**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, document review, and facility policy review, the facility failed to conduct thorough investigations for five of 19 sampled residents (R) (R1, R2, R3, R5, and R6). Failure to conduct a thorough investigation could result in further incidents occurring due to unknown factors.Findings included:A review of the facility's policy titled, Abuse Prohibition/Reporting and Investigation, dated 10/2016, revealed, . Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source/origins and misappropriation of resident property, the following investigation and reporting procedures will be followed . An Interview will be conducted with all pertinent parties. Statements will be gathered from the suspect, the person making accusations, the resident involved, reliable residents who may have witnessed the incident, and any other persons who may have some information.1. A review of R1's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, indicated R1 was admitted to the facility on [DATE], and discharged [DATE], with diagnoses that included parkinsonism, obesity, urinary tract infection, ascites, abnormal weight loss, transient ischemia attack (TIA), and cerebral infarction.A review of R1's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/24/2024 and located in the EMR under the MDS tab revealed R1 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15, which indicated R1 was moderately cognitively impaired. R1 was assessed as not exhibiting any behavior.A review of R1's FRI, dated 8/15/2024 and provided by the facility, revealed, [R1] said a girl snatched her arm. Further review of the FRI revealed that although R1, her roommate, and staff were interviewed, there were no additional residents who were interviewed or assessed for injuries.2. A review of R2's undated Face Sheet, located in the EMR under the Face Sheet tab, indicated R2 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the non-dominant side, full incontinence of feces, urinary incontinence, personal history of urinary tract infections, and dementia with mood disturbance.A review of R2's annual MDS, with an ARD of 5/27/2025 and located in the EMR under the MDS tab, revealed R2 had a BIMS score of five out of 15, which indicated R2 was severely cognitively impaired. It was recorded R2 did not have any behaviors.A review of R2's FRI, dated 10/3/2025 and provided by the facility, revealed, . Email received by responsible party (RP) that [R2] has bruises to arms. Due to injury of unknown origin, investigation initiated and pending. Further review of the FRI revealed that although R2 and staff were interviewed, there were no additional residents who were interviewed or assessed for injuries.3. A review of R3's undated Face Sheet, located in EMR under the Face Sheet Tab, indicated R3 was admitted to the facility on [DATE], and discharged on 4/13/2025, with diagnoses that included disease of the spinal cord, rheumatoid arthritis, and spondylosis with myelopathy, cervical region.A review of R3's quarterly MDS, with an ARD of 2/27/2025 and located in the EMR under the MDS tab, revealed R3 had a BIMS score of six out of 15, which indicated the resident was severely cognitively impaired. R3 was assessed as not exhibiting any behaviors and was dependent on staff for toileting hygiene, shower/bathing, lower body dressing, and personal hygiene. It was recorded that R3 required substantial/maximal assistance from staff for rolling left and right and from lying to sitting on the side of the bed, and had not sustained a fall since admission.A review of R3's FRI, dated 3/25/2025 and provided by the facility, revealed, [R3] fell, causing an injury, specifically a hematoma and laceration, while receiving care . Further review of the FRI revealed that although R3 and staff were interviewed, there were no additional residents who were interviewed or assessed for injuries.4. A review of R5's undated Face Sheet, located in the EMR under the Face Sheet tab, indicated R5 was readmitted from the hospital on 7/10/2025 after falling with injuries. Diagnoses included traumatic subarachnoid hemorrhage with fracture of the base of the skull and fracture of the vault of the skull.A review of R5's significant change MDS, with an ARD of 7/18/2025 and located in the EMR under the MDS tab, revealed R5 was unable to complete the BIMS. Staff assessment of cognitive skills for daily decision making revealed R5 was moderately impaired. It was recorded R5 was independent with all activities of daily living and mobility.A review of R5's FRI, dated 7/08/2025 and provided by the facility, revealed, . Nurse on duty was notified by another staff member that [R5] was on the floor in the hallway . noted to have decreased level of consciousness with hematoma to left posterior portion of head . R5 was admitted to hospital for post follow-up diagnostics. Review of the five-day follow-up it was revealed that . another resident was in the vicinity stating, this is what you get for coming into my room. Due to the lack of witnesses to the event, it is undetermined whether this resident contributed to the fall occurrence. Further review of the FRI revealed that although staff were interviewed, no additional residents were interviewed or assessed for injuries. R5 was unable to be interviewed due to her condition.5. A review of R6's undated Face Sheet, located in the EMR under the Face Sheet tab, indicated R6 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), major depressive disorder, and diabetes mellitus with neuropathy.A review of R6's quarterly MDS, with an ARD of 5/14/2025 and located in the EMR under the MDS tab, revealed R6 had a BIMS score of one out of 15, which indicated R6 was severely cognitively impaired. It was recorded that R6 did not exhibit behaviors.A review of R6's FRI, dated 3/27/2025 and provided by the facility, revealed, [R6] verbalized staff was being rough with her while providing care . Further review of the FRI revealed that although R6 and staff were interviewed, there were no additional residents who were interviewed or assessed for injuries.During an interview on 8/27/2025 at 9:48 am, the Director of Nursing (DON) was asked if any additional residents were interviewed or assessed during the FRI investigations. The DON stated she participated in a couple of the investigations, but not all, because they were before she was employed at the facility. The DON confirmed she did not do any other residents' interviews or physical assessments. Upon review of the FRIs, the DON was unable to provide documented evidence that resident interviews and assessments had been completed with each incident.During an interview on 8/29/2025 at 2:46 am, the Administrator was asked what his expectations were related to investigations into Facility Reportable Incidents. The Administrator stated he would expect a thorough investigation, including resident interviews and assessments, to provide insight into the incidents.

