow the orders for insulin.During a phone interview on 08/20/25 at 5:19 PM, Resident #111's Advanced Practical Registered Nurse (APRN) stated I expect to be notified if nurses are holding insulin . I expect parameters to be followed. I am usually on call. I don't think holding the long acting five units would have caused any concerns for harm, she was also getting 50 units at night and [sliding scale insulin].

Based on interview and record review the facility failed to ensure physician ordered parameters were followed related to hypertensive medications resulting in the administration of unnecessary medications for one resident (#106) out of five residents reviewed for unnecessary medications.Review of Resident #106 admission record documented diagnosis of unspecified atrial fibrillation, heart failure unspecified, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease unspecified, type 2 diabetes mellitus without complications, unspecified osteoarthritis unspecified malignant neoplasm of esophagus unspecified, and atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain).Review of Resident #106 physician order dated 3/22/2025 read, Metoprolol Succinate ER (extended release), extended release 24 hour 25 mg (milligrams) give 0.5 tablet every 12 hours for hypertension, hold for SBP (systolic blood pressure) less than 100 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60.Review of Resident #106's Medication administration record for April 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 0900 ( 9:00 AM) on 4/11/2025 with a Blood pressure (B/P) of 114/57, on 4/12/2025 with a B/P of 104/51, on 4/22/2025 with a B/P of 99/57, and on 4/27/2025 with a blood pressure of 74/36.Review of Resident #106's Medication administration record for April 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 2100 (9:00 PM) on 4/1/2025 with a B/P of 111/59, on 4/2/2025 with a B/P of 96/65, on 4/3/2025 with a B/P of 103/58, on 4/7/2025 with a B/P of 86/57, on 4/11/2025 with a B/P of 104/51, on 4/14/2025 with a B/P of 79/50, on 4/18/2025 with a B/P of 90/54, on 4/22/2025 with a B/P of 119/41 and on 4/25/2025 with a B/P of 88/63.Review of Resident #106's Medication administration record for May 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 0900 (9:00 AM)on 5/2/2025 with a blood pressure (BP) of 116/52, on 5/5/2025 with a B/P of 103/55, on 5/12/2025 with a B/P of 102/53, on 5/14/2025 with a B/P of 100/57, on 5/22/2025 with a B/P of109/54, on 5/29/2025 with a B/P of 118/59 and on 5/30/3035 with a B/P of 110/58. Review of Resident #106's Medication administration record for May 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 2100 (9:00 PM) on 5/6/2025 with a B/P of 118/54, on 5/10/2025 with a B/P of 105/57, on 5/18/2025 with a B/P of 98/58, on 5/20/2025 with a B/P of 106/52 and on 5/23/2025 with a B/P of 96/49.Review of Resident #106's Medication administration record for June 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 0900 on 6/15/2025 with a B/P of 119/59, on 6/16/2025 with a B/P of 107/58, on 6/23/2025 with a B/P of 119/54, and on 6/27/2025 with a B/P of 113/53, Review of Resident #106's Medication administration record for June 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 2100 on 6/1/2025 with a B/P of 101/59, on 6/15/2025 with a B/P of 101/59, on 6/16/2025 with a B/P of 100/56, on 6/18/2025 with a B/P of 98/53, on 6/24/2025 with a B/P of 103/54 and on 6/29/2025 with a B/P of 98/66.expect to be notified if nurses are holding insulin or blood pressure medications. I expect parameters to be followed. I am usually on call.During an interview on 8/21/2025 at 5:05 AM Staff H, Licensed Practical Nurse (LPN) stated, I didn't realize that I had given them with the blood pressure low or outside of the parameters. I always check my own blood pressure every day. I should not have administered them outside the parameters. During an interview on 8/21/2025 at 6:54 AM the DON stated, All medications should be administered or held per any parameters that are written.

Based on observation, interview, and record review and policy and procedure review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases for three residents (#1, #14, #44 and #27) out of seven residents sampled for infection control. Findings included: 1. On 08/18/2025 at 1:17 PM Resident #1's room was observed without isolation signage or personal protective equipment (PPE) available outside or in Resident #1's room, Staff E, Certified Nursing Assistant (CNA) was observed entering Resident #1's room with incontinence care supplies, closed the door, and Staff E, CNA did not don a gown prior to entering Resident #1's room. Staff E, CNA was observed assisting Resident #1 with gloves on but no gown. Staff E, CNA removed a soiled brief and provided incontinence care. Staff E, CNA stated, Oh I'm just changing [Resident #1]. Staff E, CNA confirmed Resident #1 should be on enhanced barrier precautions because she has a catheter and confirmed she should be wearing a gown because she was performing care.On 08/18/2025 at 1:45 PM the facility staff was observed in the 300 and 400 hallways placing enhanced barrier precaution signage on doorways and placing PPE of gowns and gloves outside in the hallways.Review of Resident #1's admission record document revealed diagnoses of pneumonia, unspecified Organism, type 2 diabetes mellitus without complications, chronic kidney disease stage 4 severe, paroxysmal atrial fibrillation, depression unspecified, essential primary hypertension, sarcopenia, cognitive communication deficit, obstructive and reflux uropathy comma and chronic pain syndrome. Review of Resident #1's physician order dated 08/18/2025 revealed, Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier precautions for sacral wound. every shift.Review of Resident #1's physician order dated 8/6/2025 revealed, Treatment as follows: Sacrum - Cleanse with NS, pat dry. Apply skin prep to peri wound area. Apply Santyl to wound bed; then calcium alginate AG (Silver) cover with bordered gauze. every day shift for open area AND as needed Change dressing if becomes soiled or dislodged.Review of Resident #1's care plan revealed, Focus: Resident requires enhanced barrier precautions during high contact resident care activities r/t (related to) sacral wound.Goal: enhanced barrier precautions will remain in effect for limited periods (i.e. while the risk of transmission of the infectious agent persists or for the duration of the illness) Interventions: enhanced barrier precautions: sacral wound during high contact care activities, dressing, bathing showering transferring providing hygiene changing linens changing briefs or assisting with toileting.2. On 08/21/2025 at 5:11AM observed Staff K, CNA enter Resident #14's room with supplies to provide incontinence care, there was an enhanced barrier precaution sign and PPE supplies in the hallway and in the resident's room. Staff K, CNA did not perform hand hygiene, donned gloves, removed Resident #14's brief and provided care without donning a gown. Staff K, CNA got assistance from Staff A, CNA, retrieved a mechanical lift machine and without donning PPE, both staff assisted the resident out of bed into a wheelchair.On 08/21/2025 at 5:35 AM Staff K, CNA confirmed Resident #14 was on enhanced barrier precautions and said, I should have had a gown on, I'm sorry I forgot.On 08/21/2025 at 5:43 AM Staff A, CNA stated, Oh that's right we should have had on gowns when we got [Resident #14] up.3. During an observation of Resident #44 on 8/19/2025 at 12:21 PM , Staff C, CNA entered Resident #44's room with a mechanical lift. Staff C did not perform hand hygiene and did not don a gown. Staff C, CNA assisted Resident #44 back to bed, repositioned the resident and exited the room without performing hand hygiene.During an interview on 08/19/2025 at 12:50 PM Staff C, CNA stated, He does have a G [gastrostomy] tube and I should have had a gown on.Review of Resident #44's admission record revealed an admission date of 8/6/2025 and diagnoses of metabolic encephalopathy, unspecified asthma uncomplicated, unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance anxiety, unspecified depression, chronic kidney disease unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, presence of cardiac pacemaker, venous insufficiency chronic peripheral, status gastrostomy, sarcopenia, dysphasia oropharyngeal phase, cognitive communication deficit.Review of Resident #44 physician orders dated 08/7/2025 revealed, Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier precautions r/t PEG-tube. every shift for infection control. Review of Resident #44's comprehensive care plan revealed, Focus: Resident requires Enhanced Barrier Precautions during High contact Resident care activities r/t [related to] tube feed . Goal: Enhanced Barrier Precautions will remain in effect for limited periods (i.e. while the risk of transmission of the infectious agent persists or for the duration of the illness). Interventions: Enhanced Barrier Precautions: tube feed during high contact care activities, dressing, bathing showering, transferring providing hygiene, changing linens, changing briefs or assisting with toileting.4. On 08/21/2025 at 9:18 AM observed Staff L, CNA entered Resident #27's room with incontinence care supplies, there was an enhanced barrier precaution sign at the doorway, no PPE in the room but PPE was available in the hallway. Staff L, CNA explained to Resident #27 that she was cleaning her up. Staff L, CNA did not perform hand hygiene, donned gloves, and began to provide incontinence care by removing Resident #27's brief. Staff L, CNA completed the care and exited Resident #27's room after doffing gloves. Staff L, CNA did not perform hand hygiene and went to another resident's room to provide care.On 08/21/2025 at 9:27 AM Staff L, CNA stated, [Resident #27] is on enhanced barrier precautions I should have put a gown on, I had gloves on I thought that was enough. Oh, I should have washed my hands before and after I took off my gloves.Review of the Policy and Procedure titled, Handwashing/Hand Hygiene Level I, with an approval date of 01/28/2025 revealed, Purpose: The purpose of this procedure is to provide for effective guidelines for effective hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. General Guidelines: 1. Appropriate twenty (20) second handwashing with antimicrobial or antimicrobial soap and water must be performed under the following conditions: a. Before and after direct contact with residents: .c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions. 2. The use of gloves does not replace handwashing.

Based on observations, interviews, and policy review, the facility failed to ensure food in the refrigerator was discarded upon the expiration date and the facility failed to ensure the facility had and followed a cleaning schedule for food service equipment for one of one kitchen.Findings included: A kitchen tour was conducted on 08/18/2025 at 9:07 AM with the Dietary Manager (DM). The walk-in refrigerator revealed two containers of cottage cheese that had an expiration date of 08/16/2025. The tour of the kitchen also revealed a covered piece of equipment identified as a meat slicer. The DM uncovered the meat slicer stating it was supposed to be clean when covered. An observation was made of food particle debris on the base and blade of the meat slicer.An interview with the Dietary Manager (DM) was conducted on 08/18/2025 at 9:17 AM. The DM confirmed the two expired cottage cheese containers and the food particle debris on the meat slicer. The DM verified expired foods should be disposed of prior or on the expiration date. The DM stated the meat slicer should not have been covered until it was properly cleaned.A review of the facility's policy titled Food Storage, with a revision date of 12/2024 revealed, foods shall be received and stored in a manner that complies with safe food handling practices.A review of the facility's policy titled Sanitation, with a revision date of July 2023, revealed, all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, except during tray line and production use/time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADLs) were performed for one (#3) three sampled residents related to incontinence care. Findings included: On 01/23/2025 at 9:55 a.m., an interview was conducted with Staff A Licensed Practical Nurse (LPN) and Staff C, Certified Nursing Assistant (CNA) with Resident #3. The resident was sitting in a wheelchair in her room. The resident was dressed and groomed for the day. She had no noted odors. The resident was sitting on a cushion in her wheelchair. Requested Staff A and Staff C contact the surveyor when the resident was due and needed incontinence care. On 01/23/2025 at 1:00 p.m., an observation of Resident #3 with Staff A and Staff C was conducted during the transfer of the resident to the bed from her wheelchair. They both applied gloves and transferred the resident to the bed using the sit to stand lift onto the bed. The resident was placed on her right side. Her legs had a straight line across the lower back of her thighs, her upper thighs were a deep red/purple color. The shape of the color was the shape of the wheelchair cushion. Staff C, with her gloves on, cleaned the resident's peri area. She moved the trash can to the bedside and continued to use those gloves to finish the peri-care. Staff C stated she had been trying to change her since 11:00 a.m. but could not because the trays came out and she had to pass trays. Staff C stated she was pulled to take a floor assignment because the aide scheduled to work left after she heard she was scheduled for 18 residents. Staff C stated they usually have 4 aides on the 300 / 400 halls and they only had 3 today. Staff C stated no one was doing her job (restorative) today, because they pulled her. Staff C stated when she came over at around 9:00 a.m., the resident was already up and in her wheelchair. She did not know how long the resident had been up in her wheelchair. Staff C stated she did not know when the resident was last changed, it was already done when she came on shift. Staff C changed her gloves and replaced her gloves without hand sanitizing. Resident #3's brief was removed, and an old dressing was observed on her buttocks dated 01/22/25. The dressing appeared saturated with blood-tinged drainage. After wound care was performed Staff A and Staff C replaced the brief on the resident. The resident's legs appeared to be lightening in color. Staff C removed the sit to stand lift and placed it in the hallway. Both Staff A and Staff C hand sanitized post removing their gloves. Resident #3 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to atrial fibrillation, morbid obesity, dementia, hypertension, osteoarthritis, and disorder of kidney and ureter. Review of the physician orders and January 2025 Treatment Administration Record (TAR) showed: Treatment as follows: Left buttock. Cleanse with wound cleanser, pat dry, apply antifungal powder and cover with bordered gauze dressing daily and as needed as of 01/09/2025 Treatment as follows: Right buttock. Cleanse with wound cleanser, pat dry, apply antifungal powder and cover with bordered gauze dressing daily and as needed as of 01/09/2025 Treatment as follows: Coccyx. Cleanse with wound cleanser, pat dry, apply antifungal powder and cover with bordered gauze dressing daily and as needed as of 01/09/2025 Review of the Wound APRN (Advanced Practice Registered Nurse) specialist notes showed: On 01/01/2025, Follow up of multiple wounds, the patient is a readmit due to MASD (Moisture Associated Skin Damage). Nursing staff educated on the importance of keeping the patient dry at all times. Significant contributors for impaired wound healing include generalized muscle weakness, underlying comorbidities, impaired mobility, and inevitable effects of aging. Frequent offloading and repositioning, pressure relief, and all due care have been rendered prior to today's assessment. Treatment initiated this visit, will re-assess on next provider visit. Review of the care plans showed: Resident needs assist with ADL care related to multiple factors including weakness/decreased mobility, ADL assist may vary as of 11/10/2023 and revised on 02/05/2024. Interventions included but not limited to toileting: the resident will need the extensive help of one or two staff to stand and transfer on and off he commode or bed pan the resident will probably need you to wipe, redress, and wash their hands, but allow the resident to do any part of the activity they can to promote independence Be prepared with 2 people to assist for resident safety during transfer on 0/21/2024. Transfer: the resident dependent is unable to assist with a transfer and will need assistance x 2 staff and a mechanical lift to move from bed to chair and back as of 05/21/2024. Resident is at risk for skin impairment related to fragile skin, incontinence, weakness/decreased mobility as of 05/20/2024. Goal was to keep resident free from any new skin impairment through 05/20/2024. Interventions included but not limited to encourage and assist resident to turn and reposition as tolerated as of 05/20/2024; Preventative skin treatments as ordered/indicated, as tolerated by resident as of 05/20/2024; Provide incontinence care promptly should any episode of incontinence occur as of 05/20/2024. The resident is at risk for complications related to bowel and bladder incontinence related to diverticulosis as of 05/16/2024. Goal was the resident will have no complications related to incontinence. Interventions included but not limited to administer medications as ordered by MD; provide incontinence care with each incontinence episode are tolerated. On 01/23/2025 at 2:21 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA stated they staff the residents per the census, it was adjusted based on the census. The NHA stated if an aide called off, we fill the shift. The NHA stated it would depend; we would call someone in or use someone here for the shift. The NHA stated an aide called off for the 7:00 a.m. - 3:00 p.m. shift on 01/23/2025. The NHA stated normally they had 4 to 5 aides on each side of the building. The NHA and the DON verified they only had three aides covering the 300 and 400 hallways and one aide which was on orientation and could not take a schedule. The NHA stated the Transport aide, Staff D, CNA was working the floor because they did not have anyone needing transportation today. The NHA stated the Restorative aide Staff C, CNA, was working the floor today. The NHA stated Staff C was working in the place of the aide that called off. The NHA stated they had used agency staff in the past. The NHA stated normally the aides had 10-15 residents per each aide. The DON stated the residents were changed (incontinence care) every 2 hours. The DON stated Resident #3 should have been checked (incontinence care) before going into the dining room. The DON stated Resident #3 should have been checked (incontinence care) after dining when getting ready to lay her down. The DON stated they would have changed Resident #3 when they got her up for breakfast. The DON stated breakfast came around 8:00 a.m. The DON stated the expectation was to change Resident #3 before 4 1/2 -5 hours Review of the facility's policy, ADL Care and Services, revised 01/2024 showed Standard: resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Guideline: Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: C. Elimination toileting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Quality of Care was provided related to wound care and following Infection Control Practices for one (#3) of one sampled resident. Findings included: Review of the admission record showed Resident #3 was admitted on [DATE] and readmitted on [DATE]. Her diagnoses included but not limited to atrial fibrillation, morbid obesity, dementia, hypertension, osteoarthritis, and disorder of kidney and ureter. On 01/23/2025 at 1:20 p.m., wound care was observed for Resident #3. Staff B, Licensed Practical Nurse (LPN) brought dressing supplies, normal saline in syringes, and the resident's [Antifungal] powder bottle and sat them on the overbed table. Staff B did not clean the overbed table nor place a barrier down. Staff B went into the bathroom and washed her hands. Staff B removed the old dressing and stated, that looks like calcium alginate, that was not ordered for her. Staff B stated the resident was supposed to be on [Antifungal] powder only. The affected buttocks area was a deep red beefy color and was about the size of a grapefruit. The resident had 3 approximately dime size open areas on the left side of the buttocks and 1 approximately the size of a quarter on the right side of the buttocks. Staff B removed her gloves and re-gloved. Staff B opened the normal saline syringe package and cleaned the right side or bottom area of the buttocks first. Staff B dried the area with a gauze pad. Staff B removed her gloves and replaced her gloves. Staff B squirted the normal saline on the left buttocks or top and then dried the area. Staff B removed her gloves and replaced her gloves. The [Antifungal] bottle lid fell onto the floor, she picked it up with her left hand and placed it back onto the bottle. Staff B did not change her gloves or hand sanitize. Staff B stated she would use the [Antifungal] powder since that was the order but would call the wound nurse and/or wound doctor with an update. Staff B shook the [Antifungal] powder on the right side or bottom area and placed the border dressing on. Staff B removed her gloves and re-gloved. Staff B shook the [Antifungal] powder on the left side or top area, she had a difficult time shaking the powder onto that site. Staff B removed her gloves and replaced her gloves. Staff B placed the border dressing on the left side or top. Staff B stated she had never cared for the resident before. Staff B removed her gloves and replaced them. Staff B dated both border dressings with the date and time with a red pen. Staff B closed the [Antifungal] powder and removed her gloves and replaced her gloves. Staff B gathered the used supplies and used gloves and placed them in the trash can. Staff B removed her gloves and washed her hands. Staff B left the room with the unused border dressing, the [Antifungal] powder, and the used normal saline syringes. Staff A, LPN and Staff C, Certified Nursing Assistant (CNA) replaced the brief on the resident. Both Staff A and Staff C hand sanitized post removing their gloves. During an interview with Staff A, LPN and Staff B, LPN after the wound care, they stated that the resident was not on Enhanced Barrier Precautions (EBP). They stated EBP was used if a resident had wound care, urinary catheters, was on IV therapy, ostomies. They stated you were supposed to wear gowns and gloves when providing care. Staff A and Staff B verified the resident