Based on observation, interviews, and record review, the facility failed to maintain a facility-wide effective pest control program for the current facility population of 89 residents. This failure had the potential to lead to further pest infestation in the facility and feelings of discomfort or spread of infection among the residents.Findings included:A review of the facility's policy titled, Pest Control dated 12/2012, revealed, . It is the intent of (name of facility) to ensure that all facilities have an effective Pest Control Program .A review of the facility's Resident Council Minutes for the past year, provided by the facility, revealed:2/11/2025 - One resident's family complained of rodents in the facility. The facility's response was to schedule an exterminator monthly.2/20/2025 - List of old business: Exterminator for bugs and rodents.7/18/2025 - under list of old business (resolved): Pest control-resolved and on-going.A review of the facility's Pest Control Checklist revealed the following pest/rodent sightings:3/27/2025- three residents' rooms on South 2 unit. Mice.4/3/2025- one resident's room on South 2 unit. Mice.4/9/2025- one resident's room on South 2 unit. Mice.4/24/2025- one resident's room on South 2 unit. Mice.4/29/2025- one resident's room on South 2 unit. Mice.5/15/2025- two residents' rooms on South 2 unit. Mice.6/9/2025-one resident's room on North 2 unit. Roaches.6/10/2025-one resident's room on South 2 unit. Mice.6/13/2025- one resident's room on South 2 unit. Mice.7/1/2025- two residents' rooms on South 1 unit. Roaches.7/4/2025- one resident's room on South 2 unit. Mice.7/7/2025- two residents' rooms on North 2 unit. Bugs.7/22/2025- one resident's room on South 2 unit. Mice.A group interview was conducted on 8/28/2025 at 3:37 pm with the [NAME] President of Physical Plant, Director of Maintenance, Maintenance Administrative Assistant, and Maintenance staff. The group confirmed the facility had been experiencing an infestation of field mice. The group confirmed the facility had changed pest control/extermination contractors approximately three months ago and had an intensive six-week eradication conducted. The group confirmed the facility continues with service twice monthly, and anytime there is a spotting, the company is on-call for treatment. The infestation was elevated to the quality assurance committee before changing contractors. Monitoring was initiated throughout the building, and training was held with staff and residents concerning eliminating food and environmental issues that attract mice.During a tour of the facility on 8/28/2025 at 3:45 pm, R10 and R11, residents who have witnessed mice in their rooms, reported that it had been a couple of weeks since they had spotted any mice or heard any other residents mention mice. There were no mice observed during the survey dates of 8/26/2025, 8/27/2025, 8/28/2025, and 8/29/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to submit for a Preadmission Screening and Resident Review (PASRR) Level II after a new mental health diagnosis was added for one of three residents (R) (R17) reviewed for PASRR Level II. This deficient practice had the potential to affect the level of care and services provided for R17. Findings include: The Director of Nursing (DON) revealed there was no facility policy for PASRR. Review of the electronic medical record (EMR) revealed that R17 was admitted on [DATE] without a significant mental health diagnosis. Review of R17's annual Minimum Data Set (MDS) dated [DATE] revealed section A (Identification Information) documented the resident had not been evaluated by Level II PASRR, section I (Active Diagnoses) included and documented bipolar disorder, and section O (Special Treatments and Programs) documented no therapies or treatments were received. Review of R17's Face Sheet revealed current diagnoses included bipolar disorder, current episode depressed dated 2/14/2024, and bipolar disorder in partial remission dated 8/8/2023. Review of the EMR revealed a PASRR Level I dated 1/11/2023 did not include the diagnosis of bipolar. Further review of the EMR revealed there was no PASSR Level II. Interview on 7/13/2024 at 10:50 am, the admission Coordinator stated R17 was admitted to the facility on [DATE] with a PASRR Level I and did not have a serious mental illness diagnosis at admission. She stated the diagnosis of bipolar was added on 8/8/2023. She further stated the Social Service Director (SSD) normally received the provider notes that added the diagnosis and should have submitted for a PASRR Level II at that time. The SSD was unavailable for an interview. Interview on 7/13/2024 at 11:35 am, the Director of Nursing (DON) stated the SSD was responsible for submission for a PASRR Level II when a new serious mental illness or other qualifying diagnosis was added to a resident's diagnosis list. She stated the SSD received the provider notes and should review them to ensure new diagnoses were communicated to the clinical staff and for submission of a PASRR Level II. She further revealed new diagnoses were discussed in the clinical morning meeting and the SSD attended the meetings. The DON stated it was an oversight that a submission for a PASRR Level II was not submitted for R17 after the diagnosis of bipolar was added. She confirmed the failure to submit for a PASRR Level II in a timely manner after a serious mental illness or other qualifying diagnosis had the potential to prevent residents from receiving necessary services for serious mental illness or other qualifying diagnosis and have a negative impact on a resident's clinical and psychosocial condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of facility policies titled, Assessing Vital Signs, and Care Planning-Interdisciplinary Team, the facility failed to follow the comprehensive Care Plan regarding weekly weights for one of 33 residents (R) (R82) in the sample. Findings include: Review of the facility policy titled, Assessing Vital Signs dated February 2019 revealed Weight: Each resident should be weighed upon admission and re-admission to the facility. All weights should be recorded in designated location of the residents Chart. Residents shall be weighed monthly or more often when clinically indicated. Review of the facility policy titled, Care Planning-Interdisciplinary Team, updated October 2016, under Intent, it is the intent of Magnolia Manor facilities to provide care to our residents that is person-centered, and consistent with Resident Rights. The facilities Interdisciplinary Team shall be responsible for the development and implementation of a person-centered comprehensive care plan for our residents. Under Procedural Guidelines number 2. The care plan is based on the resident's comprehensive assessment and is developed by the Interdisciplinary Team which includes, but is not necessarily limited to the following, E. Food and nutrition services. Review of the medical record revealed R82 was admitted to the facility on [DATE] and had diagnoses that included but not limited to type 2 diabetes, chronic kidney disease stage 3, and Alzheimer's disease. Review of the comprehensive care plan revealed a Nutrition Care Plan had been developed and included an intervention to weigh weekly with a start date of 5/15/2024. Review of the vital signs section of the medical record revealed a weights section which indicated the last recorded weight for R82 was on 5/29/2024. Interview on 7/13/2024 at 2:15 pm with the Director of Nursing (DON), after review of the medial record, confirmed that the last weight for R82 was performed and recorded on 5/29/2024, and R82 has not been weighed since. The DON revealed that R82's care plan listed weekly weights as a nutrition intervention. Additional interview with the DON on 7/14/2024 at 10:10 am revealed R82 was placed on weekly weights for a month after admission because R82 had weight fluctuations. The DON stated that R82's weights were discussed during PAR (performance and accountability reporting) meetings. The PAR team determined that R82 needed weekly weights, and the care plan was updated to indicate an intervention to weigh weekly. The DON revealed that once R82's weights stabilized, the PAR team decided that discussion and weekly weights were no longer required and R82 would be discharged from PAR review. Discussion for weight fluctuations for R82 was discontinued, and he was changed to monthly weights. Further interview with the DON revealed that the lead Certified Nursing Assistant (CNA) EE was responsible for residents requiring weekly weights, and restorative nursing was responsible for residents on monthly weights. The DON stated that the lead CNA and the restorative nursing CNA attend the PAR meetings which are held weekly. If a resident goes from weekly weights to monthly weights those team members should adjust their resident list at that time. The DON revealed that R82 should have been weighed weekly after his last weight on 5/29/2024. Interview on 7/14/2024 at 10:40 am with CNA EE revealed that she was responsible for any resident that required weekly weights. The CNA stated that she did attend the weekly PAR meetings and when resident's weights were discussed she will adjust her weekly weight list during the meeting. The CNA revealed that restorative nursing attended the PAR meetings and once the team determined that a resident no longer required weekly weights, restorative