was not on EBP because the area was not considered a wound, just MASD or Moisture -Associated Skin Damage. Staff B verified she had not hand sanitized between glove changes. Staff B stated the hand sanitizer is only on the hallway walls and was too far to come out here and sanitize. Staff B stated she could not leave the resident to wash her hands between glove changes. Staff B stated she did not have any hand sanitizer on her cart or with her. Staff A stated they were supposed to have it (hand sanitizer) in our pockets. Staff B stated she did take the [Antifungal] powder into the resident's room. Staff B stated she did not place any of the supplies on a barrier. Staff B stated she took the [Antifungal] powder out of the bag from the wound cart and brought it to the room. Staff B stated the [Antifungal] powder was labeled with the resident's name. Staff B stated she placed it back into the bag and into the wound care cart and placed the unused border dressing back into the wound cart. Staff B stated she did not remember picking the [Antifungal] powder cap up off the floor. Staff A stated the [Antifungal] container would be considered contaminated after going into the resident's room as well as the border dressing. Review of the physician orders and January 2025 Treatment Administration Record (TAR) showed Treatment as follows: Left buttock. Cleanse with wound cleanser, pat dry, apply antifungal powder and cover with bordered gauze dressing daily and as needed as of 01/09/2025 Treatment as follows: Right buttock. Cleanse with wound cleanser, pat dry, apply antifungal powder and cover with bordered gauze dressing daily and as needed as of 01/09/2025 Treatment as follows: Coccyx. Cleanse with wound cleanser, pat dry, apply antifungal powder and cover with bordered gauze dressing daily and as needed as of 01/09/2025 Review of the Wound APRN (Advanced Practice Registered Nurse) specialist notes showed On 01/01/2025, Follow up of multiple wounds, the patient is a readmit due to MASD (Moisture Associated Skin Damage). Nursing staff educated on the importance of keeping the patient the patient dry at all times. Significant contributors for impaired wound healing include generalized muscle weakness, underlying comorbidities, impaired mobility, and inevitable effects of aging. Frequent offloading and repositioning, pressure relief, and all due care have been rendered prior to today's assessment. Treatment initiated this visit, will re-assess on next provider visit. Wound #9 Left Buttock is a Partial Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Initial wound encounter measurements are 8 cm (centimeter) length x 4 cm width x 0.1 cm depth, with an area of 32 sq cm and a volume of 3.2 cubic cm. There is a Moderate amount of sero-sanguineous drainage noted which has no odor. Wound #10 Right Buttock is a Partial Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Initial wound encounter measurements are 4 cm length x 2 cm width x 0.1 cm depth, with an area of 8 sq cm and a volume of 0.8 cubic cm. There is a Moderate amount of sero-sanguineous drainage noted which has no odor. Wound #11 Coccyx is a Full Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Initial wound encounter measurements are 2 cm length x 0.5 cm width x 0.1 cm depth, with an area of 1 sq cm and a volume of 0.1 cubic cm. There is a Moderate amount of drainage noted which has no odor. Treatment Goals: Healing is expected to be delayed de to identified barriers to healing: impaired mobility and incontinence. On 01/08/2025 The patient is seen for a follows up of multiple wounds. Changes made to facilitate wound healing. Wound #9 Left Buttock is a Partial Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Subsequent wound encounter measurements are 8 cm length x 3 cm width x 0.1 cm depth, with an area of 24 sq cm and a volume of 2.4 cubic cm. Moderate amount of sero-sanguineous drainage noted, which has no odor. The wound is improving. Wound #10 Right Buttock is a Partial Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Subsequent wound encounter measurements are 5.5 cm length x 3 cm width x 0.1 cm depth, with an area of 16.5 sq cm and a volume of 1.65 cubic cm. Moderate amount of sero-sanguineous drainage noted, which has no odor. The wound is deteriorating. Wound #11 Coccyx is a Full Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5 cm length x 1 cm width with no measurable depth, with an area of 2.5 sq cm. Moderate amount of sero-sanguineous drainage noted, which has no odor. The wound is deteriorating. On 01/15/2024, Follow up multiple wounds on assessment the wounds are improving. Continue current treatment recommendations. Wound #9 Left Buttock is a Partial Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Subsequent wound encounter measurements are 4 cm length x 1 cm width x 0.1 cm depth, with an area of 4 sq cm and a volume of 0.4 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. The wound is improving. Wound #10 Right Buttock is a Partial Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Subsequent wound encounter measurements are 4.5 cm length x 1 cm width x 0.1 cm depth, with an area of 4.5 sq cm and a volume of 0.45 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. The wound is deteriorating. Wound #11 Coccyx is a Full Thickness Moisture Associated Skin Damage and has received a status of Not Healed. Subsequent wound encounter measurements are 1 cm length x 0.5 cm width x 0.1 cm depth, with an area of 0.5 sq cm and a volume of 0.05 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. The wound is deteriorating. Same wound care. On 01/22/2025, resident was visited by Wound APRN, the documentation had not been submitted. Review of the Wound Care form showed Left Buttock, MASD, current size, 4.0 cm x 1.0 cm x 0.1 cm. Medium sero-sanguineous drainage. Continue Nystatin powder daily and as needed. Right Buttock, MASD, current size, 4.5 cm x 1.0 cm x 0.1 cm. Medium sero-sanguineous drainage. Continue Nystatin powder daily and as needed. Coccyx was resolved. Review of the care plans showed: Resident was risk for skin impairment related to fragile skin, incontinence, weakness/decreased mobility as of 05/20/2024. Goal was to keep resident free from any new skin impairment through 05/20/2024. Interventions included but not limited to encourage and assist resident to turn and reposition as tolerated as of 05/20/2024; Preventative skin treatments as ordered/indicated, as tolerated by resident as of 05/20/2024; Provide incontinence care promptly should any episode of incontinence occur as of 05/20/2024. The resident has MASD to coccyx, left buttock, right buttock as of 01/03/2025 and revised on 01/13/2025. Goal was the resident will have no complications from rash through the review date. Interventions included but not limited to administer medication as ordered by the MD; avoid scratching and keep hands and body parts from excessive moisture; increase out of bed activity as tolerated; monitor skin rashes for increased spread or signs of infection; seek medical attention if skin becomes bloody or infected. The resident is at risk for complications related to bowel and bladder incontinence related to diverticulosis as of 05/16/2024. Goal was the resident will have no complications related to incontinence. Interventions included but not limited to administer medications as ordered by MD; provide incontinence care with each incontinence episode are tolerated. On 01/23/2025 at 2:21 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated the residents were changed (incontinence care) every 2 hours. The DON stated Resident #3 should have checked (incontinence care) before going into the dining room. The DON stated Resident #3 should have been checked (incontinence care) after dining when getting ready to lay her down. The DON stated they would have changed Resident #3 when they got her up for breakfast. The DON stated breakfast came around 8:00 a.m. The DON stated the expectation was to change Resident #3 before 4 1/2 -5 hours. The DON stated Resident #3 would not be on Enhanced Barrier Precautions with MASD, that was not considered a wound. The DON stated Resident #3's wound care was done by the wound practitioner and wound manager on 01/23/2024. The DON stated they were supposed to follow the wound care orders, or the wound practitioner should have put in a change in wound care orders. The DON stated based on the verbal report and Wound Care form that was given to her Resident #3 had MASD and no change in wound care. The DON stated hand hygiene was to be done before touching a resident, after touching a resident, after touching an object, before putting on gloves, and between glove changes. The DON stated if the antifungal powder bottle goes into the resident's room it was contaminated. The DON stated that they have little cups they can dump some of the powder into to take to the room. The DON stated all supplies should be placed on a barrier after the overbed table was cleaned. The DON stated the supplies needed to be on a barrier due to infection control: clean the table, barrier down, lay supplies down. The DON stated any supplies not used during the care that have been taken into a resident's room need to be trashed or left in that resident's room in a drawer. The supplies should not be taken out of the room and placed back in the wound cart; they are contaminated. The DON stated if a antifungal powder bottle lid falls on the floor, she would throw the lid away. The DON stated once the lid was picked up with the gloved hands, the gloves were contaminated. The gloves needed to be removed, hands sanitize and re-glove. The DON stated she would date the dressing prior to putting it on the resident, not after it was on the resident's buttocks. Review of the facility's policy, Clean Dressing Change, revised 01/2025 showed the purpose of this procedure is to provide guidelines for the application of dry, clean dressing. Procedure: 1. verify that that there is a physician's order for the procedure 2. review the residence care plan, current orders, and diagnosis to determine if there are special resident needs. 3. appeared assembled the equipment and supplies as needed per physician orders or facility protocol. 5. Perform hand hygiene as indicated throughout procedure 6. Position and prep resident and supplies for the procedure. 7. Remove all dressing of applicable per physician orders and dispose of as indicated. 8. Performed clean dressing change procedure as indicated per physician orders. 9. Document completion of procedure and the resident record. Review of the Clinical Safety: Hand Hygiene for Healthcare Workers, https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html on 01/24/2024 showed hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with hand washing antiseptic hand rub. Cleaning your hands reduces: the potential spread of deadly germs to patients. Recommendations when to clean your hands: immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. Review of the facility's policy, Enhanced Barrier Precautions, 05/28/2024 showed the facility will decrease the transmission of multidrug-resistant organisms by maintaining infection control standards. Enhanced Barriers precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one (#4) of one resident sampled for self-administration of medications was assessed for the administration of nebulizer treatments. Findings included: The admission Record for Resident #4 showed resident was admitted on [DATE] with diagnoses not limited to chronic obstructive pulmonary disease with (acute) exacerbation, unspecified heart failure, and acute and chronic respiratory failure with hypoxia. On 8/13/23 at 12:24 p.m., Resident #4 was observed lying in bed, eyes closed, and wearing a nebulizer mask with a nasal cannula. The nebulizer mask did not have any aerosol being emitted and no liquid was observed in the medication cup of the mask. An observation was made on 8/13/23 at 12:31 p.m., of the resident removing the nebulizer mask after his lunch tray was placed on the over-bed table. The observation continued at 12:40 p.m., Staff A, Licensed Practical Nurse (LPN) was observed in a room across the hall from resident #4 obtaining the occupant's blood glucose level. On 8/16/23 at 8:52 a.m., Resident #4 was observed sitting in a wheelchair, facing the head of bed, wearing a nebulizer mask. An unknown Certified Nursing Assistant (CNA) was assisting the resident's roommate and Staff E, agency LPN, was observed in the hallway dispensing medications to other residents from a medication cart parked 2 rooms from Resident #4's. An observation at 9:00 a.m. on 8/16/23 showed that Staff E continued to be dispensing medications from the medication cart parked in the same location. On 8/16/23 at 9:04 a.m., Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM), said a physician order would be needed to self-administer medications. Staff D reviewed Resident #4's available assessments and confirmed the resident had not been assessed for self-administration of medications. In an interview with Resident #4 at 10:30 a.m. on 8/16/23, she said she had done nebulizer's forever and staff did not stay with her during the administration. A review of Resident #4's physician orders indicated an order for Albuterol Sulfate Nebulization Solution (2.5 milligram/3 milliliter) 0.083% inhalation orally via nebulizer every 6 hours for congestion, Ipratropium-Albuterol Solution 0.5-2.5 mg/3 mL orally every 4 hours as needed for COPD, and Ipratropium-Albuterol Solution 0.5-2.5 mg/3 mL orally every 6 hours as needed for congestion. The physician orders did not include an order for the resident to self-administer any medications. A review of Resident #4's care plan showed the resident was at risk for adverse effects related receiving steroid therapy to treat lung inflammation and for altered respiratory status/difficulty breathing related to episodes of shortness of breath. The interventions did not show the resident was assessed for self-administration of medications. On 8/16/23 at 10:35 a.m., the Director of Nursing (DON) reported not wanting to speak about a resident needing an assessment for self-administration (of medication). The Regional Nurse Consultant (RNC) reported reaching out to another RNC regarding a policy for self-administration. The RNC stated, on 8/16/23 at 10:43 a.m., the expectation was for the resident to be evaluated for self-administration (of medications). On 8/16/23 at 11:07 a.m., the RNC stated that an evaluation/assessment for self-administration should be done before being allowed for self-administration. The DON confirmed, on 8/16/23 at 11:47 a.m., that Resident #4 had no self-administration evaluation to be provided to this writer. The policy - Self-Administration of Medications, revised October 2010, identified that Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The interpretation and implementation of the policy included the following: - As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. - The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. The interpretation indicated that in addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment for the resident which included the resident's ability to read and understand medication labels, comprehension of the purpose and proper dosage and administration time for his or her medications, ability, and ability to recognize risks and major adverse consequences of his or her medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents received medications in accordance with professional standards related to monitoring of blood pressure medications parameters and to ensure the physician was notified of held doses for one (#56) of six residents sampled for unnecessary medications. Findings included: During a facility tour on 08/15/23 at 09:56 a.m., Resident #56 was observed lying on his bed. He stated he did not feel well because his blood pressure was too low. Resident #56 stated this had been going on for weeks and he had not seen the nurse practitioner or a physician. The resident said, I get dizzy, they said it's my ears, I don't think so. I am sweating all the time. The resident stated he had notified the nurses on multiple occasions, and they just held his blood pressure medication at that time. Resident #56 said, Last night my bed was soaked. I was sweating profusely. The CNA (Certified nursing Assistant) said I had spilled juice. It was not juice I was sweating badly. Review of an admission record dated 08/16/23 showed Resident #56 was admitted to the facility on [DATE] with diagnoses to include hypotension unspecified. Review of a Minimum Data Set (MDS) dated [DATE], showed Resident #56 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognitive response. Section G - Functional patterns showed the resident was totally dependent on staff for mobility and transfers. On 08/15/23 at 11:27 a.m., a follow up was conducted with Staff G, LPN (Licensed Practical Nurse) assigned to the resident. She stated she was aware the resident was having low blood pressure. She stated when this happens, they hold the medication. She stated they should notify the doctor whenever medications were held. During the interview, review of Resident #56's medication orders was conducted. Staff G noted the orders did not have parameters to hold the medication. When asked how she would know when to hold, Staff G said, when it is low. Review of a Medication Administration order with an effective date of 03/12/23, showed, Metoprolol Tartrate Tablet 25 Milligram (mg). Give 0.5 tablet by mouth every morning and at bedtime for HTN (Hypertension) for total of 12.5 mg each dose. Losartan Potassium oral tablet 25 mg. Give 0.5 mg tablet in the morning for HTN. On 08/15/23 at 12:34 p.m., Staff G, LPN confirmed the order did not have parameters to hold. She stated she had made the nurse practitioner aware of patient's concerns related to low blood pressures, and feeling like he was getting sick. She stated she had received new orders to discontinue Losartan and obtain labs. Staff G stated she had made the resident aware of all new orders. Review of MAR (Medication Administration Record) dated 8/01/23 to 8/31/23 showed Resident #56's Metoprolol documented with a number 5 indicating it was held on 8/1/23, 8/3/23, 8/8/23, 8/9/23 ,8/12/23 and 8/14/23. The MAR further showed Losartan Potassium was documented with a number 4 indicating it was outside of parameters on 8/02/23 , 8/03/23 and 8/08/23. The MAR dated 7//01/23 to 7/31/23 showed Resident #56's Metoprolol was documented with a number 5 indicating it was held on 7/3/23 and 7/26/23. The Metoprolol was documented with a number 4 indicating it was outside of parameters on 7/2/23, 7/17/23, 7/28/23 and 7/30/23. The Losartan Potassium was held on 7/16/23 and it was outside of parameters on 7/2/23, 7/17/23, 7/28/23 and 7/30/23. Review of progress notes revealed the physician was not notified the medications were held, or they were outside parameters for 20 out of 60 encounters. On 08/15/23 at 10:19 a.m., an interview was conducted with the Director of Nursing (DON). He stated he should have expected there to be orders to hold. He reviewed the resident's orders with this surveyor. The resident did not have orders to hold and did not have parameters for blood pressure. Review of an undated facility policy titled, Physician Orders, showed orders for medications and treatments will be consistent with principles of safe and effective order writing. (1.) Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Medications should be given per the written order. (9.) Orders for medications should include: (e) Any interim follow-up requirements ( . therapeutic medication monitoring.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility did not ensure a resident with contractures received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence. The facility failed to ensure restorative services were provided for one (Resident #56) of 14 residents. Findings included: On 08/13/23 at 10:01 a.m., an interview was conducted with Resident #56. The resident stated therapy was discontinued for him because of funding. The resident stated he was not receiving restorative services from the facility. Resident #56 was noted with a left arm contracture. He stated he was paralyzed on his left side and had some nerve ending damage. Resident #56 stated he used to receive exercises from nursing staff, but it had been a long time. He stated he was afraid of being contracted even more. Review of an admission record, dated 08/16/23 showed Resident #56 was admitted to the facility on [DATE] with diagnoses to include contracture, left shoulder, contracture on left elbow, contracture of muscle on left lower leg, Hemiplegia and Hemiparesis following infarction affecting left non-dominant side. Review of a Minimum Data Set (MDS) dated [DATE], showed Resident #56 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognitive response. Section G- Functional patterns showed the resident was totally dependent on staff for mobility and transfers. Review of a care plan dated 03/12/23 showed Resident #56 was at risk for loss of range of motion related to physical limitations. Interventions included assisted Range of Motion (ROM) of upper/lower extremities with ADL (Activities of Daily Living) care. On 08/15/23 at 3:00 p.m., an interview was conducted with the Director of Rehabilitation Services. He stated Resident #56 as a long-term resident who had received several episodes of therapy. He was discharged from Occupational Therapy (OT) and Physical therapy (PT) on 6/19/23 because his progress had plateaued, and he did not meet his goals. He stated Resident #56 wanted on-going therapy. He stated they would re-screen him because, We don't want him to decline. The DOR said, Right now there is no restorative program. We discharge residents to nursing staff and encourage nursing staff to do some ROM. We give them a therapy follow-up program. The DOR stated the follow-up program was specific to a resident's plan of care. He stated when Resident #56 was discharged from therapy, nursing received a therapy follow-up program for him. On 08/15/23 at 3:15 p.m., an interview was conducted with Staff G and Staff I, Licensed Practical Nurses (LPN). They confirmed they knew Resident #56 very well. They worked with him often. They both stated they did not know about the therapy follow-up program. Staff G said, I never heard of it. On 08/15/23 at 3:19 p.m., an interview was conducted with Staff J, CNA (Certified Nursing Assistant). She stated she had not seen any ROM tasks on the CNA assignments for Resident #56. Staff J stated she had seen the program in the past. She stated the restorative tasks would show in the CNA task log. She said, an example of a task log would be to complete passive ROM during care. It would be specific to each resident. I have not seen it in a while. On 08/15/23 at 03:49 p.m., an interview was conducted with the Director of Nursing (DON). He said, We do not have a restorative program. It is a wish list right now. Staffing does not allow us to assign that program. The DON stated the nursing staff should be completing the restorative program, but they had not started. On 08/16/23 at 10:02 a.m., an interview was conducted with the Regional Clinical Consultant (RCC). She stated she did not know about the facility's restorative program. She said, You should speak with the DON about that. A follow-up interview was conducted with the DON on 08/16/23 at 10:27 a.m. He stated they had been discussing the restorative program and identified they have a problem. The DON said, We have not been able to activate because the Unit Manager is new. we have not been able to do it. He confirmed a restorative program was to help maintain the level of function through assisting in ADLs and ROM. He stated the CNA's should be doing ROM during care. On 08/16/23 at 10:49 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She confirmed they did not have an established plan in place for their restorative program. A review of a facility policy titled, Restorative Nursing Services, dated 08/2022, showed a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Restorative nursing program refers to interventions that promote the resident's ability to adapt and adjust to living independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Under guideline, (2.) Residents may start on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care. (6.) Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a pain assessment was conducted in a timely manner for one (Resident #13) of two residents reviewed for pain. Findings included: On 08/13/23 at 10:00 a.m., an interview was attempted with Resident #13. The resident did not speak English. Staff F, CNA (Certified Nurse's Assistant) stated she would interpret for the surveyor. When asked if she had any concerns, Resident #13 motioned her hand over her peri area while grimacing and spoke in Spanish. The resident displayed frowning and clenching of her jaw as she spoke to Staff F. Staff F, CNA interpreted and stated the resident said she felt some irritation and pain in her peri area. Staff F stated the resident said the pain had started two days earlier. Resident #13 was observed wrinkling her nose and squeezing her eyes shut as she described how she was feeling. Resident #13 reported it hurts when she urinates. Staff F stated she would let the nurse know immediately. Staff F was observed leaving the room and heading to the nurse who was on her medication cart. Review of an admission Record for Resident #13 dated 08/16/23 revealed the resident was admitted to the facility on [DATE] with diagnoses to include, Unspecified severe protein calorie malnutrition, dementia, Parkinson's disease, anxiety disorder, and Alzheimer's disease among others. A review of a Minimum Data Set, dated , 08/02/23, section G- functional status, showed Resident #13 required extensive assistance for all ADLs (Activities of Daily Living). Review of a care plan dated 03/23/21 showed a focus, Resident #13 is at risk for pain related to complaints of generalized pain with a goal to reduce episodes of pain breakthrough. Interventions included reporting non-verbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. On 08/14/23 at 1:27 p.m., an interview was conducted with Staff F, CNA. She confirmed she had notified Staff G, LPN (Licensed Practical Nurse) of Resident #13's pain the day before. Staff F said, I told the nurse the resident had stated she had pain, burning and irritation in her vaginal area, and that it hurts when she urinates. Staff F stated she did not know what the nurse did about it. On 08/14/23 at 1:32 p.m., an interview was conducted with Staff H, LPN Agency. She stated she was assigned to Resident #13. She stated she did not know this resident had any pain concerns. She was not notified and there was no documentation related to new pain concerns. Staff H and this writer spoke to the resident. Resident #13 was observed grimacing and closing her eyes and her hands moving in circular motion as she pointed to her vaginal area. Staff H said, The resident confirmed she was still in pain. She described tingling and irritation to her vaginal area. Staff H stated she would let the doctor know. She stated she thought the resident might have an untreated infection. On 08/14/23 at 1:47 p.m., an interview was conducted with the Director of Nursing (DON). He stated the nurse who was initially notified of the pain should have completed a change in condition at the time the resident reported pain and irritation. The DON said, at the very least, the report would include a pain assessment and to notify the doctor. The DON stated there should be a note documenting the encounter. The DON confirmed there was no documentation related to the pain report. He stated he would assess the resident and notify the ARNP (Advanced Registered Nurse Practitioner). On 08/15/23 at 9:46 a.m., an interview was conducted with Staff G, LPN. She confirmed she had worked on Sunday 08/13/23 the 7:00 a.m. to 3:00 p.m. shift. Staff G said, The CNA told me [Resident #13] had some pain, she reported she had irritation and burning in her peri area. To be honest, it was my mistake. I forgot. Staff G stated what she should have done was notified the doctor and also fill out the Change in Condition. On 08/15/23 at 01:51 p.m., a follow -up was conducted with the Regional Clinical Consultant (RCC). She stated she would expect the nurses to follow their policies. On 08/16/23 at 11:00 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated her expectation would have been to have the resident assessed for pain right away. The NHA stated she expected their residents would be receiving quality care. The NHA said, A resident should not wait to be assessed for pain. It is absolutely unacceptable. That nurse did not do what she was supposed to do. The NHA confirmed a timely response should have followed. Review of a facility policy titled, Pain Evaluation and Management, revised, February 2023, showed, acute pain (or significant worsening of chronic pain) should be evaluated 30 to 60 minutes after the onset and re-evaluated as indicated until relief is obtained.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and seven errors were identified for three (#73, #11, and #446) of four residents observed. These errors constituted a 25.93% medication error rate. Findings included: 1. On 8/13/23 at 11:11 a.m., an observation of medication administration with Staff A , Licensed Practical Nurse (LPN), was conducted with Resident #73. Staff A obtained a blood glucose level of 207 from the resident and dispensed the following medication: - Novolog FlexPen The staff member dialed the pen to 4 units, placed the pen and needle in a plastic cup, and entered the residents room. Staff A applied a needle to the pen and injected the insulin in the back of the residents' left arm. Staff A did not prime the insulin pen prior to the injection. The Director of Nursing (DON) stated, on 8/15/23 at 2:14 p.m., Novolog pens needed to be primed. The DON reported to prime insulin pens was to set it (dose selector) to 2 units, with needle pointed upwards, push it to zero, then dial to the units and administer. The DON provided documentation for instructions for use of Humalog KwikPen that showed staff were to Prime before each injection. The instructions showed Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. According to the manufacturer instructions, located at https://www.novo-pi.com/novolog.pdf, identified the following: - Giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - E. Turn the dose selector to select 2 units; - F. Hold your with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the NovoLog® FlexPen® needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog® FlexPen® and contact [manufacturer] A small air bubble may remain at the needle tip, but it will not be injected. 2. On 8/14/23 at 8:24 a.m., an observation of medication administration with Staff B, Licensed Practical Nurse (LPN), was conducted with Resident #11. Staff B dispensed the following medications: - Iron 325 milligram (mg) tablet - Wellbutrin 150 mg Extended Release (XL) tablet - Eliquis 5 mg tablet - Furosemide 40 mg tablet - Lactulose 10 gram/15 milliliter (gm/mL) - 30 mL's - Diltiazem Extended Release (ER) 240 mg capsule - Potassium Chloride 20 milliequivalent's (meq) tablet - Multi Vitamin with mineral tablet - Senna 8.6 mg - 2 tablets - Sodium chloride 1 gm tablet - Acidophilus tablet - Vitamin C 500 mg tablet - Zenpep 5000 unit capsule - Aranesp injectable 25 microgram (mcg) syringe - Metoprolol Tartrate 25 mg - 2 tablets A review of Resident #11's August Medication Administration Record (MAR) showed the resident was to receive the following physician ordered medications and not the ones observed as administered: - Multi Vitamin oral Tablet (did not include minerals) - 2 tablets of Senna Plus 8.6-50 mg The website: medline.gov described Senna as Senna is used on a short-term basis to treat constipation. It also is used to empty the bowels before surgery and certain medical procedures. Senna is in a class of medications called stimulant laxatives. It works by increasing activity of the intestines to cause a bowel movement. The website: webmd.com described Senna Plus as This product is used to treat constipation. It contains 2 medications: Sennosides and Docusate. Sennosides are known as stimulant laxatives. They work by keeping water in the intestines, which helps to cause movement of the intestines. Docusate is known as a stool softener. It helps increase the amount of water in the stool, making it softer and easier to pass. 3. On 8/14/23 at 9:17 a.m., an observation of medication administration with Staff C, Registered Nurse (RN), was conducted with Resident #446. Staff C dispensed the following medications: - Tamsulosin 0.4 mg capsule - Thiamin B1 100 mg capsule - Pantoprazole Delayed Release (DR) 40 mg tablet - Nifedipine 30 mg ER tablet - Clopidogrel 75 mg tablet The staff member confirmed dispensing 5 tablets prior to entering Resident #446's room and assisting the resident with the administering. After returning to the medication cart Staff C reported the medication pass was complete and moved the medication cart to the nursing station then sat down behind the station. A review of Resident #446's August Medication Administration Record (MAR) showed the resident was to receive one tablet of Thiamine 250 mg instead of the one 100 mg tablet observed as given. The MAR showed Staff C documented the following medications had been administered: - Polyethylene Glycol 3350 powder - 17 gm's by mouth one time a day for constipation; - Carvedilol 6.25 mg tablet two times a day for hypertension; - Docusate Sodium 100 mg capsule two times a day for constipation. An interview was conducted on 8/15/23 at 11:18 a.m., with Staff D, LPN/Unit Manager (UM) regarding the administration of medication for Resident #446. Staff D reviewed Resident #446's MAR and said Staff C had confirmed 5 tablets had been dispensed for Resident #446. Staff D confirmed Staff C had documented on 8/14/23 at 9:25 a.m. the resident had received Polyethylene Glycol, Carvedilol, and Docusate sodium. The Director of Nursing (DON) stated on 8/15/23 at 2:14 p.m. the expectations were for staff to follow physician orders and follow the 5 rights of medication administration that included: Right patient, right dose, right medication, and right time. On 8/14/23 at 1:24 p.m., the Regional Nurse Consultant (RNC) stated the Medication Administration policy was generic, the facility followed physician orders, and said an insulin administration policy would be a general policy. The facility policy - Medication Administration, undated, showed Orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy instructed staff on the documentation required for obtaining a physician order and not staff responsibilities for the dispensing and administration of medications. The policy - Documentation of Medication Administration, revised April 2007, indicated that The facility shall maintain a medication administration record to document all medication administered. The interpretation and implementation portion of the policy indicated that Administration of medication must be documented immediately after it is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment was reported immediately to all outside agencies for one (Resident #1) out of the sampled three residents. Findings included: A review of the admission Record Report for Resident #1 showed she was admitted into the facility on [DATE] with a diagnosis that included but was not limited to unspecified dementia. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A review of the Order Summary Report with active orders as of [DATE] revealed the following order: Full Code (04 13/21). Progress Notes revealed the following note: [DATE] at 04:38- Certified Nursing Assistant (CNA) returned from 30-minute break and alerted nursing staff that resident was not breathing. Nursing assesses, code blue called, and CPR (cardiopulmonary resuscitation) was initiated. Provider made aware. 911 arrived and resident was pronounced expired at 4:42 a.m. by Emergency Medical Services (EMS). Family was called and informed that the resident expired. A code form was not completed for this event. A review of the care plans did not reveal a care plan related to code status. On [DATE] at 1:20 p.m., the Administrator (NHA) reported on 4/14 she received a call from the Director of Nursing (DON) concerned that she heard from the nurse practitioner that she spoke to Staff G, Registered Nurse (RN), and was concerned that she did not remain with her patient during the code process. After that, she called Staff G, RN, to suspend her pending investigation as to why she didn't remain with the patient. Staff G, RN, was supposed to meet with the Administrator and the DON on the following Monday or Tuesday, but she had a family emergency, and couldn't come in to meet until the 24th. When she came in on the 24th, they started the interview process and could not complete the interview as Staff G, RN, was upset and left the building. The NHA stated Sometimes the question can seem pointed. She and the DON were getting loud, and it was getting heated. The Administrator stated she excused the DON and the nurse stated she was not going to complete the interview process. Staff G, RN, had emailed regarding a complaint about the DON but not in response to completing the interview. The DON began to interview other staff. She came back with reports from staff that indicated there was a five-minute delay in giving CPR to Resident #1. The DON did not have a witness when she conducted her interviews and there should always be a witness, stated the Administrator. The NHA stated With that concern and delay for initiating treatment, a one-day neglect report was completed for the potential delay in initiating CPR. The Department of Children and Families (DCF) and law enforcement were contacted. The family was also notified of the investigation. Interviews were completed by the DON, and she provided information that there was a concern coming from Staff O, Licensed Practical Nurse (LPN), related to a delay in providing CPR. When the Administrator interviewed Staff O, LPN, there were no concerns. Staff O, LPN, stated he went to go to the bathroom in the breakroom and on his way back he was near the conference room door and heard code blue paged three times. They said 400 hall and he grabbed the crash cart and Staff M, RN, asked if he had the Automated External Defibrillator (AED), he said no she grabbed it and followed him down the hall. He went in the room and visually Resident #1 wasn't breathing, touched her wrist, she appeared warm, and no pulse. He opened the crash cart and set up the Ambu bag. Staff R, LPN, was on the left and Staff N, Certified Nursing Assistant (CNA), was on the right putting the board under her. Staff M, RN, opened the AED. As soon as he got air in the Ambu bag, he gave it to Staff R, LPN, and initiated compressions. After 2 sets they followed the AED directions and continued compressions until Emergency Medical Services (EMS) came. Staff responded immediately less than 30 seconds. They all worked together and did what they had to do. He said there was not really a delay. They all jumped in. Staff G, RN, came down with EMS. The CNA returned from lunch break and found Resident #1 unresponsive. It was approximately 4:10 a.m. No code sheet was completed. The CNA called for help to her hall partner. Staff G, RN, and Staff J, CNA, ran to the room. Staff G, RN, ran to the desk and paged code blue. She left the aide in the room. Staff G, RN, should have remained in the room. The interview between the Administrator, DON, and Staff G, RN, got heated because Staff G, RN, didn't stay with the resident instead of the aide. She should have sent the aide to get help. Resident #1 was full code. The family was trying to get her to agree to hospice and she wanted to be a full code. Staff G, RN, said she was on the phone making calls and wanted to be sure she was a full code. The nurse left the resident with two aides to call the code. The code was called less than 30 seconds. Within 10 seconds, staff were in the room to do CPR. They expected Staff G, RN, to stay in the room. Aides can do CPR if they are CPR certified. Staff E, CNA, stated she didn't initiate CPR because she was not aware of her code status. Staff G, RN, called Staff P, Nurse Practitioner, to inform her that Resident #1 coded. When she asked what the time of death was, and nurse stated she had not expired yet and Staff P, Nurse Practitioner asked why she on the phone with her and not assisting the resident. Staff G, RN, stated she knew Staff E, CNA, could do CPR so she went to call the code blue. After Staff G's, RN, interview on 04/25, the DON informed her that she spoke with Staff O, LPN, and there was a concern of a delay. They contacted regionals and decided to report neglect and delay in initiating CPR. The nurse should direct the code, call code blue, aides should be the runners. On [DATE] at 1:53 p.m., the DON stated 80% of nurses were not CPR certified in the facility. She stated Staff G, RN, did not initiate CPR timely, saying Resident #1 stated she didn't want to be hospice and wanted to be full code a few days ago. The nurse went to the room and said you're right she's not breathing and left to call the code. Why didn't she send the CNAs to call the code? What happened was neglect. The DON continued The nurse left her patient. The nurse didn't deny any of the things that happened. The nurse asked what's the difference between and RN and CNA initiating CPR. She didn't instruct the CNA to initiate CPR. The nurse walked into the room and didn't initiate CPR. There was a time delay by her leaving the patient. She walked past two phones in the hallway on the way to the nursing station and couldn't work the phone at the desk. The DON stated the immediate report submitted to the agency was inaccurate. It was neglect. Staff G, RN, didn't instruct anyone to do anything. Resident #1 was a retired nurse who said she wanted to live a couple days ago. The CNA that stayed in the room was CPR certified. The DON reported she had written people up about not being in the room during CPR in the past. The DON said Staff E, CNA, stated Staff G, RN, never came back to the room. She only stated let her make some calls and left the room. Staff E, CNA, stated she didn't know Resident #1 was a full code. Why didn't the CNA initiate CPR? You can't get to the desk in three to five seconds. Staff G, RN, was on the phone with the nurse practitioner and calling the family while CPR was being done. The nurse said there was nothing wrong with this. They DON stated they need to get the CPR certified nurses and spread them out in the building. The DON stated There's a nurse working in the facility that had not been CPR certified since 2019. She stated Corporate and the Administrator stated staff does not have to be CPR certified. On [DATE] at 1:01 p.m., Staff P, Nurse Practitioner, stated around 4:30 in the morning she received a call from Staff G, RN, stating that Resident #1 was coding and EMS was coming. She asked if she wanted her to call the family and said paramedics had yet to arrive. Told her to hang up and all hands-on deck to assist with the code. After that, the paramedics arrived. The next day, Staff P, Nurse Practitioner told the DON that they need to implement the process of the code and to stay with the patient until the patient was moved to the Emergency Room. She never had anyone to call her in the middle of the code and especially about calling the family. Normally the rule was you stay with the patient until 911 arrived or paramedics show up and then you call the family. Staff G, RN, said the code was running while she was talking to her. Staff P, Nurse Practitioner stated she told Staff G, RN, that she was the primary care nurse and would have the most information about the resident to inform the paramedics. She told her to hang up the phone and go back over there. She should have initiated CPR. Staff P, Nurse Practitioner, stated she does not know how long it took to get to point A or B, but it was no longer than thirty seconds. Staff G, RN, called her after she called 911. She didn't know if an extra 30 seconds to a minute would revive her. Resident #1 was not eating and refusing meds. She stated she heard about two aides in the room after the fact. The staff need more education. CPR should have been initiated that second. On [DATE] at 12:55 p.m., the Administrator stated she was notified about the possible delay on 04/14. The information about the delay was reported to the DON on 04/14. and the day one report was done on 04/25. The Immediate Report was completed on [DATE]. The Five-Day Report was reported to the Abuse Registry on [DATE], Department of Children and Families on [DATE], and law enforcement on [DATE]. The Patient Protection Abuse, Neglect, Mistreatment, and Misappropriation Prevention policy dated 10/2021 provided by the facility revealed the following: Reporting Allegations of Abuse In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. 