knew they needed to add to the monthly weight list. The CNA revealed if she is not able to attend the PAR meeting, the DON will let her know which residents have been added to the weekly weight list and which residents no longer require weekly weights. The CNA stated that if restorative nursing does not attend the PAR meeting and a resident is discharged from requiring weekly weights, she will communicate that change from weekly weights to monthly weights. The CNA revealed that she must have missed communicated with restorative nursing and should have notified them to add R82 to the monthly weight list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled, Scope of Assessments, the facility failed to complete an admission nutrition assessment for one of five residents (R) (R82). The deficient practice had the potential to prevent R82 from receiving required nutrients in accordance with the resident's nutritional needs. Findings include: Review of the facility's policy titled, Scope of Assessments dated March 2014 revealed under Procedural Guidelines number 11. Nutritional assessments should be completed on admission, at least quarterly, and as needed based on the resident's condition and dietary needs. Review of the medical record revealed R82 was admitted to the facility on [DATE] and had diagnoses that included but not limited to, type 2 diabetes, chronic kidney disease stage 3, and Alzheimer's disease. Review of the physician orders revealed R82 had a diet order of CCD (controlled carbohydrate diet) renal. R82 was also ordered Prostat nutrition supplement 30 mL (milliliters) three times a day for low albumin and total protein level. Review of the medical record revealed, an admission nutrition assessment completed by the registered dietitian or nursing could not be found. Interview on 7/13/2024 at 2:15 pm the Director of Nursing (DON) was unable to locate an admission nutritional assessment for R82. The DON revealed that she would reach out to the registered dietitian to see if an admission nutrition assessment was completed. The DON confirmed that with no admission nutrition assessment in the medical record, nursing staff were not able to review for dietary guidance. Interview on 7/14/2024 at 10:10 am with the DON revealed the registered dietitian was not able to find a nutrition assessment for R82. The DON stated that she expected the dietitian to complete an admission nutrition assessment shortly after the resident admitted to the facility. The DON revealed that nutrition assessments were documented directly in the medical record system where data could be entered using a template. Continued interview revealed that the IDT (Interdisciplinary Team) reviewed new admission medical records to ensure all admission assessments were completed by each department. If there was no assessment the IDT should notify the responsible department/person to complete. The DON stated that IDT should have contacted the registered dietitian to complete the admission nutrition assessment for R82.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the electronic medical record (EMR) revealed R59 was admitted to the facility on [DATE] and pertinent diagnoses included but was not limited to, heart failure, cardiomegaly, chronic pulmonary edema, pleural effusion, and chronic obstructive pulmonary disease. Review of R59's admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11, which indicated R59 had moderate cognitive impairment. Review of the Care Area Assessment (CAA) on the admission MDS assessment dated [DATE] triggered care planning areas of cognitive loss/dementia, visual function, Activities of Daily Living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, and pressure ulcer. Review of R59's care plan initiated on 6/24/2024 did not include interventions related to oxygen use. Review of the EMR revealed physician's orders for R59 included but was not limited to, oxygen at two liters per minute via nasal cannula continuously dated 7/12/2024. Observations made on 7/12/2024 at 9:42 am and 3:10 pm, and on 7/13/2024 at 8:00 am, R59 was lying in bed with oxygen via nasal cannula, the flow rate was set at four liters per minute. Interview on 7/13/2024 at 8:25 am, and observation at that time of R59's oxygen flow rate, RN BB confirmed the oxygen flow meter for R59's oxygen was set at four liters per minute. RN BB revealed R59 was recently admitted to hospice services and was just ordered oxygen therapy at two liters per minute via nasal cannula on 7/12/2024 and she confirmed R59's oxygen should be on two liters per minute. RN BB also confirmed that the order in the EMR was for oxygen at two liters per minute via nasal cannula. Interview on 7/13/2024 at 9:45 