4. Report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to perform adequate assessments for worsening pressure ulcers for one of three sampled residents (#2). Findings included: Resident #2 was admitted on [DATE] and discharged on 03/30/2023. Review of the admission showed diagnoses included but were not limited to wedge compression fracture of the third lumbar vertebrae, dementia, hypertension, weakness, neuromuscular dysfunction of the bladder, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 6 or severe impairment. Section G showed she required extensive assistance of two for bed mobility and transfers. She had a stage I pressure ulcer and 1 venous and arterial ulcers. Record review of the physician orders showed: Prosource 30 ml (milliliters) daily for a supplement; House shake twice a day; wound care appointment on 03/27/23; Left dorsal foot care: cleanse with normal saline, apply Prisma collagen, cover with foam dressing every Monday, Wednesday and Friday as of 03/29 Left ischial wound care: apply Dakin's wet to dry dressing daily as of 03/27 Right heel wound care: cleanse with normal saline, apply Santyl ointment to wound bed, apply wet to dry gauze dressing daily as of 03/27 Left lower buttock / gluteal fold wound care: apply Dakin's wet to dry dressing daily as of 03/27 Resident to stay in bed on air loss pressure mattress as of 03/27 Reposition resident side to side as of 03/27 Prevalon boots on at all times as of 03/27 Do not place resident in wheelchair as of 03/27 Place resident on back for meals and medication administration. Then reposition pt [patient] on her side for offloading purposes as of 03/27 Doxycline hyclate 100 mg (milligrams) every 12 hours for cellulitis of right ankle for 7 days as of 03/21 Record review of the Progress notes showed: On 02/21/23, a stage II wound to the sacrum area. It was 1.0 x 0.5 cm (centimeters) with scant drainage, pink surrounding tissue, and wound bed. Treatment was in place. Resident had an air mattress. Boots were worn while in bed. She was receiving protein shakes and prosource. On 03/01 Weekly Wound Rounds performed: stage II ulcer to the sacrum 1.5 cm x 0.5 cm, 70% slough and 30% granulation. Pressure Ulcer Healing Chart (Push) score of 7. The right heel wound showed a deep tissue injury (DTI) measuring 2.2 cm x 1.0 cm. The wound bed has 90% slough and 10% granulation. The surrounding tissue was macerated. Had a Push score of 9. On 03/01 the treatment was changed to the right heel. Cleanse with normal saline and apply triple antibiotic ointment and cover. On 03/06, the treatment to the right heel was changed to medi-honey. On 03/08, Weekly Wound Rounds performed: Stage II to sacrum of 1.0 cm x 0.5 cm. Push score was 4. Right heel DTI 2.0 cm x 1.5 cm. The wound had 75% granulation and 25% slough. Maceration was present. The Push score was 10. On 03/15, Weekly Wound Rounds performed: Sacrum 1.5 cm x 1.5 cm. PUSH score of 7. Right heel DTI 2.0 cm x 1.5 cm. Copious amount of drainage from wound bed with 75% granulation and 25% slough. Maceration present. A Push score of 13. On 03/20 a wound appointment was scheduled for 03/27 with the Wound Care Center. On 03/21, the provider was made aware of redness to the right ankle and odor to open area on heel. New orders for wound culture and Doxycycline 100 every 12 x 7 days. On 03/22 Weekly Wound Rounds performed: Sacrum area 6.5 cm x 2.5 cm copious amounts of drainage. The wound bed was 100% granulation and pink and surrounding tissue. The Push score was 14. Right heel DTI measuring 3.0 x 3.0 with copious amount of drainage from the wound bed with 50% granulation and 50% slough. Maceration present. The Push score was 13. On 03/27 received all new orders from the wound care center. On 03/29 Weekly Wound Rounds performed: Sacrum measure 6.2 cm x 3 cm x 1.8 cm with 75% necrosis and 25% slough to wound bed. Moderate amount of drainage. Push score of 15. Pressure wound to the right heel 1.3 cm x 1.2 cm, with scant amount of exudate and with 50% slough and 50% necrosis. Push score of 9. Pressure wound to left dorsal foot measures 1.0 cm x 1. cm with no drainage. Push score of 5. Pressure wound to left ischium 2.2 cm x 3 cm x 2.9 cm with 50 % slough and 50% granulation, with moderate amount of exudate and a PUSH score of 12. She was seen by the wound care center. Impaired mobility and incontinence which may contribute to further skin breakdown. On an air mattress and is repositioned side to side except for meals and meds. Not up in wheelchair. Record review of the care plans showed resident had a pressure ulcer to sacrum area related to immobility. Interventions included administering treatment per physician orders, pressure redistributing support surface and repositioning during ADLs. Right heel pressure area care plan related to diabetes, impaired mobility, vascular disease. Interventions included administering treatment per physician orders, elevating heels as able, pressure reducing surface on bed /wheelchair, use pillow and /or positioning devices as needed. Right ankle wound care plan showed interventions included treatment per physician orders, elevate heels as able, follow up care with physician as ordered, report evidence of infection to physician as needed. Resident had pressure ulcers on left dorsal foot. Interventions included administering treatment per physician orders and pressure redistributing support surface. Resident had a pressure ulcer to left ischium care plan. Interventions include administer treatment per physician orders, daily body audit, dietary consult, incontinence management, pressure redistributing support surface, repositioning during ADLs, skin barrier. An interview on 05/01/23 at 12:04 p.m. with Staff H, Registered Nurse (RN) and Staff F, RN, both Unit Managers. They stated that Resident #2 had a pressure ulcer discovered on 02/21. On 03/01 they stated they changed the wound care order due to slough being present. Staff H and Staff F stated they used the wound care guidelines provided by corporate and then reported to the ARNP regarding the resident's wound, wound orders and change in wound care orders. The resident was on protein and wore boots. Staff F, RN stated that she was not a wound care nurse and documented it to the best of her ability. Staff F stated the coccyx wound did get worse and she did not increase the staging. They stated that they did know the pressure ulcers were getting worse and the family knew it was getting worse. That was why they got an order to see a wound care doctor at the wound care clinic (WCC). The resident needed to be seen by a wound care doctor. She was seen by the WCC due to the facility not having a wound care doctor in-house. They stated that they did not have a big enough census to have a wound care nurse according to corporate. Staff H stated that she had called the WCC about the Prism order. Staff H stated that she only called about the dressings, she did not go and look at the wounds. They stated that the dorsal wound was discovered on 03/22. The nurses should have described the dorsal wound between 03/22 and the wound care center visit of 03/27. It should have been documented in the notes. They confirmed that the left dorsal wound was described on 3/29 in the PUSH report. Staff F and Staff H stated that there was no communication found regarding the increase in size of the coccyx wound from 03/15 and 03/22 in the progress notes. When it was noted that the resident's PUSH number went up, and it was not getting better and getting worse, she was sent to the WCC. They based the treatment of the wounds on the protocols they were provided from corporate. Dakin's was not on the wound protocol; it was not an option for them to use on the resident. They both stated that they had no formal wound care training, just following the protocols. The resident was on an antibiotic. Interview on 05/03/23 at 12:36 p.m. with the Director of Nursing (DON) regarding wound care. She stated that upon admission they do two skin assessments. The Unit Managers (UM) are notified of any new wounds coming in. The UM goes in and measures the wounds. They are the only ones who do measurements, so the wounds will not be off. If the UMs feel the need to send the residents out to WCC they will get an order. If the resident was admitted with a stage 2 or above pressure ulcer, they will get an order to send out for evaluation. If the pressure ulcer was acquired in the facility and was not getting any better, they will send them out for wound evaluation. She stated that about a month ago they had a wound manufacturing company come in and give an in-service for about 2 hours. She stated that they did have a wound care nurse but removed her from the position. The UMs are monitoring the wounds, doing wound rounds, and measurements. She stated that they just hired a new wound nurse to replace the old one. The wound nurse will perform the wound care Monday through Friday and the floor nurses will on the weekends. If the wound gets worse, they are to let the UMs know and contact the MD and see the wound. They are to get an order for the WCC as needed. She stated that they do not have a wound care doctor here. The DON stated that the UMs nor the wound care nurse are certified. We have staging material that can describe it and the WCC will stage the wound. The nurse should have let the UM know about an increase in wound size. The DON verified there was no documentation that the nurses had let the UMs know there was an increase in wound size for Resident #2 between 03/15 and 03/22. There was a lack of documentation. There should have been documentation. Record review of the facility's, Skin Quick Reference, dated 02/2022 showed documenting skin: on admission / readmission -document history and risk. Second skin check within 24 hours of admission on the progress note. New pressure injury develops after admission document on incident report, Braden, PUSH took, Pressure ulcer UDs, progress note, treatment orders, eTAR, care plan. New skin alterations develop after admission document on incident report, skin alteration record, treatment orders, eTAR, care plan. Weekly wound Rounds document on PUSH tool, Pressure Ulcer Weekly Note, eTAR, care plan. Role of the Nurse: complete documentation requirements as above. Components of wound Evaluation: location, wound etiology, measurements, state, wound bed, wound edges/border, per-wound appearance, tunneling, undermining, exudate, signs/symptoms of infection, pain, odor, wound status, signs /symptoms of healing, response to treatment, goal of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to have systems in place supported by policies and procedures to ensure there was an adequate number of staff present at all times who were properly trained and/or certified in CPR (Cardiopulmonary Resuscitation) for Healthcare Providers to be able to provide CPR until emergency medical services arrive and failed to document the code event and interventions associated with the code on the code form per policies and procedures for three of the three sampled residents. Findings included: A review of the admission Record Report for Resident #1 showed she was admitted into the facility on [DATE] with a diagnosis that included but was not limited to unspecified dementia. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A review of the Order Summary Report with active orders as of [DATE] revealed the following order: Full Code (04 13/21). Progress Notes revealed the following note: [DATE] at 04:38- Certified Nursing Assistant (CNA) returned from 30-minute break and alerted nursing staff that resident was not breathing. Nursing assesses, code blue called, and CPR was initiated. Provider made aware. 911 arrived and resident was pronounced expired at 4:42 a.m. by Emergency Medical Services (EMS). Family was called and informed that the resident expired. A code form was not completed for this event. A review of the care plans did not reveal a care plan related to code status. A review of the admission Record Report for Resident #2 revealed she was admitted into the facility on [DATE] with a primary diagnosis of wedge compression fracture. Section C Cognitive Patterns of the quarterly MDS dated [DATE] indicated the resident had a BIMS score of 06 out of 15 indicating severe impairment. A review of the Order Summary Report with active orders as of [DATE] revealed the following order: Full Code ([DATE]). Progress Notes revealed the following note: [DATE] at 23:41- At 1720 during the middle of passing medications, a CNA called about the patient bleeding from the mouth. The patient was bloody and unresponsive. Called for help. Staff performed CPR and 911 was called. EMS arrived at 1730 and took the patient out at 1740. The physician, family, and the Director of Nursing (DON) were notified. A code form was not completed for this event. A review of the care plans did not reveal a care plan related to code status. On [DATE] at 2;57 p.m. Staff A, CNA, stated she was taking the linen out of the other resident's room and looked in rooms as she was walking by and saw blood all over Resident #2. Called for the nurse. She was bleeding and not looking good. The nurse checked her and sent her to get the AED and they put the AED pads on her. They did CPR and waited for the AED to kick in. EMS came and took her away. She had their machine on and it was doing compression when EMS took her out. She was not CPR certified. Another nurse took over CPR until EMS came. Staff A, CNA, stated she helped with the CPR but did not have a certification, it expired two years ago. A review of the admission Record Report for Resident #3 revealed the resident was admitted into the facility on [DATE] with a diagnosis that included but was not limited to hypertension. Section C Cognitive Patterns of the 5 Day MDS dated [DATE] showed Resident #3 had a BIMS score of 06 out of 15 indicating severe impairment. A review of the Order Summary Report with active orders as of [DATE] revealed the following order: Full Code ([DATE]). Progress Notes showed: [DATE] at 0415- Resident found without pulses or respirations. Code paged. Automated External Defibrillator (AED) applied and CPR started. [DATE] at 0425- 911 here and resident evaluated. Code called off. A code form was not completed for this event. A review of the care plans did not reveal a care plan related to code status. An Inservice/Training Sign in Form dated [DATE] showed a training topic of documentation. Eleven staff signatures were verified on this form. Documentation provided by the facility showed only eighteen out of a total of twenty- six nurses had a CPR certification. Documentation provided by the facility showed only eight out of a total of fifty-three CNAs had a CPR certification. On [DATE] at 1:20 p.m., the Administrator reported on 4/14 she received a call from the Director of Nursing (DON) concerned that she heard from the nurse practitioner that she spoke to Staff G, Registered Nurse (RN), and was concerned that she didn't remain with her patient during the code process. After that, she called Staff G, RN, to suspend her pending investigation as to why she didn't remain with the patient. Staff G, RN, was supposed to meet with the Administrator and the DON on the following Monday or Tuesday, but she had a family emergency, and couldn't come in to meet until the 24th. When she came in on the 24th, they started the interview process and couldn't complete the interview as Staff G, RN, was upset and left the building. Sometimes the question can seem pointed. She and the DON were getting loud, and it was getting heated. The Administrator stated she excused the DON and the nurse stated she was not going to complete the interview process. Staff G, RN, had emailed regarding a complaint about the DON but not in response to completing the interview. The DON began to interview other staff. She came back with reports from staff that indicated there was a five-minute delay in giving CPR to Resident #1. The DON did not have a witness when she conducted her interviews and there should always be a witness, stated the Administrator. With that concern and delay for initiating treatment, a one-day neglect report was completed for the potential delay in initiating CPR. The Department of Children and Families (DCF) and law enforcement were contacted. The family was also notified of the investigation. Interviews were completed by the DON, and she provided information that there was a concern coming from Staff O, Licensed Practical Nurse (LPN), related to a delay in providing CPR. When the Administrator interviewed Staff O, LPN, there were no concerns. Staff O, LPN, stated he went to go to the bathroom in the breakroom and on his way back he was near the conference room door and heard code blue paged three times. They said 400 hall and he grabbed the crash cart and Staff M, RN, asked if he had the Automated External Defibrillator (AED), he said no she grabbed it and followed him down the hall. He went in the room and visually Resident #1 wasn't breathing, touched her wrist, she appeared warm, and no pulse. He opened the crash cart and set up the Ambu bag. Staff R, LPN, was on the left and Staff N, Certified Nursing Assistant (CNA), was on the right putting the board under her. Staff M, RN, opened the AED. As soon as he got air in the Ambu bag, he gave it to Staff R, LPN, and initiated compressions. After 2 sets they followed the AED directions and continued compressions until Emergency Medical Services (EMS) came. Staff responded immediately less than 30 seconds. They all worked together and did what they had to do. He said there was not really a delay. They all jumped in. Staff G, RN, came down with EMS. The CNA returned from lunch break and found Resident #1 unresponsive. It was approximately 4:10 a.m. No code sheet was completed. The CNA called for help to her hall partner. Staff G, RN, and Staff J, CNA, ran to the room. Staff G, RN, ran to the desk and paged code blue. She left the aide in the room. Staff G, RN, should have remained in the room. The interview between the Administrator, DON, and Staff G, RN, got heated because Staff G, RN, didn't stay with the resident instead of the aide. She should have sent the aide to get help. Resident #1 was full code. The family was trying to get her to agree to hospice and she wanted to be a full code. Staff G, RN, said she was on the phone making calls and wanted to be sure she was a full code. The nurse left the resident with two aides to call the code. The code was called less than 30 seconds. Within 10 seconds, staff were in the room to do CPR. They expected Staff G, RN, to stay in the room. Aides can do CPR if they are CPR certified. Staff E, CNA, stated she didn't initiate CPR because she was not aware of her code status. Staff G, RN, called Staff P, Nurse Practitioner, to inform her that Resident #1 coded. When she asked what the time of death was, and nurse stated she had not expired yet and Staff P, Nurse Practitioner asked why she on the phone with her and not assisting the resident. Staff G, RN, stated she knew Staff E, CNA, could do CPR so she went to call the code blue. After Staff G's, RN, interview on 04/25, the DON informed her that she spoke with Staff O, LPN, and there was a concern of a delay. They contacted regionals and decided to report neglect and delay in initiating CPR. The nurse should direct the code, call code blue, aides should be the runners. On [DATE] at 1:53 p.m., the DON stated 80% of nurses were not CPR certified in the facility. She stated Staff G, RN, did not initiate CPR timely. Resident #1 stated she didn't want to be hospice and wanted to be full code a few days ago. The nurse went to the room and said you're right she's not breathing and left to call the code. Why didn't she send the CNAs to call the code? What happened was neglect stated the DON. The nurse left her patient. The nurse didn't deny any of the things that happened. The nurse asked what's the difference between and RN and CNA initiating CPR. She didn't instruct the CNA to initiate CPR. The nurse walked into the room and didn't initiate CPR. There was a time delay by her leaving the patient. She walked past two phones in the hallway on the way to the nursing station and couldn't work the phone at the desk. The DON stated the immediate report submitted to the agency was inaccurate. It was neglect. Staff G, RN, didn't instruct anyone to do anything. Resident #1 was a retired nurse who said she wanted to live a couple days ago. The CNA that stayed in the room was CPR certified. The DON reported she had written people up about not being in the room during CPR in the past. Staff E, CNA, stated Staff G, RN, never came back to the room. She only stated let her make some calls and left the room. Staff E, CNA, stated she didn't know Resident #1 was a full code. Why didn't the CNA initiate CPR? You can't get to the desk in three to five seconds. Staff G, RN, was on the phone with the nurse practitioner and calling the family while CPR was being done. The nurse said there was nothing wrong with this. They DON stated they need to get the CPR certified nurses and spread them out in the building. There's a nurse working in the facility that had not been CPR certified since 2019 from her audits. She stated Corporate and the Administrator stated staff does not have to be CPR certified. On [DATE] at 10:38 a.m., Staff D, Staffing Coordinator, stated the scheduling was based off the census. Aides were 2.05 and nurses were 1.2. All staff have a set schedule and it rotates every two weeks unless they are PRN (as needed). They all rotate weekends and work every other weekend. The master schedule rotates every two weeks. She fills in with PRN when staff wants a day off. If there's a hole in the schedule, they use the PRN schedule. She schedules based on discipline and how many she needs per hallway. Does not know which staff were CPR certified. No one ever asked her to look at it. She could have staff on the schedule and none of them could be CPR certified because that was something she did not look at. On [DATE] at 1:21 p.m., the DON stated there was no other documentation but the two statements by the nurse on the code in the progress notes. She stated that the staff did not do a code sheet. She stated the Administrator told her they did not have to do one (code sheet). She did a documentation in-service on [DATE] regarding documentation in general. On [DATE] at 12:47 p.m., the DON stated she had been doing code drills, but had no idea that she was doing drills with were noncertified staff. She look it up and the board of nursing says if you are a CNA, LPN, or RN you have to have a CPR certification. On [DATE] at 12:50 p.m., the Administrator stated they did not have a system in place related to sufficient staff to ensure there was staff in the building that were CPR certified prior to the incident with Resident #1. She went through the two-week schedule and highlighted to make sure they had at least one staff on each side of the building moving forward. They are going to be tracking. Wanted to make sure there was at least one person on each side of the building. They would only have one nurse to do a code. The Administrator stated she had never done a code and didn't know that it could require more than one staff member. On [DATE] at 12:53 p.m., the DON stated 100% of staff should be certified. She was trying to lessen the risk to make sure they had sufficient staff. The DON stated the