am with the Director of Nursing revealed her expectation was that her staff follow the physician orders for oxygen administration and the flow rate should be what the physician ordered. She revealed that once orders are received the care plan should be addressed and updated. She revealed this practice could result in a resident experiencing respiratory distress and if the care plan does not reflect the use of oxygen could result in the team not knowing the parameters of the physician orders related to oxygen use and not providing care as ordered. Based on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Therapy, the facility failed to ensure oxygen (O2) was administered according to physician order for two of 15 residents (R) (R5 and R59) receiving oxygen. In addition, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for one of 15 residents (R11) receiving oxygen. The deficient practices had the potential to place R5, R59, and R11 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled, Oxygen Therapy, dated March 2024, revealed the Intent was, It is the intent of Magnolia Manor facilities to ensure that oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. The Procedural Guidelines, Oxygen Therapy - Mask and Nasal Cannula section stated 5. The external filter on the oxygen concentrators should be checked weekly and cleaned as needed. 1. Review of R5's diagnoses included chronic pulmonary edema, dependence on oxygen, and chronic respiratory failure. Review of R5's annual Minimum Data Set (MDS) assessment dated [DATE] revealed section GG (Functional Abilities and Goals) documented R5 was dependent on staff for activities of daily living (ADLs), and section O (Special Treatments and Programs) documented R5 received oxygen therapy while a resident. Review of the care plan revealed a focus area that R5 required the use of oxygen continuously. Interventions included administering oxygen therapy as ordered. Review of the active physician's orders revealed R5 had an order dated 2/6/2023 for oxygen at 2 liters per minute via nasal cannula continuously. Observations on 7/12/2024 at 8:40 am and 3:05 pm, and on 7/13/2024 at 7:50 am revealed R5 receiving oxygen via a nasal cannula with the flow rate set at 3.5 liters per minute. Observation on 7/14/2024 at 8:10 am with Registered Nurse (RN) BB, confirmed R5 was receiving oxygen via nasal cannula at 3.5 liters per minute, and the physician's order was for oxygen at 2 liters per minute via nasal cannula. RN BB stated that depending on the resident's diagnosis and condition, receiving too much oxygen could cause harmful effects for the resident. She stated the nurse normally checked resident's oxygen settings every shift and ensured the flow rate was set to the physician's orders. She further stated oxygen equipment was checked during daily rounds but was unsure if the flow rate was checked. RN BB revealed R5 was unable to adjust the flow rate of the oxygen. Interview on 7/13/2024 at 11:15 am, the Director of Nursing (DON) confirmed oxygen flow rates should be set to the physician's order, and the nurses were responsible for ensuring the flow rate was set to the ordered rate. She stated the nurse should check the flow rate every shift and ensure it was being administered at the ordered flow rate. She further stated administering oxygen at a rate higher than ordered by the physician could cause harmful side effects for the resident. 3. Review of R11's medical record revealed an order dated 6/11/2024 for continuous oxygen via nasal cannula (NC) at 2 liters per minute to maintain oxygen saturation above 90%. Observation of R11's oxygen concentrator on 7/12/2024 at 10:00 am, and 7/13/2024 at 8:38 am revealed that the external oxygen filter on the oxygen concentrator was visibly dirty, with accumulated dust over the entire filter. Observation of R11 on 7/12/2024 at 10:00 am and 7/13/2024 at 8:38 am revealed he was receiving oxygen via NC per MD orders. Interview with the LPN AA on 7/13/2024 at 8:43 am, she revealed she was the nurse for R11 on 7/13/2024 and had administered his medications earlier in the morning. LPN AA reported that the exterior oxygen filters on the concentrators were to be cleaned weekly and as needed. She acknowledged that R11's oxygen filter was dirty and said it was the nursing staff's responsibility to ensure it was cleaned. Interview with the DON on 7/13/2024 at 1:50 pm, she acknowledged the external oxygen filter on R11's oxygen concentrator was dirty and had accumulated dust covering the filter. The DON said she expected staff to clean the outside of the concentrators weekly and assess as needed to ensure the filter was clean. The DON added the exterior filter should always be clean.

Based on staff interviews and record review, the facility failed to ensure that medications were administered as care planned and ordered, for one of three residents (R) (R1). The deficient practice had the potential to prevent R1 from obtaining care in accordance with their care needs. Findings include: R1 was admitted to the facility with diagnoses of but not limited to type 2 diabetes mellitus. Review of the clinical record revealed that R1 had a nutrition care plan, dated 1/17/2023, that included the diagnosis of diabetes. The nutrition care plan included an intervention, dated 2/22/2024, for nursing staff to administer medication as ordered. Review of R1's physician's orders revealed an order, dated 12/18/2023, for 6 units of Novolog insulin to be administered before meals. There was also an order, dated 12/18/2023, for 30 units of Lantus insulin to be administered daily, in the morning for a diagnosis of diabetes. However, facility nursing staff failed to administer insulin medication as ordered and as care planned on 6/10/2024. Review of a Patient Instructions for Hospital Procedure form, dated 5/9/2024, for R1, from the Cardiologist office, revealed that R1 was scheduled for a vascular procedure, an Atherectomy with runoff (procedure to remove plaque buildup and open narrow or blocked arteries), on 6/10/2024. The instructions on the form included to hold insulin the day of the procedure. Review of a 6/7/2024 7:13 pm nurse's note revealed that pre-operation orders were noted for a surgical procedure scheduled for 6/10/2024. The nurse's note documented that the orders included not to give diabetic medications or insulin the day of the procedure. Review of R1's June 2024 electronic Medication Administration Record (eMAR) revealed the order of do not give any diabetic medications or insulin the day the procedure, 6/10/2024 was documented. However, further review of the June 2024 eMAR revealed that licensed nursing staff administered 6 units of Novolog insulin at 11:30 am and 4:30 pm and 30 units of Lantus insulin at 12:00 pm on 6/10/2024. During an interview on 6/25/2024 at 4:50 pm, DON stated that even though there was an order to hold insulin on 6/10/2024, there was a computer input error. When she reviewed the hold history, the Novolog insulin had been put on hold for 6/10/2024, but the time of the hold was from 12 am to 10 am, instead of the whole day, in error. Cross reference to F684

Based on staff interviews, and record review, the facility failed to ensure that medications were administered, and fingerstick blood sugar levels were obtained, as ordered by the physician, for one of three residents (R) (R1). The deficient practice had the potential to increase the probability of R16 blood glucose levels not to be maintained according to the residents' care needs. Findings included: R1 was admitted to the facility with a diagnosis of type 2 diabetes mellitus. Review of R1's physician's orders revealed an order, dated 12/18/2023, for 6 units of Novolog insulin to be administered before meals. There was also an order, dated 12/18/2023, for 30 units of Lantus insulin to be administered daily, in the morning for a diagnosis of diabetes. However, facility nursing staff failed to administer insulin medication as ordered on 6/10/2024. Review of a Patient Instructions for Hospital Procedure form, dated 5/9/2024, for R1, from the Cardiologist office, revealed that R1 was scheduled for a vascular procedure, an Atherectomy with run off (procedure to remove plaque buildup and open narrow or blocked arteries), on 6/10/2024. The instructions on the form included to hold insulin the day of the procedure. Review of a 6/7/2024 7:13 pm nurse's note revealed that pre-operation orders were noted for a surgical procedure scheduled for 6/10/2024. The nurse's note documented that the orders included not give diabetic medications or insulin the day of the procedure. During an interview on 6/26/2024 at 3:05 pm, the Director of Nursing (DON) stated that transportation picked R1 up on 6/10/2024 at 6:29 am for his procedure that day and returned to the facility at 12 noon. Review of the surgical center procedure notes revealed that R1 underwent an Atherectomy/Runoff on 6/10/2024. Review of R1's June 2024 electronic Medication Administration Record (eMAR) revealed the order of do not give any diabetic medications or insulin the day of the procedure, 6/10/2024 was documented. However, further review of the June 2024 eMAR revealed that licensed nursing staff administered 6 units of Novolog insulin at 3:49 pm and 6:30 pm and 30 units of Lantus insulin at 12:00 pm on 6/10/2024. During an interview on 6/25/2024 at 4:50 pm, DON stated that even though there was an order to hold insulin on 6/10/2024, there was a computer input error. When she reviewed the hold history, the Novolog insulin had been put on hold for 6/10/2024, but the time of the hold was from 12 am to 10am, instead of the whole day, in error. Further review of R1's clinical record revealed a physician's order, dated 12/18/2023, for licensed nursing staff to obtain finger stick blood sugar (FSBS) levels before meals and at bedtime. Review of the December 2023 through June 2024 eMARs revealed that FSBS levels were obtained at 6:00 am, 11:30 am, and 4:30 pm. However, there was no bedtime FSBS level scheduled or obtained until after surveyor inquiry on 6/18/2024. During an interview on 6/20/2024 at 1:00 pm, the DON stated there was no evidence of the bedtime FSBS reading being scheduled on the eMAR or done.