documentation related to code had always been on the code form. The form had not been completed not one time. The code form should be part of the chart. She had a code the second week she worked in the facility and only two people showed they were strong with doing a code. She was unaware that a lot of the staff were not CPR certified. Seen that it was weak during the code drills but didn't know why. The Job Description for the charge nurse, LPN/staff nurse, LPN provided by the facility revised 01/16 revealed the following: Special Nursing Care Responsibilities-Based on State Nurse Practice Act Emergency procedures: properly administer oxygen, suctions, performs CPR, and uses the ambu bag. The policy provided by the facility Code Management revised [DATE] revealed the following: Critical Notes: Licensed staff are responsible for following applicable state laws, practice acts, administrative codes, declaratory statements and/or other guidance issued by their state licensing board; as well as, applicable ProMedica Senior Care policy, to assist them in exercising professional judgement, and determining whether the performance of a procedure is within their score of practice and appropriate for the location of patient/resident care services. Each staff member is responsible for complying with the standard of care applicable to their practice. Introduction Ideally, the code team should consist of health care workers trained in advanced cardiac life support (ACLS), although health care workers trained in basic life support (BLS). Implementation An ACLS trained nurse acts as the code leader until the practitioner arrives. Meanwhile, another code team member should document events and treatment. Documentation Documentation associated with code management involves adding to the code form the events and interventions in as much detail as possible, including: whether someone witnessed the arrest or that no one witnessed it time of the arrest time CPR began time the code team arrived and their names total resuscitation time number of defibrillations times they were performed energy dose patient's cardiac rhythm before and after defibrillation presence or absence of a pulse procedures o time of the procedure o patient's tolerance of the procedure time of death pronounced The policy provided by the facility Emergency Management dated 06/2021 revealed the following: Purpose: To provide guidelines for documentation after the provision of emergency services to a resident. To establish a process defining roles and responsibilities of caregivers involved in the care of a resident in an emergent situation. Documentation of Emergency Services Provided: Document the following in a progress note after a resident emergency event: o Resident status o Time medical emergency was identified, and type of emergency care initiated o Evaluation of resident's level of consciousness, circulation, airway and breathing o Verification of resident's code status o Occurrence and time the CPR was started, if applicable o Time and person contacting EMS o Step by step description of care provided: initiation of CPR (if applicable), AED use (If applicable), vital sign check and results, suctioning (if applicable) o Physician notification, response received, orders obtained o Family notification, response received o EMS arrival and transfer of care o Time and resident status upon transfer from community o Any additional applicable information Emergency Response Guidelines: Documentation of actions taken, notifications made, and other relevant information identified is documented in progress notes by the licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to ensure that the electronic medical record accurately reflected resuscitative code status and failed to obtain physician's orders for resuscitative code status for two (Resident #40 and Resident #195) of 40 sampled residents. Findings included: A review of Resident #40's Medical Record revealed that Resident #40 was admitted to the facility on [DATE] with diagnoses of Hypertension, End Stage Renal Disease, and Dependence on Renal Dialysis. A review of Resident #40's Physician's Orders did not reveal an order related to resuscitative code status. A review of Resident #40's Care Plan did not reveal information related to resuscitative code status. A review of Resident #40's Electronic Medical Record (EMR) revealed, under the section titled Code Status, no resuscitative code status information. An interview was conducted on 08/25/2021 at 07:39 AM with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN stated that residents who had a code status of Do Not Resuscitate (DNR) would have paperwork in their chart. If a resident had a status of Full Code, then the resident would not have any paperwork in the chart. Staff F, LPN stated that a physician's order did not need to be in the resident's chart if they had a code status of Full Code. When a resident's profile was pulled up in the EMR, it would display the resident's code status information under the Code Status section. Staff F, LPN addressed that Resident #40 did not have any information documented in the EMR related to code status and stated that she would expect to see the status documented in the EMR. Staff F, LPN was not able to state who entered in the code status information in the EMR. A review of the facility policy titled Social Services Guidelines, dated August of 2021, revealed under the section titled Code Status, that the resident's code status is established at the time of admission/re-admission through a physician's order. The code status order is entered into the EMR by nursing using the Advance Directives Template. Once entered into the EMR, it appears in the header of the electronically generated documents and is visible in the resident's [NAME]. 2. A review of the admission Record Report indicated that Resident #195 was admitted into the facility on [DATE] with a primary diagnosis of acute kidney failure. A review of the banner on the electronic medical record, indicated that the section for code status was blank. A review of the Order Summary Report with active orders as of 08/25/2021 reflected that there was no order for code status. A review of the care plans for Resident #195 did not reflect a care plan related to code status. On 08/24/21 at 4:06 p.m., Staff R, Registered Nurse (RN) Supervisor, stated she would look at the banner and in the orders to find the code status. Staff R stated that Resident #195 was a full code and that she knows because he was on her assigned hall. Staff R viewed Resident #195's electronic medical record and stated that because nothing was listed on the banner for the code status, that means he was full code. On 08/25/21 at 9:23 a.m., Staff E, Licensed Practical Nurse (LPN) Supervisor, stated the code status would be on the banner of the electronic chart. Staff E stated she could show me where to find the code status and that she would pull up a random resident. The code status was observed on the random resident's electronic chart. When asked to look up the code status for Resident #195, Staff E stated, Oh I see what you mean, I'll get the hard chart and add it now. On 08/25/21 at 9:39 a.m., the Director of Nursing (DON) stated that residents should have an order for the code status, and the code status should be listed on the banner of the electronic record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure air conditioning units were maintained in a sanitary manner for 3 out of 4 days of survey (08/22/21, 08/23/21 and 08/24/21) in 10 out of 14 resident rooms in hall 200 (200, 201, 202, 203, 207, 208, 209, 210, 211 and 213) Findings included: During a facility tour on 08/22/21 between 10:13 a.m. and 12:32 p.m., air conditioning unit filters were observed with dirt, debris, and bio growth in resident rooms in hall 200. The filters were noted fully clogged with visible dark ashy-looking material in rooms 200, 201, 202, 203, 207, 208,209, 210, 211 and 213. room [ROOM NUMBER]'s unit was observed with bio-growth. room [ROOM NUMBER]'s unit was observed with a towel placed underneath the unit to collect the water leaking from the air-conditioner. The observations were made on 3 of the 4 days of survey. Photographic evidence was obtained. On 08/22/21 12:10 p.m., an interview was conducted with the housekeeping supervisor (HS). The HS stated that his department maintained all the rooms in the facility including the cleanliness of the equipment in the rooms. He stated that CNAs (certified nurses' aides) clean personal care equipment and housekeeping cleans everything else in the rooms. On 08/24/21 09:19 a.m., a tour of hall 200 was conducted with the HS. He stated that when it comes to maintaining the air-conditioning units, housekeeping and maintenance department split the task. When asked how often the units are inspected, HS stated that they recently swapped all the filters to washable ones, so that they can easily care for them. When asked when the air conditioning filters are cleaned, HS said, When I do the rooms I always check. The HS stated that he had checked filters the end of last month. During the walk through of hall 200, the HS observed filters in 10 out of 14 rooms and said, this is definitely not how they should look, we should clean more than that. The HS observed the unit in room [ROOM NUMBER] with bio-growth and said, it should not look like that. It's because of condensation. HS stated they should probably clean more than once a month. HS was asked for a copy of the facility's policy on air conditioning maintenance. On 08/24/21 09:33 a.m., an interview was conducted with director of nursing (DON) who was shown the photographic evidence of air conditioning filters in hall 200. The DON stated that this is not what they should look like, thank you for letting me know. When asked what the expectation of maintaining air conditioning filters was, DON said, it is our expectation that the filters should be maintained in a sanitary manner. Residents should definitely not be breathing through that. On 08/25/21 10:26 a.m. an interview was conducted with the HS. He stated that they did not have a policy in place but that he would increase the cleaning to at least monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to follow-up on recommendation from the registered dietitian for one resident (#37) out of 7 sampled residents reviewed for unplanned weight loss. Findings included: A review of the admissions record revealed that Resident #37 was admitted to the facility on [DATE], with diagnoses including unspecified dementia without behavioral disturbances, Parkinson disease, dysphagia, oropharyngeal phase, and other symptoms and signs concerning food and fluid intake. A review the Quarterly Minimum Data Assessment (MDS) dated [DATE] documented in Section G, Functional Status, indicated that the resident needed supervision while eating. Further review of Section K, Swallowing/Nutritional Status, revealed that Resident #37 had unplanned weight loss. A review of Resident #37's care plan dated 3/23/21 revealed a focus area of: Resident # 37 is at risk for alteration in nutritional status r/t (related to) Parkinson, dysphagia. Need for therapeutic diet . Interventions included: Encourage and assist as needed to consume foods and/or supplements and fluids. A review of the Registered Dietitian (RD) note dated 7/16/21 revealed: Resident continues to lose weight this week. Sig. wt. loss of 11.2% X 30 days, -17% X90; -15.8% <180 days (Significant weight loss of 11.2% in 30 days, -17% in 90 days and -15.8% in less than180 days). Further review of the Registered Dietitian (RD) notes titled Nutrition/Weight dated 8/23/21, revealed recommendation for ProSource 30 ml BID (30 milliliter two times daily). On 8/25/2021 review of Resident #37's physician orders and medication administration record (MAR) did not reveal documentation or administration of ProSource 30 ml BID as recommended by the RD. On 08/25/2021 at 09:56 a.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN). She stated that the order for ProSource should have been recorded on Resident # 37's physician order and on her medication administration record (MAR). Staff G reviewed Resident #37's MAR and confirmed that recommendation for ProSource was not recorded in the physicians order nor in the resident MAR. Staff G stated that she does not know who carries out the RD's recommendations. She stated that there was an alert in the Resident's medication administration record indicating that recommendation for ProSource is in a queue. On 08/25/21 at 10:03 a.m., during an interview the DON stated that the RD's recommendations are inputted into resident's Electronic Medical Records (EMR) by the registered dietician. She stated that the input will appear in the resident's electronic medical record (EMR), and nurses on each shift, usually identified recommendations triggered in the EMR, and notify the resident's Primary Care Physician (PCC) if necessary and carry out the recommendation. She stated that it is her expectation that recommendations are carried out within 24 hours. She stated that nurses are educated on checking and following through with recommendations queued in the residents' EMR. On 08/25/21 at 10:59 a.m., during a telephone interview with the RD, she confirmed writing the recommendation for ProSource 30 ml BID, and inputted it in Resident #29's EMR on 8/23/21. She stated that she would have expected the recommendation to be carried out as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide intravenous (IV) fluid therapy in accordance with professional standards of practice for one (Resident #248) of one resident receiving intravenous fluid therapy in the facility. Findings included: A review of Resident #248's Medical Record revealed that Resident #248 was admitted to the facility on [DATE] with a diagnosis of Cellulitis of Right Lower Limb. A review of Resident #248's Care Plan revealed a problem, revised on 08/06/2021, that Resident #248 had cellulitis of the right lower extremity. Interventions included to administer medications as ordered, obtain lab work as ordered, diagnostic tests as ordered, and record temperature as clinically indicated. Resident #248's Care Plan also revealed a problem, revised on 08/24/2021, that Resident #248 had potential complications at the IV insertion site, with an intervention to change IV tubing per physician orders. A review of Resident #248's Physician's Orders revealed the following orders: - An order, dated 08/05/2021, to change the needleless device for central line/midline every week and as needed. - An order, dated 08/05/2021, to flush the IV line with 5 milliliters (ml) of normal saline before and after medication administration. - An order, dated 08/15/2021, to place a new green curros cap on the IV port after infusion is complete. - An order, dated 08/05/2021, for Cefepime Hydrochloride (HCl) solution 2 grams (g) per 100 ml IV every 12 hours for left foot cellulitis for six weeks. - An order, dated 08/05/2021, for Vancomycin HCl Solution Reconstituted 1.5 g IV every 12 hours for wound infection for six weeks. Resident #248's Physician's Orders did not reveal an order related to changing of the IV dressing site or frequency of IV tubing changes. A review of Resident #248's Minimum Data Set (MDS) Assessment revealed under Section C - Cognitive Patterns, a BIMS score of 13, which indicated intact cognition. Resident #248's MDS Assessment also revealed, under Section O - Special Treatments, Procedures, and Programs, that Resident #248 received IV medications before admission to the facility and while he was a resident at the facility. An observation was conducted on 08/22/2021 at 02:46 PM of Resident #248's peripherally inserted central catheter (PICC) site. The dressing of the PICC site, located in Resident #248's upper arm area, was observed to be dated 08/05/2021. Resident #248 stated that the PICC dressing had not been changed by the nursing staff at the facility since his admission on [DATE]. An observation of Resident #248's IV line tubing did not reveal a date labeled on the tubing. An observation was conducted on 08/24/21 at 10:00 AM in Resident #248's room. An observation of Resident #248's IV line tubing did not reveal a date labeled on the tubing. Resident #248 stated that the nursing staff normally changes the IV tubing out every 2 or 3 days but was not able to state when the nursing staff last changed the IV tubing. An interview was conducted on 08/25/2021 at 07:57 AM with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN stated that the Registered Nurses (RN) were the only ones that changed PICC line dressings in the facility and that residents should have a physician's order related to the dressing change and frequency. Staff F, LPN stated that IV tubing sets were good for 24 hours and that it would normally be dated with the date that it was changed. Staff F, LPN stated that she conducted an assessment of Resident #248's IV site every shift but she did not notice that the PICC dressing was dated 08/05/2021. Staff F, LPN also stated that sometimes she would date the IV tubing using tape and would sometimes write directly on the IV tubing but it would wear off over time. An interview was conducted on 08/25/2021 at 4:41 PM with the facility's Director of Nursing (DON). The DON stated that dressings for PICC lines should be completed by an RN in accordance with physician's orders. The DON addressed that Resident #248 did not have a physician's order related to dressing changes for his PICC line and stated that the dressing should have been changed sooner. The DON stated dressing changes should be in accordance with the physician's order. The DON stated that IV tubing should be changed every 24 hours and that it should have the date when it was changed labeled. A review of the facility policy titled Intermittent IV Therapy via Programmable Pump, dated January of 2009, revealed under the section titled General Information that administration sets should be changed every 72 hours and that tubing should be labeled with the date, time, and initials of the nurse. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to provide ongoing monitoring for complications before and after dialysis treatments for 1 (Resident #40) of 4 resident receiving dialysis services in the facility. Findings included: A review of Resident #40's Medical Record revealed that Resident #40 was admitted to the facility on [DATE] with diagnoses of COVID-19 and Dependence on Renal Dialysis. A review of Resident #40's Care Plan revealed a problem, revised on 07/02/2021, that Resident #40 had renal insufficiency related to End Stage Renal Disease and presence of a fistula, graft, or catheter. Interventions included to the access site for lack of thrill or bruit, evidence of infection, swelling, or excessive bleeding per facility guidelines and coordinate dialysis care with dialysis treatment center. A review of Resident #40's Physician Orders revealed an order, dated on 07/03/2021 to check Resident #40's arteriovenous (AV) fistula site for thrill and bruit every day shift. Resident #40's Physician Orders also revealed an order, dated on 07/03/2021, for dialysis site observation every day shift. A review of Resident #40's Electronic Treatment Administration Record (ETAR) for July 2021 revealed the following: - No documentation of order, dated on 07/03/2021 to check Resident #40's arteriovenous (AV) fistula site for thrill and bruit every day shift on 07/03, 07/04, 07/06, 07/07, 07/17, or 07/21/2021. - No documentation of order, dated on 07/03/2021, for dialysis site observation every day shift on 07/03, 07/04. 07/06. 07/07. 07/17, or 07/21/2021. A review of Resident #40's ETAR for August 2021 revealed the following: - No documentation of order, dated on 07/03/2021 to check Resident #40's arteriovenous (AV) fistula site for thrill and bruit every day shift on 08/03, 08/05, or 08/18/2021. - No documentation of order, dated on 07/03/2021, for dialysis site observation every day shift on 08/03, 08/05, or 08/18/2021. A review of Resident #40's Dialysis Communication Forms revealed the following: - 07/29/2021: No Dialysis Communication Form from the facility to the dialysis center. No assessment data prior to dialysis treatment. - 08/05/2021: No communication documentation from the dialysis center to the facility. - 08/10/2021: No Dialysis Communication Form from the facility to the dialysis center. No assessment data prior to dialysis treatment. - 08/12/2021: No Dialysis Communication Form from the facility to the dialysis center. No assessment data prior to dialysis treatment. - 08/14/2021: No Dialysis Communication Form from the facility to the dialysis center. No assessment data prior to dialysis treatment. An interview was conducted on 08/25/2021 at 07:39 AM with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN stated that the Dialysis Communication Form was completed by the nurse at the facility upon the resident leaving for dialysis to include assessment of the site and vital signs. The dialysis center would be responsible for filling out the remainder of the form, but they usually just send a print out from the visit to be included with the form. Staff F, LPN stated that no assessment was completed by the facility when the resident returns from the dialysis center after treatment. An interview was conducted on 08/25/2021 at 09:13 AM with the facility's Director of Nursing (DON). The DON stated that the facility nurse was responsible for completing the Dialysis Communication Form prior to the resident leaving for dialysis and that the dialysis center completed the bottom portion of the form. The DON stated that she expected the nurse to go into the resident room and speak with the resident as well as perform an assessment of the dialysis site once the resident returned to the facility. The DON stated that Resident #40 had an order in place for nursing staff to assess the dialysis site daily on day shift but addressed that some days were missing documentation in the ETAR. The DON was not able to state why some of the Dialysis Communication Forms were missing in Resident #40's dialysis communication book. A review of the facility policy titled Dialysis Guidelines, dated in November of 2017, revealed under the section titled Guidelines, that the center staff remains aware and identifies changes in patient behavior, especially for cognitively impaired patients, which may impact the safe administration of dialysis and notifies the attending medical practitioner and dialysis facility of changes. This may require more frequent observations and monitoring of the patient before, during, and after dialysis treatment. The policy also revealed that both the center and the dialysis facility are responsible for shared communication regarding patients receiving dialysis services and that the Hemodialysis Communication Form is to be used.

Based on observations and interviews, the facility failed to ensure that Nurse Staffing Information was posted accurately for two of four days. Findings included: An observation was conducted on 08/22/2021 at 09:35 AM at the front entrance of the facility. A Staff Posting Report, which reports the number of nursing staff assigned in the facility for the day, was observed posted at the front desk and was observed to be dated for 08/20/2021. An interview was conducted following the observation with Staff Y, Receptionist. Staff Y, Receptionist stated that she was not sure who posted updates to the Staff Posting Report and addressed that the posting was dated 08/20/2021. An observation was conducted on 08/24/2021 at 09:22 AM at the front entrance of the facility. A Staff Posting Report was observed posted at the front desk and was observed to have no date and no facility name information. The facility's Director of Nursing (DON) was also at the front entrance during the observation and was interviewed. The DON stated that the Staff Posting Report sheet should be dated for the effective date and should contain the facility name on it. A telephone interview was conducted on 08/25/2021 at 10:03 AM with Staff Z, Staffing Coordinator (SC). Staff Z, SC stated that she was responsible for posting the Staff Posting Report daily to reflect the facility's staffing levels for the day on Monday through Friday. Before leaving on Friday, the anticipated staffing is left at the reception desk to be posted on Saturday and Sunday. Staff Z, SC stated that the receptionist that was assigned over the weekend may not have known to post the Staff Posting Report and stated that the report should have the correct date and that facility name on the sheet. A request was made on 08/24/2021 at 10:20 AM for a facility policy related to the Staff Posting Report to the DON. A facility policy was not provided. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure that the medication error rate was below 5% for one resident (# 5) of four sampled residents who were observed for medication administration. This resulted in two errors from 29 medication administration opportunities for a medication error rate of 6.9%. Findings included: A review of Resident # 5's admissions record revealed that he was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to, chronic obstructive pulmonary disease (COPD), major depressive disorder (MDD), anemia, and type 2 diabetes. A review of the active physician orders dated 08/1/21 revealed the medications ProAir HFA (hydrofluoroalkane) Aerosol Solution 108 (90 base) 1 puff inhale orally every 4 hours for SOB (Shortness of Breath) order date 01/20/21, and an order date of 01/20/2021 for Fish Oil Capsule 1200 mg (milligram) (Omega-3 Fatty Acids) give one capsule by mouth one time a day for supplement. On 08/24/21 at 9:00 a.m., a medication administration observation with Staff E, revealed that Staff E gave two puffs of the handheld inhaler ProAir HFA, and 1000 mg of the Fish Oil Capsule. In an interview with Staff E, she reviewed the medication administration record and confirmed that the correct puff for ProAir HFA was one puff, instead of the 2 puffs given, and the dosage for the Fish Oil Capsule was 1200mg. Staff E stated that she will notify Resident #5's primary care physician, and his responsible party, and complete a documentation related to the medication administration error. On 08/24/21 at 03:25 p.m. during an interview with the pharmacist consultant, he stated that his expectation is that the nurses follow the physician order when administering medications. On 08/24/21 at 03:27 p.m., during an interview with the Director of Nursing (DON), she stated that it is her expectation that nurses follow the 5 or 8 rights of medication administration when administering medications. Review of the facility policy and procedure titled, Medication and Treatment Administration Guidelines. Updated 03/2018. Under the subheading Medication Administration the first bullet point revealed: Medications are administered in accordance with the following rights of medication administrations. Eight checks were revealed including but not limited to the following rights: Right patient, right medication, and right dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility's quality assurance (QA) and assessment committee failed to implement an effective QA program related to: 1) proper deployment of staff in order to provide assistance with Activities of Daily Living (ADL's) to four (Residents #9, #12, #22, #25) of six residents dependent on staff for eating on the 200 hall and one additional resident (#24) who was dependent on staff for an additional food item requested during the 10/26/21 lunch meal, 2) following professional standards of practice for obtaining physician orders related to care and removal of the dressing on the dialysis access site following dialysis treatment for two (#15, #1) of three dialysis residents reviewed, and 3) ensuring behavior monitoring occurred for seven of seven sampled residents reviewed for the use of psychotropic medications (#12, #1, #2, #6, #8, #11, #13). Findings included: 1. Record review of the facility's policy, Quality Assurance and Performance Improvement Practice Guide, dated 01/2019 showed Quality Assurance (QA) is a process of meeting quality standards and assuring that care reaches an acceptable level. QA is a reactive, retrospective effort to look at why there was a system failure. QA activities do improve quality, but efforts frequently end once the compliance or standard has been met. The purpose of QAPI is to take a pro-active approach to continually improve the quality of care we provide, the quality of life our patients experience, the ability to honor patient choices and provide care in the appropriate clinical environment. FOUNDATIONAL ELEMENTS: Root Cause Analysis: Root cause analysis is a problem solving method aimed at identifying primary causes of problems or issues. It is predicated on the belief that issues are best resolved by eliminating or correcting root causes, as opposed to addressing obvious symptoms or popular assumptions. By directing corrective action to the underlying cause, it is likely reoccurrence will be minimized. The administrator is responsible for creating the environment for change, a culture that supports continuous process improvement and facilitating implementation of the QAPI process. 2. Review of the facility's plan of correction for the survey ending 8/25/21 with a completion date of 9/24/21 revealed the following measures would be taken to correct the deficient practice which was identified for concerns with meal tray delivery and call light response: III. Licensed nurses and direct care staff were educated on timely delivery of meal trays by the Administrator/designee. Licensed nurses and direct care staff have been educated on timely call bell responses by the Administrator/designee. IV. Audits of meal tray delivery will be completed by the IDT (inter-disciplinary team) Team. Call bell audits will be completed by the IDT Team. Audits will be completed weekly x 4 weeks and then monthly for 2 months. Results of these reviews will be presented at the monthly QA meeting for review and recommendations. 3. During an observation of the lunch meal on the 200 hall on 10/26/2021 beginning at 11:50 a.m., two meal carts and one beverage cart were noted to be parked at the top of the hall. Two aides began to pass trays to independent diners at 11:55 a.m. On 10/26/21 at 12:00 p.m., Aide A, commented that there were many residents on the 200 hall that needed assistance, and they passed meal trays to the independent diners first. She confirmed that meal trays for dependent diners remained in the closed cart until a staff member was ready to provide assistance. After Aide A obtained a tray for a resident and left the cart, Nurse C approached the meal cart and passed two trays to two independent residents. She then left the cart and returned to the nurse's station. On 10/26/21 at 12:15 p.m., two of the unit's three aides were each sitting with a resident assisting them with eating. The third aide was observed providing nail care to Resident #25. The aide was pushing the resident's cuticles back prior to painting her nails. After the aide finished polishing the resident's nails, the resident was ask about the meal service. Resident #25 reported that the food usually wasn't very good, no variety and was usually cool, but her daughter was bringing lunch for her today. She reported that she would have liked to been given something to drink though as she wasn't meeting her daughter for another half hour. She reported that she often had to wait for something that she asked for as there didn't seem to be much help. It was noted at this time that only three aides were covering the east/rehab side of the building during lunch directly assisting with or ensuring that approximately 26 residents received their afternoon meal. The two nurses assigned to the area and the UM were not observed assisting the residents with the lunch meal. On 10/26/21 at 12:17 p.m., the Administrator was found in her office eating pizza while talking with the staffing coordinator. The Administrator was asked where the 200 hall UM could be found. The Administrator reported that she did not know, but she would find her. On 10/26/21 at 12:20 p.m., the surveyor returned to the 200 hall after speaking with the Administrator and observed a call light was illuminated/ringing. No staff were present to respond to the light. After five minutes without any staff response, the surveyor asked the resident with the ringing call light (Resident #24) what she needed. The resident reported that her pasta was dry and needed sauce on it. She pointed to her roommate's pasta and commented that the roommate had gravy on it. The Certified Dietary Manager was notified of the request and within another five minutes, the resident was provided with some brown gravy. On 10/26/21 at 12:30 p.m., all three aides were observed assisting three residents with eating to include Resident #22. On 10/26/21 at 12:35 p.m., the Activity Aide was observed noted walking down the hall and looking for residents that still needed assistance. She obtained a meal tray and began to assist a resident with eating. On 10/26/21 at 12:40 p.m., Aide B was observed standing next to Resident #12, who was refusing her meal. An attempt to ask Resident #12 about her meal at this time revealed no response from the resident. When Aide B left Resident #12, she obtained another meal tray and sat with Resident #9 to begin assisting with eating. During the meal observation, Resident #9 reported that her meal was good. On 10/26/21 at 12:45 p.m., the UM was observed in her office looking at her computer screen. She was called to the floor and reported that she had just returned from lunch. She asked the staff if they needed help with the lunch meal. At that time, two residents requiring assistance were still waiting to receive their lunch meal. On 10/26/21 at 12:50 p.m. (one hour after meal trays arrived on the hall) the last resident received her tray and received assistance to eat. On 10/26/21 at 1:50 p.m., the Administrator reported that the UM should be providing oversight during the meal process. The Administrator reported that everyone on the hall that was needed was present so the UM probably thought she was able to go to lunch. The Administrator was not aware of who was on the hall and was informed that only three aides were on the hall to assist up to six residents with their meals, one of the three aides was painting Resident #25's nails during lunch, and approximately 20 additional residents needed their trays delivered and set-up. On 10/26/21 at 2:35 p.m., the Administrator provided a plan for residents to be assisted at meals. She reported that aides and other nursing staff would be assigned to residents who needed assistance so there would be adequate staff and no resident would need to wait for their meal. Interview with the Administrator on 10/27/2021 beginning at 10:25 a.m., revealed the audits to ensure timely meal service were reviewed and noted for providing no details as to what was audited. The audits included resident names and room numbers and a check mark indicating that the meal pass had been timely. There were no details as to whether the residents listed were dependent diners, at what time the meal cart arrived to the hall and when the residents received their meals, if the meal was satisfactory to the residents, especially the temperature of the meal which would be dependent on the time it took for the meal to be provided to the resident. The Administrator reported that their goal is for meals to be passed within 30 minutes of the cart arriving to the floor. It was pointed out that the in-service that was provided to the staff to ensure timely meal service did not reflect a plan for how that would be accomplished. The Administrator was made aware that the meal service observed on 10/26/2021 on the 200 hall mirrored the deficient practice observed during the survey ending 8/25/21. A review was conducted of the Resident Council Minutes for the last two months. It was noted that issues that had been identified on the survey ending on 8/25/21 were still on-going in September and October 2021. The Resident Council minutes from 09/27/2021 documented concerns with long call light time (responses), cold food, food too tough to chew, food that was bland and menus needing variety. The Resident Council minutes dated 10/14/2021 documented continued concerns with answering call lights and assisting with activities of daily living. Residents complained about tough food, and food served at the wrong temperature and without flavor. When these issues of continued noncompliance were discussed with the Administrator on 10/27/2021 in an interview that began at 2:00 p.m. the Administrator reported that she was not aware that the residents at the council meeting were continuing to have concerns with staffing, call bell response, and meals. The Administrator reported that she must have misunderstood the Activities Director when the content of the meetings was discussed with her. Review of the facility's audits revealed no audits were available after 10/11/21. In an interview with the Administrator on 10/27/2021 beginning at 10:25 a.m. the lack of audits per the facility's plan of correction was questioned. Audits were noted to have been conducted per the plan during the last week of September and up until 10/11/2021 , but no other audits were available after 10/11/2021. The plan of correction indicated audits would be conducted during the first two weeks from their Plan of Correction (POC) date of 09/24/2021, ending on approximately 10/08/2021. The POC then indicated audits would be conducted weekly for two weeks, ending on approximately 10/22/2021. The Administrator was not able to provide audits after 10/11/2021. 4. Review of the facility's plan of correction for the survey ending 8/25/21 with a completion date of 9/24/21 revealed the following measures would be taken to correct the deficient practice which was identified for concerns with dialysis: II. DON/Designee completed audit of current residents for dialysis communication sheets completed and dialysis site observations. III. DON/Designee will re-educated licensed staff on completing and receiving the communication sheet from the dialysis center after each visit and documentation of site observation daily. IV. Don/Designee will conduct audits of communication sheets and site observation bi weekly X2, weekly X2, then monthly X2. Findings will be reported to QA for review and further recommendations. 5. *A revisit to the survey ending 8/25/21 was conducted on 10/26/21 and 10/27/21. This revisit revealed on-going concerns with dialysis as follows: On 10/26/21 at 10:10 a.m., Resident #1 was observed lying in bed on his left side, watching a video. A dialysis access site was observed on the upper left arm. A review of Resident #1's admission Record Report revealed an original admission date of 12/14/2020 with diagnoses that included ESRD (End Stage Renal Disease) with dependence on renal dialysis. A review of the physician's orders related to the resident's dialysis care, revealed orders for the resident's dialysis at the dialysis center at 12 p.m., every Monday, Wednesday, Friday for ESRD, check the AV (arterio-venous) fistula site thrill/bruit every shift, and dialysis site observation every shift, dialysis site observation as needed. There was no additional orders for the care of the access, including when to remove the dressing after the dialysis treatment. Review of the nurse's notes revealed documentation that the bruit and thrill were present after dialysis treatment on 10/19/21 (dialysis site clean and dry, positive bruit and thrill noted). On 10/27/21 at 9:00 a.m., Resident #15 was observed lying in bed with a clean and dry dressing on his upper left arm. He stated that he went to dialysis yesterday and that was the dressing they applied at dialysis. He stated that nursing staff get around to removing the dressing from his arm. Review of the admission Record Report for Resident #15 revealed an admission date of 10/13/2021 with diagnoses that included End Stage Renal Disease (ESRD) with dependence on renal dialysis. Record review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired). A review of the physician's orders related to the resident's dialysis care, dated 10/18/2021 and 10/19/2021, included a high protein renal diet, check AV (arterio-venous) fistula site -thrill/bruit every shift for AV fistula site thrill/bruit check; dialysis site observation as needed and one time a day, and hemodialysis per physician order Tues, Thurs, Sat. There was no order for removal of the dressing that was applied to the dialysis AV fistula after the dialysis treatment. A review of the resident's 12 page care plan, initiated upon admission revealed no additional care plans related to the AV fistula access site. A review of the resident's Nursing Notes from 10/01/2021 until 10/27/2021 did not reveal documentation that the dressing had been removed, only that the site had been observed and the bruit and thrill was noted. In an interview with the Administrator and the acting Director of Nurses on 10/27/2021 beginning at 2:00 p.m., it was confirmed that there should be an order for care of the AV fistula site to include when to remove the dressing applied after the site had been accessed for dialysis. The Administrator confirmed during that interview that the document Dialysis Guidelines was the document used to train staff and also used as reference for care for the dialysis residents. Review of the Dialysis Guidelines dated 11/2017 revealed: Both the center and the dialysis facility are responsible for shared communication regarding patients receiving dialysis services . Collaborative communication included information regarding physician and treatment orders, and adverse reactions or complications and recommendations for follow up observations and monitoring including those related to the vascular access site. 6. Review of the facility's plan of correction for the survey ending 8/25/21 with a completion date of 9/24/21 revealed the following measures would be taken to correct the deficient practice which was identified for concerns with psychotropic medication monitoring: III. Quality Assurance Consultant provided education to the DON and Unit Manager related to reviewing psychotropic medication daily for new orders and that monitoring is started as well as identifying the targeted behaviors. DON/Designee will provide education to licensed nursing staff related to adding monitoring for all new psychotropic medications and identify targeted behaviors on care plans. IV. DON/Designee to conduct audits on psychotropic monitoring and targeted behaviors weekly x2, biweekly x 2 monthly x2. Findings will be reported to the QA for further review and recommendations. 7. A revisit to the survey ending 8/25/21 was conducted on 10/26/21 and 10/27/21. This revisit revealed on-going concerns with psychotropic medication monitoring as follows: *On 10/26/21 at 9:30 a.m., Resident #13 was lying in bed watching TV. She had no complaints or concerns, and no behaviors were noted. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section N, Medications, showed she was receiving antidepressants. Record review of the progress notes showed On 10/01/21 she refused to have vital signs for the 11 p.m. to 7 a.m. shift on 09/30 through 10/01/21. On 10/01/21 she refused a bed bath and shower several times. On 10/06/21, resident refused to be weighed. On 10/26/21 at 22:26 (10:26 p.m.) just before dinner, when observed resident, she was crying. The resident cries often and stated she was tired of being sick and does not like to be touched. The Nurse Practitioner was informed. Review of physician orders, Treatment Administration Record (TAR), and Medication Administration Record (MAR) for October 2021 showed Resident #13 received Mirtazapine 15 mg at bedtime for depression / insomnia. Monitor for side effects related to use of psychotropic medication, Mirtazapine. My initials indicate absence of signs and symptoms of side effects, monitor every shift for side effects of psychotropic medications. The physician orders and / or MAR lacked orders and monitoring of behaviors for psychotropic medications. Review of the care plans for Resident #13 revealed no interventions related to monitoring for behaviors/targeted behaviors associated with the use of psychotropic medications. *Record review of Resident #11's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 08 (moderately impaired). Section N, Medications, showed she was receiving antianxiety medication. Record review of active physician orders and the October MAR showed Resident #11 received Trazodone HCL 50 mg by mouth at bedtime for depression as of 10/21/21. Monitor for side effects related to the use of psychotropic medication, Trazodone. My initials indicate absence of signs and symptoms of side effects. Check every shift as of 10/26/21. Zoloft 50 mg daily for depression. Monitor for side effects related to use of psychotropic medication, Zoloft. My initials indicate absence of signs and symptoms of side effects. Check every shift. Vistaril 25 mg twice a day for anxiety ending on 10/20/21. The October MAR lacked monitoring for side effects for Vistaril for anxiety. The physician orders and/or MAR lacked orders and monitoring of behaviors for psychotropic medications. Progress notes reviewed showed on 10/19/21 the resident had increased confusion, different from her normal confusion. Resident stated, I am so nervous I don't think I can breathe. Oxygen saturation was 93% on room air. Oxygen was applied and resident eventually calmed down. A call was placed to the Nurse Practitioner and received an order to check her urine. The Vistaril for anxiety was discontinued on 10/20 and Trazodone was started on 10/21. The progress notes, physician orders and/or MAR lacked any documentation regarding her behaviors post medication change. Record review of the care plans showed the resident was an exit seeking / elopement risk related to cognitive impairment initiated 7/2/21 and revised 7/29/21. Interventions included but were not limited to calmly redirect to an appropriate area, alert bracelet, and check for placement and function daily. Care plan for risk for adverse effects related to use of antidepressant medication, Zoloft initiated on 9/10/21 and revised on 9/13/21. Interventions included but were not limited to evaluate effectiveness and side effects of medications for possible decrease / elimination of psychotropic drugs; notify physician of decline in ADL ability or mood / behavior related to a dosage change, provide patient teaching of risks and benefits of medications as needed, report to physician signs of adverse reactions. No care plan was present related to anxiety. *On 10/26/21 at 1:40 p.m., Resident #2 was sitting at bedside watching TV. She was dressed and groomed for the day and had her personal possessions in her room. No behaviors were noted. Record review of the annual Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section N, Medications, showed she was receiving an antidepressant. Record review of active physician orders and October MAR showed Bupropion HCL ER (XL) 24-hour 150 mg every other day for depression. Monitor for side effects related to use of psychotropic medication, Bupropion. My initials indicate absence of signs and symptoms of side effects, monitor every shift. Lexapro 10 mg at bedtime for depression. Monitor for side effects related to use of psychotropic medication, Lexapro. My initials indicate absence of signs and symptoms of side effects, monitor every shift. Trazodone HCL 50 mg give 0.5 tablet by mouth at bedtime on Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday for depression with insomnia. Monitor for side effects related to use of psychotropic medication, Trazodone. My initials indicate absence of signs and symptoms of side effects, monitor every shift. Monitor for side effects related to use of psychotropic medications. Check every shift as of 01/02/21 and discontinued on 10/26/21. Monitor for side effects related to use of psychotropic medication, Reglan (chronic ileus). My initials indicate absence of signs and symptoms of side effects, monitor every shift. The physician orders and / or MAR lacked orders and monitoring of behaviors for psychotropic medications. Review of the care plans showed no interventions related to monitoring for behaviors/targeted behaviors associated with the use of psychotropic medications. *Observed Resident #8 was lying in bed watching TV on 10/26/21 at 1:50 p.m. He had eaten his lunch. No behaviors were noted. Record review of the annual Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact).Section N, Medications, showed he was receiving antianxiety and antidepressant medication. Record review of physician orders and October MAR showed Resident #8 received Zoloft 100 mg at bedtime for depression. Monitor for side effects related to use of psychotropic medication, Zoloft. My initials indicate absence of signs and symptoms of side effects, monitor every shift. Buspirone HCL 7.5 mg three times a day for anxiety. Monitor for side effects related to use of psychotropic medication, Bupropion. My initials indicate absence of signs and symptoms of side effects, monitor every shift. The physician orders and/or MAR lacked orders and monitoring of behaviors for psychotropic medications. Record review of the care plans showed no interventions related to monitoring for behaviors associated with the use of psychotropic medications. Record review of progress notes for the month of October did not show any documentation related to behavior monitoring. *Observed Resident #6 lying in bed on 10/26/21 at 1:48 p.m. watching TV. She would not answer any interview screening questions. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 09 (moderately impaired). Section N, Medications, showed she was receiving an antipsychotic, antianxiety, and antidepressant medications. Record review of the physician's orders and October [DATE] showed Resident #6 received Ativan 0.5 mg at bedtime for anxiety and hold for sedation. Monitor for side effects related to use of psychotropic medication, Ativan. My initials indicate absence of signs and symptoms of side effects, monitor every shift. Seroquel 25 mg at bedtime for schizophrenia. Monitor for side effects related to use of psychotropic medication, Seroquel. My initials indicate absence of signs and symptoms of side effects, monitor every shift. Sertraline HCL 25 mg daily for depression. Monitor for side effects related to use of psychotropic medication, Sertraline. My initials indicate absence of signs and symptoms of side effects, monitor every shift. The physician orders and/or MAR lacked orders and monitoring of behaviors for psychotropic medications. Record review of progress notes for the month of October revealed no documentation related to behavior monitoring. Record review of the care plans showed the resident was at risk for behavior symptoms related to depression, dementia, and coprophagia (ingestion of feces) revised 9/16/20. Interventions did not indicate what the at risk behaviors/targeted behaviors were to monitor. The resident had inappropriate sexual behavior, attempting to be overly affectionate with male residents related to cognitive impairment and mood disorder revised 8/12/20. Interventions included but were not limited to distract, if possible, explain and explore effects of behavior on others, offer dim lights, TV, snacks, soft music; remain calm and avoid angry reactions if exhibits behavior, set limits for acceptable behavior. At risk for changes in mood related to depression, dementia, and mood disorder revised 8/12/20. Interventions included but not limited to administer medications per physician orders and observe for effectiveness and signs and symptoms of side effects. Elicit family support, watching TV, reading books/ magazines; validate feelings of loss. Episodes of anxiety related to diagnoses of anxiety initiated 2/12/21. Interventions included but not limited to administer medications per physician orders, identify and decrease environmental stressors. At risk for adverse effects related to use of antidepression medications, Zoloft revised 9/13/21. Interventions included but was not limited to evaluate effectiveness and side effects of medications for possible decrease / elimination of psychotropic drugs; notify physician of decline in ADL ability or mood / behavior related to a dosage change; report to physician signs of adverse reactions. At risk for adverse effects related to use of antianxiety / anxiolytic medication, Ativan revised 9/13/21. Interventions included but was not limited to evaluate effectiveness and side effects of medications for possible decrease / eliminations of psychotropic drugs; notify physician of decline in ADL ability or mood / behavior related to a dosage change; report to physician signs of adverse reaction. At risk for adverse effects related to use of antipsychotic medication, Seroquel revised 9/13/21. Interventions included but was not limited to evaluate effectiveness and side effects of medications for possible decrease / eliminations of psychotropic drugs; notify physician of decline in ADL ability or mood / behavior related to a dosage change; report to physician signs of adverse reaction. *Review of Resident #12's Physician's orders revealed an order dated 09/25/2021 for the medication Mirtazapine 7.5 mg by mouth at bedtime for nutritional enhancement. The medication Mirtazapine is an antidepressant that is also used as an appetite stimulant. An order for side effect monitoring was also noted: monitor for side effects related to the use of psychotropic medications: Mirtazapine. A review was conducted of the Minimum Data Set (MDS) Assessment conducted on 09/07/2021 for Resident #12. The assessment documented the resident as having moderately impaired cognitive function. The assessment documented her use of no antipsychotics but the use of an antidepressant. A care plan had been developed on 9/12/21 and revised on 9/13/21 for Resident # 12's use of the antidepressant Mirtazapine. The Focus of the care plan identified the risk for adverse effects of the medication and her diagnosis of failure to thrive for its use. Interventions included evaluating the effectiveness and the side effects of the medication for possible decrease or elimination of the psychotropic medication. Also, the physician was to be notified of a decline in the resident's ADL (activities of daily living) abilities or decline in mood/behavior related to a dosage change. The physician was to be notified of signs of adverse reactions as well. The care plan included no interventions related to monitoring for behaviors associated with the use of psychotropic medications. Review of the resident's Medication and Treatment Records did not reveal guidance and an area to document the presence or absence of behaviors that the resident might be eliciting. There was an order to monitor side effects of the medication with the clarification that my initials indicate absence of signs and symptoms of side effects. There was no guidance that side effects when present needed to be documented in the nurse's notes, or what specific side effects the resident might elicit. A review of the nurse's progress notes for October 2021 revealed the resident was followed by Hospice and had an increase in her pain medication on 10/15/2021. Nurses notes prior to 10/15/21 revealed scratching was noted on her bilateral inner thighs which received treatment. On 10/09/2021 at 16:06 (4:06 p.m.) and 10/13/2021 at 17:58 (5:58 p.m.) the nurses note documented the resident's behavior of screaming and yelling and refusing the treatment. On 10/26/2021 during the lunch meal, Resident #12 was observed being assisted with her meal. The resident was observed taking a small bite of fish out of her mouth and placing it back on her plate. The aide commented that the resident usually did that and didn't usually eat anything. An observation of Resident #12 on 10/27/2021 during the lunch meal revealed she was accepting bites of the fruit cocktail from her lunch tray. The aide confirmed that she refused the meal but seemed to be enjoying the sweet fruit. A review of the resident's weights revealed upon admission on [DATE] the resident had weighed 124.4 lbs. On 08/02/2021 the resident weighed 119.5 lbs., on 09/01/21 the resident weighed 102.8 lbs., and on 10/01/21 the resident weighed 101.6 lbs. *Resident #1 was admitted to the facility initially on 12/14/2020. The resident had current diagnoses that included major depressive disorder and anxiety disorder. Review of the resident's active Physician's orders revealed an order for Zoloft 100 mg, give 300 ml by mouth at bedtime for major depressive disorder and and order for Restoril 15 mg, give one cap by mouth at bedtime for insomnia. Current orders were also noted to monitor the side effects related to the use of the psychotropic medications Zoloft and Restoril. The order included the statement, My initials indicate the absence of signs and symptoms of side effects. Resident #1 had an Annual MDS Assessment conducted on 07/22/2021 which identified the resident as having no cognitive deficits. The assessment included the diagnoses of anxiety and depression with an antihypnotic, and antidepressant administered on 7 days during the week. A care plan was reviewed for the Focus area of being at risk for behavior symptoms related to depression, anxiety, and insomnia, as well as noncompliance with the ordered diet and lab draws initiated 7/16/20 and revised on 1/11/21. Interventions included observations for mental status/behavior changes when new medications are started or with changes in dosages. The Physician's order for monitoring side effects was not included as an intervention in the care plan for at risk behaviors and there was no guidance given in the care plan for what behaviors should be monitored based on the medications the resident was taking. *During an interview on 10/27/21 at 1:57 p.m. the new interim DON entered, Staff G. She stated that today was her first day in the position of DON. She stated t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide necessary treatment and services related to documenting measurements and wound descriptions for three of three sampled residents (#15, #16, #13) with pressure sores out of seven total facility residents with pressure sores. Findings Included: 1. During observation and interview on 10/27/21 at 9:00 a.m., Resident #15 was observed lying in bed. The resident was observed to have an IV access in his right hand with a dressing dated 10/26 and a clean and dry dressing on his upper left arm. The resident stated that this was the dressing applied when he went to dialysis the day before. Review of Resident #15's admission Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Continued review of the MDS revealed the resident required extensive assistance of two for bed mobility, transfers, and toileting and had one unstageable pressure ulcer on admission due to coverage of wound bed by slough and/or eschar. Record review of the physician orders showed a wound culture of the sacrum to be performed on 10/14/21; cleanse sacrum wound and apply [wound care product] ointment topically and apply foam dressing every day as needed as of 10/14/21 and increased to every 8 hours on 10/27/21. Review of the admission Evaluation dated 10/13/21 revealed under Clinical Evaluation of Skin: coccyx stage II open wound with foam dressing. The medical record lacked the Pressure Ulcer Healing Chart, (PUSH) form or any other documentation of a wound description or measurements upon admission on [DATE]. Record review of the progress notes showed the following notes related to the pressure ulcer: 10/14/21 at 1:39 a.m. Stage II wound on his bottom with a wet to dry and foam dressing in place to cover the wound bed. On 10/14/21 at 11:37 a.m. Resident was complaining of pain of the buttocks, the Tramadol as needed was given and repositioned for comfort. Resident's provider was in to assess resident and orders received for treatment of coccyx wound. On 10/14/21 at 12:44 p.m. resident reported no change with pain of buttocks after Tramadol or Tylenol. Registered Nurse (RN) notified Nurse Practitioner (NP) of resident concerns of no pain relief. NP thinks he just needs the buttocks dressing changed. RN to change dressing. On 10/14/21 at 22:07 (10:07 p.m.) nurse documented wound care performed. On 10/19/21 at 14:47 (2:47 p.m.) wound to sacral area noted to have an odor and the wound dressing was saturated with a large amount of drainage. Area noted to have slough in the middle of wound bed. Area cleansed and new treatment applied. Writer educated resident to leave dressing in place and to turn onto their side while in bed. On 10/20/21 at 13:15 (1:15 p.m.) Resident had one unstageable wound to the sacrum. The wound measured 9.0 cm x 6.0 cm x 3 cm. and had moderate drainage. The wound bed was 75% slough and 25% eschar. The Pressure Ulcer score was 16. The wound was recently treated with [wound care product] and foam padding. Resident had a diagnosis of diabetes, left femur fracture and end stage renal disease. Resident was currently doing dialysis three times a week. Resident's nutritional intake currently included a high protein diet with [brand name] Liquid Nutritional Supplements, and additional nutritional snacks. His nutritional intake was good, and appetite had been normal. Recent labs showed elevated BUN (Blood Urea Nitrogen) of 31, and Creatinine of 5.39 also showed a low total protein of 5.6 and Hemoglobin at 8.9 and hematocrit at 27.3. Resident denied pain during wound dressing change. Wound culture was pending. Treatments will continue as ordered pending wound culture. Resident updated on plan of care and status of wound. The care plan was updated on wound status. Staff D, Registered Nurse (RN) On 10/21/21 at 23:00 (11:00 p.m.) resident returned from dialysis in stable condition. The wound care was rendered, and he tolerated it well. Record review of the Wound Culture Results dated 10/21/21 showed (1) heavy growth of proteus mirabilis, (2) moderate growth of Escherichia coli and (3) heavy growth of enterococcus faecalis. The wound organism one and two was sensitive to Ciprofloxacin. Continued review of the clinical record revealed additional progress notes related to the pressure ulcer: 10/25/21 at 10:26 a.m. Weekly Wound Rounds showed resident had one unstageable wound to the sacrum. Wound currently measured 9.0 cm x 6.0 cm x 3.5 cm. and had moderate yellow drainage. The wound bed was 75% slough and 25% eschar. The Pressure Ulcer score was 16. Awaiting Medical Doctor (MD) reassessment of wound. Resident currently has a diagnoses of end stage renal disease, diabetes and a left femur fracture. Resident's nutritional intake included a high protein diet, with [name brand] Liquid Nutrition with additional nutritional snacks. Nutritional intake has been adequate with a good appetite. Wound culture completed; results sent to MD awaiting new orders from wound culture results. Wound dressing changed per MD orders; resident reports no pain with treatment. Resident updated on plan of care and status of wound. Staff D, Registered Nurse (RN) On 10/27/21 at 01:10 a.m. Resident on IV antibiotic for coccyx wound. No adverse reactions noted. IV site to right hand without signs of infection. On 10/27/21 at 11:05 a.m. Resident was up in wheelchair for therapy. Resident sacral wound saturated foam dressing and was half off. RN changed dressing per MD order, resident tolerated. Well. Resident denies removing the dressing, I didn't take it off, it fell off. Wound with strong odor, continues on IV antibiotic for sacral wound. No signs and symptoms of reaction from antibiotic. Record review of the care plans related to the pressure ulcer revealed a focus of infection of wound/skin initiated on 10/27/21 (date of survey). Interventions included but not limited to administer medication per physician orders. During an interview on 10/27/21 at 1:57 p.m., the Nursing Home Administrator (NHA), the interim Director of Nursing /MDS Coordinator (DON/MDS), and the Regional Nurse, verified that Resident #15 did not have any wound sizes documented on admission. The Regional Nurse reported that when not measuring wounds on admission and throughout the resident's stay, It can worsen, the wound, and not know it. They stated that they expected to see both a wound and infection care plan for Resident #15 that had been initiated before 10/27/21, since he was admitted on [DATE]. 2. Review of Resident #16's admission record report revealed an admission date of 10/08/21 and diagnoses to include pressure ulcer, sepsis, COVID-19, anemia and diabetes and end stage renal disease. Record review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section G Functional Status showed she required extensive assistance of two for bed mobility, transfers, and toileting. Record review of physician orders showed cleanse coccyx, right buttock and left buttock wound with normal saline and apply [wound care product] gel and foam dressing daily and as needed as of 10/09/21 through 10/20/21. A new order on 10/20/21 to cleanse coccyx, right buttock and left buttock wounds with normal saline and apply xeroform gauze and cover with foam dressing daily and as needed. October Treatment Administration Record (TAR) showed orders performed as given. Review of the admission Evaluation dated 10/08/21 showed under Clinical Evaluation of Skin, coccyx, coccyx, right buttock, left buttock. Record review of the Pressure Ulcer Healing Chart (PUSH) forms times three dated 10/08/21 showed Resident #16 had a stage II pressure ulcer on her right buttocks and the form lacked sizes or healing graph. Had a PUSH form for the Left Buttocks stage II pressure ulcer and it lacked sizes or healing graph. Had a PUSH form for stage II coccyx wound which had a dated section of 10/22/21 showing wound was 1.5 x 0.8, with light exudate, and granulation tissue. No additional measurements of wounds could be located in the clinical record. Review of care plans showed a risk for alteration in skin integrity related to impaired mobility initiated 10/12/21. Interventions dated 10/12/21 included encourage to reposition as needed; pressure redistributing device on bed/chair. A second care plan showed resident had a pressure ulcer on the right buttock. Interventions included to administer treatment per physician orders, daily body audit, incontinence management and repositioning during Activities of Daily Living. The care plan and all interventions were initiated on 10/20/21 by Staff D, Registered Nurse (RN). Record review of the progress notes showed: On 10/09/21 resident had a stage II pressure wounds to left buttock, right buttock and two on her coccyx. Treatment was in place for pressure wounds. On 10/10/21, resident had treatment to coccyx and bilateral buttock wounds, continued as ordered. On 10/11/21, progress note by Nurse Practitioner showed no mention of pressure ulcers and not mentioned in plan. On 10/15/21, progress note by Nurse Practitioner showed no mention of pressure ulcers and not mentioned in plan. On 10/20/21, left buttock wound, cleansed with normal saline and applied [wound care product] gel and foam sponge until left buttock is healed. On 10/20/21 at 12:21, Medical Doctor (MD) updated wound care, new orders received for right and left buttocks and coccyx. Registered Nurse (RN) notified the resident of changes and all questions were answered. On 10/27/21 at 1:57 p.m., an interview was conducted with the NHA, interim DON/MDS Coordinator, and the Regional Nurse. The interim DON/MDS Coordinator and the Regional Nurse verified that Resident #16 had wounds on admission on [DATE]. They also verified that there were no wound sizes taken on admission. The interim DON/MDS coordinator stated that the wound sizes are to be documented in the progress notes. She stated, I thought they were getting done, but they were not, (related to wound sizing). The DON/MDS coordinator and Regional Nurse verified that only one of the three wounds Resident #16 had been measured since admission. Staff D, Registered Nurse, Unit Manager (RN/UM) entered the interview and stated that starting 10/28/21, she will be performing the wound sizes, during weekly rounds. Staff D stated that wound sizes on admission are to track and see if the wound was getting better or not. Record review of the facility's policy, Phase 1: Assess, Pressure Ulcer Prevention Pathway dated 2013 showed the tool can be used by the wound team as a training tool for frontline staff and as an ongoing clinical reference tool. Patient is admitted or readmitted , do both a head-to-toe skin evaluation and Braden Scale. Document skin issues, including color, temperature, turgor, moisture status, integrity, pressure ulcer if present or known, healed pressure ulcer. If have a current or healed pressure ulcer to document the pressure ulcer: location, length, width, depth, PUSH tool. The wound team stages the pressure ulcer. Obtain order for treatment from physician and obtain consultations needed. Daily body audits performed. Braden Scale performed. 3. Clinical record review for Resident #13 revealed she was initially admitted on [DATE] with readmissions after hospital stays on 03/30/2021 and a hospital stay from 09/10/2021 until 09/17/2021. Review of the resident's diagnoses included a pressure ulcer of the right heel, unspecified stage and pressure ulcer of the sacral region, unspecified stage. A readmission assessment for Resident #13 was completed upon return to the facility from the hospital on [DATE]. The section of the assessment for the clinical evaluation of the skin included skin issues at the right heel and the coccyx but contained no description of either site, including neither measurements nor stage. A review was conducted of the resident's MDS Quarterly Assessment completed on 10/01/2021 which identified the resident as having no cognitive deficits (Brief Interview for Mental Status score of 15). The resident was assessed as having one stage 2 pressure ulcer and one stage 4 pressure ulcer, both present upon admission. The resident was assessed as needing extensive assistance with two staff members for bed mobility and transferring, having an indwelling urinary catheter and always incontinent of bowel. A review was conducted of the October 2021 Physician's orders and was noted to include an order to cleanse the right heel with normal saline, apply [wound care product] to the wound bed and cover with gauze and tape, every day. A second order was noted for negative pressure wound therapy 125 mm Hg (millimeters of mercury) to coccyx ulcer, every day shift on Monday, Wednesday, and Friday, for the coccyx wound. Wound vac (vacuum) to coccyx, change Monday, Wednesday Friday, every day shift related to sepsis. A record review of the Skin notes revealed only two notes documenting weekly wound rounds for October. On 10/06/2021 the weekly rounds documented the resident's stage III coccyx wound as: length 6.7 cm x width 7.0 cm x depth 1.2 cm. The wound bed had 90% granulation with 10% necrosis on the edges. The PUSH (pressure ulcer scale for healing) score was 12. The peri-wound was blanchable without redness. The resident had a foley catheter, ate less than 25% or refused meals and received nutrition support. The resident also had a deep tissue injury to her right heel. The length measured 2.5 cm and the width measured 1.5 cm. The PUSH score was 6. Further review of the October Skin notes did not reveal another weekly wound round until 19 days later, on 10/25/21. The size of the stage III coccyx wound was documented as : length 5.8 cm x width 6.4 cm x depth 1.2 cm. The wound bed was described as pink, with 100% granulation. The PUSH score was a 16. The peri-wound was blanchable without redness and the wound vacuum was in place and is changed Monday/Wednesday/Friday. The wound note also included that the resident had a foley catheter, was receiving an intravenous antibiotic beginning on 10/16/21 for a urinary tract infection; she ate 25-50% of her meals and received other nutrition support. She had a deep tissue injury to her right heel which measured as 2.4 cm and the width 1.5 cm. The PUSH score for the heel was 6. During an interview on 10/27/2021 that began at 2:00 p.m. with the NHA and interim DON, it was confirmed that the nurses documented their daily wound care on the Treatment Administration Record and once a week wound rounds by the Unit Managers would document measurements and observations of the wounds. This documentation would be located under the section entitled Skin in the Progress Notes section of the resident's electronic medical record. During this interview, at approximately 2:35 p.m., the NHA confirmed that in mid-October there was a problem with the Registered Nurses being able to cover all tasks and for some tasks there was no follow through. She reported that wound care had been delegated to the floor nurses to do the treatments and the Unit Managers were to conduct the documentation on the weekly evaluations, but she confirmed she was just made aware that the documentation had not been made. Review of the Pressure Ulcer healing Chart used to monitor trends in the PUSH score over time for Resident #13 revealed that there were entries dated 08/11 and 08/20, and then no entries until 10/06/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident # 2 was admitted to the facility on [DATE]. Review of Resident # 2's current admission Record Report did not reveal any diagnoses relevant to psychotropic medication use. A review of active physician orders dated 8/18/2021 for Resident # 2 included the medication Buspirone Hydrochloride (HCL) 7.5 milligrams (mg) by mouth three times a day for anxiety and Sertraline HCL100mg, one tablet by mouth at night for depression. Resident #2's Physician's Orders did not reveal an order for monitoring of side effects related to psychotropic medication use or monitoring for targeted behaviors related to psychotropic medication use. A review of the last completed quarterly Minimum Data Set (MDS) dated [DATE] revealed Section N (Medication) revealed that Resident # 2 received anti-depressant medication seven times during the assessment period, medication for anxiety seven times, and hypnotic medications seven times during the assessment period ending 5/12/2021. A review of Resident #2's Medication Administration Record (MAR) for August 2021, revealed documentation of administration of Sertraline HCL and Buspirone HCl as ordered by the physician. Review of the MAR did not reveal documentation of monitoring for side effects or targeted behaviors related to the use of psychotropic medications. An interview was conducted on 08/25/2021 at 1:08 p.m. with Staff E, Licensed Practical Nurse Supervisor (LPN), Staff E stated that the expectation was that all residents who are on psychotropic medications have monitoring done every shift for behaviors, and medication side effects. Residents should have a behavior symptom assessment completed when the medication is started. There should be an order for behavior and side effects monitoring for each medication. Staff E, LPN confirmed that there were no active physician orders for behavior monitoring or side effect monitoring for Resident #2 related to psychotropic medication use. Staff E, LPN stated that it was the responsibility of the Unit Manager to input physician orders into the Electronic Medical Record (EMR) when a resident is admitted to the facility. Staff E stated, I guess that would be our responsibility during off hours, but I do not know how to put the order in, but I do not know how to do that. 3. Resident # 3 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbances, Alzheimer disease, mood disorder, major depressive disorder, and anxiety disorder. A review of the minimum data set (MDS) dated [DATE] section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) of 09, which reflected Resident # 3's cognition was moderately impaired. A review of the active physician orders dated 08/01/21 for Resident # 3 included the psychotropic medications Seroquel 25 mg (milligram) by mouth at bedtime for schizophrenia, sertraline HCL (Hydrochloride) 25 mg daily for major depressive disorder, and Ativan 0.5 mg at bedtime for anxiety. The physician order included an order for psychiatry consult related to behaviors. There was no physician order for the monitoring of behaviors related to the psychotropic medications, nor were there monitoring recorded on her medication administration record. A review of the plan of care initiated on 03/06/20 with a revision date of 08/12/2020 for Resident # 3 included a focus on Psychotropic Drug Use, with a goal of: Notify physician of decline in ADL (Activity of Daily Living) ability or mood or behavior related to a dosage change. A review of Resident # 3 medication administration record (MAR) for the period of 6/1/21 to 8/24/21 revealed that the psychotropic medications were administered as ordered; no documentation for behavior monitoring was recorded. On 08/24/21 at 12:15 p.m., in an interview with Staff G, Licensed Practical Nurse (LPN). Staff G stated that behavior monitoring is documented for Resident #3 in her MAR. Staff G reviewed the MAR and confirmed that there were no behavior monitoring notations for Resident #3. Staff G stated, I guess we just document if the resident has a behavior. She stated that she does not know the facility policy on behavior monitoring for residents on psychotropic medications. On 08/24/21 at 02:05 p.m., an interview with the Director of nurses (DON) was conducted. She stated that it was her expectation that all residents on psychotropic medications have orders for behavior monitoring, and that the nurses monitor, and document behaviors observed on the MAR. On 08/24/21 at 03:25 p.m., in an Interview with the pharmacist consultant, he stated that he would have expected behavior monitoring to be in place for psychotropic medications. A review of the facility policy and procedure titled, Psychotropic Medication use revision date 08/2018, revealed under the subheading Procedure #1. The nursing Center should comply with the Center for Medicare and Medicaid Services (CMS) SOM (State Operations Manual) and all other Applicable Law related to the use of psychotropic medications. Based on interviews, record reviews, and review of facility policy, the facility failed to ensure behavioral monitoring and side effect monitoring for psychotropic medication use was implemented for four (Resident #40, Resident #21, Resident #3, and Resident #2) of six residents sampled for Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review and failed to ensure that psychotropic medications used on an as needed basis had appropriate rationale of continued use for one (Resident #40) of six residents sampled for Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review. Findings included: 1. A review of Resident #21's Medical Record revealed that Resident #21 was admitted to the facility on [DATE] with diagnoses of anxiety, Major Depressive Disorder, and insomnia. A review of Resident #21's Physician's Orders revealed the following orders: - An order, dated 06/15/2021, for Klonopin 0.5 milligrams (mg) 1 tablet by mouth once daily and 1/2 tablet by mouth at bedtime for anxiety. - An order, dated 06/04/2021, to monitor for side effects related to use of psychotropic medication Klonopin every shift. - An order, dated 06/07/2021, to monitor for side effects related to use of psychotropic medication Klonopin every shift. - An order, dated 05/13/2021, for Trazodone Hydrochloride (HCl) 25 mg by mouth at bedtime for insomnia. Resident #21's Physician's orders did not reveal orders for monitoring of target behaviors for Klonopin or Trazodone HCl use or monitoring of side effects for use of Trazodone HCl. A review of Resident #21's Care Plan revealed a problem, last revised on 11/30/2019, that Resident #21 was at risk for behavior symptoms related to having a history of depression and anxiety. Interventions included to observe for mental status and behavioral changes when new medications started or with changed in dosages. Resident #21's Care Plan also revealed a problem, dated on 06/04/2021, that Resident #21 was at risk for adverse effects related to use of antianxiety, anxiolytic, and antidepressant medication use. Interventions included to evaluate for effectiveness and side effects of medications for possible decrease or elimination of psychotropic drugs and report to the physician any signs of adverse reactions. A review of Resident #21's Minimum Data Set (MDS) Assessment revealed, under Section N - Medications, that Resident #21 received antianxiety and antidepressant medications for 6 days out of the 7 day assessment period. 2. A review of Resident #40's Medical Record revealed that Resident #40 was admitted to the facility on [DATE] with diagnoses of insomnia and COVID-19. A review of Resident #40's Physician's Orders revealed the following orders: - An order, dated on 07/01/2021, for Xanax 0.25 mg by mouth at bedtime for anxiety. - An order, dated on 07/01/2021, for Xanax 0.25 mg by mouth once daily as needed for anxiety and agitation. The order for Xanax 0.25 mg by mouth once daily as needed did not have an end date. A review of Resident #40's Physician's Order did not reveal an order for monitoring of target behaviors related to use of Xanax or an order for monitoring of side effects related to use of Xanax. A review of Resident #40's Care Plan revealed a problem, dated on 07/06/2021, that Resident #40 had episodes of anxiety related to a diagnosis of anxiety. Interventions included to administer medications per physician's order and remove to a quiet area and reassure. Resident #40's Care Plan revealed a problem, dated on 07/06/2021, that Resident #40 had a sleep cycle issue related to a diagnosis of insomnia. Interventions included to limit caffeinated products during the day and eliminate after evening meal and provide opportunity for adequate exercise throughout the day. A review of Resident #40's MDS Assessment revealed, under Section N - Medications, that Resident #40 received antianxiety medications 7 times during the 7 day assessment period and hypnotic medications 2 times during the 7 day assessment period. An interview was conducted on 08/25/2021 at 07:39 AM with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN addressed that Resident #40 had an order for Xanax as needed once daily and also received Xanax at bedtime and stated that she was not able to find orders for monitoring of target behaviors related to use of Xanax or an order for monitoring of side effects related to use of Xanax. Staff F, LPN stated that nursing staff would normally document for effectiveness, side effects, and target behavioral monitoring on residents that received psychotropic medications. Staff F, LPN also addressed that there was no order for monitoring of target behaviors for Klonopin or Trazodone HCl use or monitoring of side effects for use of Trazodone HCl for Resident #21. A review of the facility's Behavior Practice Guide, issued in July 2015, revealed under the section titled Medications, that medications can affect a patient's mental status and subsequently affect their behavior. Some of these behaviors may be considered as part of the therapeutic benefit of the medication, or as a negative consequence or response to the medication. Select medications may be prescribed specifically targeting modification of patient behavioral symptoms. Medications that have historically been used to modify patient behavioral symptoms include antipsychotics, antidepressants, hypnotics, and anxiolytics. The section of the guide titled Documentation revealed that patient behavioral symptoms are documented in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles regarding medications on two (400, 200) of 4 units, and unlocked medication and treatment carts on four (100, 200, 300, 400) of 4 units. Findings included: 1. On [DATE] at 09:42 a.m. during a tour of the facility a treatment cart in hallway 400 was observed with the bottom drawer opened and a plastic container, containing a tube of cream on top of the treatment cart. A closer inspection of the treatment cart revealed that the cart was unlocked. Further observation of hallway 400 revealed a cup with medication left unattended on top of the medication cart in the hallway (photographic evidence obtained). Subsequently observation of hallway 300, a second treatment cart was observed. A closer observation of the treatment cart revealed that the treatment cart was unlocked. On [DATE] at 09:48 a.m. in an interview with Staff U, Registered Nurse, RN. Staff U stated that she went to administer medications (meds) to one of the residents, but the resident was asleep, and she put the meds on top of the cart with the intention to return and medicate the resident. She stated that she does not normally leave medications on the medication cart unattended, and she understood that she should have locked the medications in the cart. Staff U stated that she is responsible for the unlocked treatment cart on unit 400. She confirmed that the treatment carts should have been locked and cream siting on top of the cart should have been stored inside. On [DATE] at 10:26 a.m. In an interview with the Director of Nursing (DON) she stated that she expected treatment carts to be locked when staff are not directly in view of the carts. She stated that treatment creams and medications should have been stored in the locked carts and not on top of treatment cart or the medication carts. 2. On [DATE] at 9:10 a.m., during an observation of the 400 hallway medication cart with Staff E, Licensed Practical Nurse (LPN). In the first drawer to the right revealed an inhaler Wixela Inhub 500/50, with a handwritten date on the package, dated [DATE]. There was no legible open date (photographic evidence obtained). A second Inhaler was observed unlabeled (without name of a resident, dispense date, and an open date). In an interview with Staff E, she stated that she was not sure if [DATE] was the open date of the Wixela Inhub 500/50 inhaler. She stated she was not sure how long after opening the inhaler, it should be discarded. She stated that she would call the pharmacy and confirm how many days after opening the inhaler it should be discarded. Staff E confirmed that the inhalers should have been labeled and dated. She stated that the unlabeled inhaler should have been removed from the cart. On [DATE] 09:05 a.m. during a follow up interview with Staff E, she stated that she confirmed with the pharmacy that the Wixela Inhub inhaler should be discarded 30 days from the open date. 3. On [DATE] at 11:25 a.m. on Unit 200 with Staff F an unlabeled insulin pen was observed in the first drawer of the medication cart. Further observation revealed a bottle of eye drops, stored with an insulin multi-dose vial, in the insulin box. In an Interview with the Staff F she stated that she saw the unlabeled insulin pen and she was going to remove the pen. She stated she was not aware of the eye drops being stored with the multidose insulin in the insulin box. On [DATE] 11:39 p.m. the DON was present and observed the unlabeled insulin pen, and the storage of the eye drops with the insulin multi-dose vial. She stated that the storage she observed was not appropriate, and she expected insulin pens to be labeled with the resident's name and dated upon opening. She confirmed that the eye drops, and insulin was inappropriately stored. On [DATE] at 03:25 p.m. a telephone Interview was conducted with the pharmacy consultant. The pharmacy consultant was informed of observations made with staff not locking the treatment carts and leaving medications unattended on top of the medication cart. The pharmacy consultant stated that, Medication should not be left on the medication cart if the nurses are not in view of the cart; and treatment carts must be locked if not being used by a nurse. The pharmacy consultant stated that all medications should be labeled and stored appropriately, that insulin and insulin pens should be labeled and dated when opened. He stated that if an insulin pen cannot be identified it should have been removed from the medication cart. A review of the facility policy and procedure titled LTC (Long Term Care) Facility's Pharmacy Services and Procedure [NAME]. 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with the most recent revision date of [DATE], reflected the following: Number 3.3: Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Number 4: Facility should ensure that medications and biologicals that (1) have an expired date on the label: (2) have been retained longer than recommended by the manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 4. An observation was conducted on [DATE] at 10:05 AM during a tour of the 100 unit of the facility with the facility's Director of Nursing (DON). A treatment cart was observed to be unlocked in the unit hallway with no nursing staff members in the area of the treatment cart. The DON addressed that the treatment cart was left unlocked in the unit hallway and stated that the treatment cart should have been locked if there was not a nurse using the cart. The DON also stated that she would expect for the treatment cart to be locked at all times when it was not in use. An observation was conducted on [DATE] at 06:58 AM on the facility's 200 unit of an unlocked medication cart in front of the unit nurse's station. Staff F, Licensed Practical Nurse (LPN), Staff V, Registered Nurse (RN), and Staff W, LPN were observed sitting at the nurse's station and performing shift change report. An interview was conducted following the observation with Staff W, LPN. Staff W, LPN addressed that the medication cart was unlocked and stated that she had just counted the narcotics in the cart to prepare for shift change and left the cart unlocked. Staff W, LPN also stated that the medication cart should remain locked at all times. An observation was conducted on [DATE] at 07:10 AM on the facility's 300 unit of an unlocked medication cart in front of the unit nurse's station. Staff X, LPN was interviewed following the observation. Staff X, LPN addressed that the medication cart was left unlocked and stated that she was going to clean the medication cart as part of shift change procedures. Staff X, LPN was observed walking away from the medication cart while it was still unlocked and returned to the cart with sanitizing wipes to clean the medication cart. An interview was conducted following the observation with Staff X, LPN. Staff X, LPN stated that she would not normally walk away from the medication cart while it was unlocked and stated that it was the first time she had ever left the medication cart unlocked. A review of the facility policy titled Medication and Treatment Administration Guidelines, last revised in March of 2018, revealed the following under the section titled Medication Storage and Security: - Medications and biologicals are securely stored in a locked cabinet, cart, or medication room, accessible to only licensed nursing staff and pharmacist or authorized pharmacy staff, and maintained under a lock system when not actively utilized and attended to by nursing staff for medication administration, receipting, or disposal. - Only licensed nursing staff have key access to medication storage areas. - Medications are stored in accordance with standards of practice. Photographic evidence obtained.

Based on observations, record reviews, and staff interviews, the facility failed to ensure the kitchen was maintained in a sanitary manner related to inappropriate storage of PPE (personal protective equipment), ppm (parts per million) for the sanitizer in the three-compartment sink was reading too low, failed to maintain ceiling vents, improper storage of paper goods, improper storage of foods in the walk-in cooler and walk in freezer, and failed to maintain the ice machines in the Nutrition Rooms. Findings included: On 08/22/21 at 9:30 a.m., entered the kitchen to conduct the initial tour. A male unidentified staff member reported the manager did not work on weekends and that Staff A, Cook, was in charge. During the tour, a face shield was observed sitting on the top of a stack of four serving trays (photographic evidence obtained). The sanitizer in the three-compartment sink was tested by Staff A, Cook, and the ppm reading was 170. Staff A stated that the ppm should be between 272-700 ppm. Staff A stated that the chemical company was supposed to come out but had not come yet. She stated that this concern had been pointed out to them by another outside agency. Black buildup was observed on the ceiling vent in the dry storage room above a box of alfredo mix, individual containers of cornflakes, and plastic bins of spoons, forks, and knives. Used oxygen concentrators were observed sitting next to paper goods stored on the floor in the hallway outside of the kitchen. Condensation was observed dripping from the ceiling vents above the prep table and the serving line (photographic evidence obtained). On 08/22/21 at 10:10 a.m., the Certified Dietary Manager (CDM) arrived and verified the following observations in the walk-in cooler: a plastic bag of opened carrots and cabbage without a date; a bag of opened shredded cheese without a date; a container of soup without a date; an expired container of potato salad with a use by date of 08/11/21; and an expired container of creamy cole slaw with a use by date of 08/12/21. An observation of the walk-in freezer revealed a bag of biscuits and egg patties without a date, and ham wrapped in aluminum foil with no date (photographic evidence obtained). The CDM confirmed all the findings. On 08/22/21 at 3:15 p.m., the ice machine in the Nutrition Room shared by the 300s and 400s unit was observed with an excessive amount of calcium buildup (photographic evidence obtained). On 08/24/21 at 11:32 a.m., the CDM reported that PPE, such as the faceshield, should be stored in the locker, or they should keep it on. She reported that the sanitizer was new, and the ppm should be at 272. The CDM reported that she was not sure of the name of the sanitizer they use, because it is a new one. She reported that the chemical company was called, and the concern was reported. The CDM reported that she pointed the ceiling vents out to maintenance and stated the vents were concerning. She stated that paper goods should be 6 inches off the floor. The CDM stated that she was not sure if maintenance or housekeeping was responsible for cleaning the ice machine. On 08/22/21 at 11:42 a.m., the ice machine in the Nutrition Room shared by the 100s and 200s unit was observed with an excessive amount of calcium buildup (photographic evidence obtained). This was confirmed by the CDM. On 08/25/21 at 1:07 p.m., the Director of Maintenance stated that they are trying to get a replacement piece for the ice machine. He stated that the kitchen staff should put a work order in if there are concerns in the kitchen. He reported that he was aware of the vents in the kitchen and had been going back and forth with contractors about the pricing to repair the vents. The contractors were giving him the run around. The Director of Maintenance stated that he decided to repair the vents himself. He stated that he had to order the supplies and would order them on Tuesday. The document provided by the facility Three Compartment Sink- Sink & Surface Cleaner Sanitizer Concentration undated revealed the following: Testing solution should be between 272-700 pp, DDBSA (Dodecylbenzenesulfonic Acid). The policy Safe Food Handling Dietary Procedures Manual dated 11/20 revealed the following: use by date is the last date recommended for the use of the product while at peak quality. This has been determined by the manufacturer. 2. While the 2017 Food Code states that food held for more than 24 hours are marked, it is recommended that all items placed in refrigeration units be labeled with the name of the item, the date the item is placed in the refrigerator and/or the date it is to be used. 6. Refrigerators and storage areas are routinely checked for temperatures, labeling, and dating of food items with food being discarded when beyond the use-by date. A policy for the maintenance of the ceiling vents and ice machines was requested and not provided.