Based on staff interviews, record reviews, and review of the facility policies titled, Infection Prevention and Control, and COVID-19 Response, the facility failed to maintain an infection control program that included thorough and complete surveillance for one of 16 residents (R) (R16), who tested positive for COVID-19. Findings include: Review of the facility policy titled, Infection Prevention and Control, revision and approval date of February 2020. Under Procedural Guidelines number 4. Maintains a record of incidents and corrective actions related to infections. The facility also had a COVID-19 Response policy with a revision and approval date of July 2023. The policy's Documentation section number 2. Resident test results must be maintained in the resident's medical record, 9. A log should be kept for all resident and employee testing. Record review for R16 revealed a nurse's note entry dated 1/24/2024 at 12:47 am that documented R16 was positive for COVID and had no symptoms. The nurse's note further documented that R16's vital signs were stable, R16 denied pain or discomfort, there was no acute respiratory distress, and the plan of care continued to be in progress. A 1/25/2024 at 1:46 am Registered Dietician note also documented that R16 was diagnosed with COVID-19. Record review for R16 revealed a care plan problem, dated 1/31/2024, that R16 was at high risk for contracting COVID-19 due to risk factors of hypertension. The goal of the care plan was that R16 would be free from COVID-19 complication that required hospitalization, with an intervention start date of 1/23/2024. During an interview on 6/25/2024 at 4:11 pm the Director of Nursing (DON) stated that R16 and her roommate (R2) both tested positive for COVID-19 and remained in the room together. Although R16's clinical record included documentation of her positive COVID-19 status, she was not included in the facility's infection control surveillance information. Review of the January 2024 Line Listing of Resident Infections, a part of the facility's infection control program, and review of the facility line list (for 2024) specifically for COVID-19 positive residents, revealed that R16 was not included in either tracking log. During an interview on 6/27/2024 at 4:30 pm, the DON stated that there was no evidence of a COVID-19 testing sheet for R16 for the 1/24/2024 positive COVID-19 test.

Based on staff interviews, record review, and review of the facility policy titled, Infection Prevention and Control, the facility failed to ensure that the Pneumococcal vaccine was administered to three of 18 residents (R) (R12, R13, and R16). Findings include: Review of the facility policy titled, Infection Prevention and Control revision and approval date of February 2020. Under section titled, Influenza and Pneumococcal Immunization number 1. Each resident or resident representative must receive education regarding the benefits and potential side effects from the Pneumococcal immunization. 3. Each resident will be offered the vaccine on admission, and 5b. documentation must include if the resident received the immunization. 1. Review of R12's clinical record and facility vaccination information revealed a Pneumococcal Polysaccharide Vaccine (PPSV23) Informed Consent, signed and dated 10/14/2022. The form documented that R12 consented to receiving the pneumococcal vaccine. However, there was no evidence in the clinical record that the vaccine had been administered. During the interview on 6/27/2024 at 4:30 pm, the DON stated that she could not find evidence of the pneumonia vaccine being given to go with the consent. 2. Review of R13's clinical record and facility vaccination information revealed a Pneumococcal Immunization Informed Consent form, signed and dated 10/17/2022. The form documented that R13 consented to receive the pneumococcal vaccine. However, there was no evidence in the clinical record that the vaccine had been administered. During the interview on 6/27/2024 at 4:30 pm, the DON stated that she could not find evidence of the pneumonia vaccine being given to go with the consent. 3. Review of R16's clinical record and facility vaccination information revealed a Pneumococcal Immunization Informed Consent form, signed and dated 12/1/2023. The form documented that R13's responsible party consented to her receiving the pneumococcal vaccine. However, there was no evidence in the clinical record that the vaccine had been administered. During an interview on 6/27/2024 at 4:30 pm, when the Director of Nursing (DON) was asked about the process for influenza and pneumococcal vaccinations, she responded that the assigned nurse is to offer the vaccine and administer once the consent is obtained. When the vaccine is administered, it is to be documented on the electronic Medication Administration Record (eMAR). The Infection Preventionist (the Assistant Director of Nursing) oversees that process. The unit managers also assist with obtaining vaccination consent and communication to the assigned nurse. DON stated that she could not find evidence of the pneumonia vaccine being given to go with the consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of policy titled, Abuse Prohibition/ Reporting and Investigation, it was determined the facility failed to ensure residents were free from misappropriation of property for one (Resident #38) of two residents reviewed for abuse, neglect, misappropriation of resident property, and exploitation. Specifically, the facility failed to ensure Resident #38 was free from alleged misappropriation of property related to missing medication. Findings include: A review of the facility policy, Abuse Prohibition/ Reporting and Investigation, revised on 04/2017, revealed the policy defined misappropriation of resident property as the Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Per the policy, Each facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. A review of an admission Record revealed the facility admitted Resident #38 with diagnoses that included polyneuropathy (nerve pain), chest pain, dorsalgia (back/spine pain), and major depressive disorder. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed Resident #38 received as needed (PRN) pain medication and was almost constantly in pain. A record review of Resident #38's care plan, initiated on 03/01/2022, revealed the resident complained of daily headaches, some severe in nature, and the pain medication relieved the resident's pain. The facility developed an intervention to administer pain medication as ordered and/or indicated. During an interview on 10/03/2022 at 10:40 AM, Resident #38 reported pain in both feet and ankles but was unsure if they (the resident) received any pain medication for the pain. A review of Resident #38's Physician Orders indicated the resident had an order for an opioid pain medication, hydrocodone/acetaminophen (APAP) 5 milligrams (mg)/325 mg, and to take one tablet every six hours as needed for pain, with a start date of 07/20/2022. A review of Resident #38's Medication Administration Record (MAR) for September 2022 was reviewed and revealed the resident received the hydrocodone/APAP on the following dates: 09/04/2022, 09/08/2022, 09/09/2022, 09/13/2022, 09/22/2022, 09/24/2022, and 09/27/2022. The back page of the MAR, where any PRN medication was documented, included the date/time given, the medication, the route of administration, the reason for administration, the results/response of the medication, the time noted of the results, and the nurse's signature. For the hydrocodone/APAP, the back of the MAR indicated the resident received the medication on 09/04/2022 at 9:00 PM, on 09/08/2022 at 8:00 PM, on 09/09/2022 at 9:00 AM, on 09/13/2022 at 7:00 PM, on 09/22/2022 at 9:15 PM, on 09/24/2022 at 8:00 PM, on 09/27/2022 at 9:00 AM, and on 09/28/2022 at 8:00 PM. The front of the MAR did not indicate any hydrocodone was provided to the resident on 09/28/2022 at 8:00 PM. A review of Control Drug Record for Resident #38 indicated the medication hydrocodone-APAP 5-325 tablet was signed out on 09/04/2022 at 10:00 AM, on 09/04/2022 at 9:00 PM, on 09/06/2022 at 5:00 PM, on 09/08/2022 at 8:00 PM, on 09/09/2022 at 9:00 AM, on 09/13/2022 at 7:00 PM, on 09/16/2022 at 10:45 AM, on 09/22/2022 at 9:20 PM, on 09/24/2022 at 8:00 PM, on 09/27/2022 at 9:00 PM, on 09/28/2022 at 8:30 PM, and on 09/30/2022 at 6:30 PM. The September MAR did not include the medication that was documented on the Control Drug Record for four doses recorded on 09/04/2022 at 10:00 AM, 09/06/2022 at 5:00 PM, 09/16/2022 at 10:45 AM, and 09/30/2022 at 6:30 PM. Three of the four doses were signed out by Licensed Practical Nurse (LPN) DD and one dose by LPN MM. The bottom of the document indicated there were missing doses for doses #17-22. No date was listed next to the note to indicate when the missing doses were noticed. A review of Resident #38's Medication Administration Record (MAR) for October 2022 was conducted on 10/04/2022 by the surveyor, which indicated the resident did not receive any hydrocodone/APAP from 10/01/2022 to 10/04/2022. A review of Control Drug Record for Resident #38 indicated the medication hydrocodone-APAP 5-325 tablet was signed out on 10/01/2022 at 9:30 PM and on 10/02/2022 at 6:05 PM by LPN DD. The October MAR did not include the medication that was documented on the Control Drug Record for the two doses recorded. A review of an untitled, undated facility incident regarding missing narcotic medication for Resident #38 included a photocopy of the resident's medication card/bubble pack. The medication card had 16 tablets left in the card and handwritten notes that indicated the incident occurred on 09/10/2022 at 7:10 PM for which the Director of Nursing (DON) was notified and then the on-call pharmacist was notified at 7:25 PM. A Communication Result Report indicated the pharmacy was faxed a copy of the medication card on 09/10/2022 at 8:00 PM. Two drug screening reports were provided with the incident as well as the Control Drug Record that had the same handwritten information as the medication card/bubble pack regarding notifications. During an interview on 10/05/2022 at 9:06 AM, LPN DD stated the resident had an order for hydrocodone 5 mg/325 mg and took it as needed. At this time, LPN DD reviewed the MAR and stated the resident received the medication every six hours, as needed. LPN DD then reviewed the Narcotic Log and stated the last time she provided the resident with the medication was on 10/02/2022. LPN DD stated that when she provided the medication to the resident, she documented it on the front of the MAR, the back of the MAR, documented it in the progress notes in the resident's electronic health record (EHR), and signed the medication out in the narcotic book. After reviewing the MAR and narcotic book, LPN DD stated she did provide the narcotic on 10/01/2022 and 10/02/2022 and the medication should have been documented on the MAR and stated, I don't have an excuse for why it's not documented on the MAR. LPN DD further stated that staff were supposed to document on the back of the MAR, the pain level, the date/time the medication was given, and document the medications effectiveness. At this time, LPN DD was asked to review the discrepancies for the medication provided in September 2022, and LPN DD stated for every entry on the narcotic log, she provided the medication to the resident. LPN DD stated the documentation at the bottom of the narcotic log that indicated missing medication was documented by LPN EE, also the Unit Manager, and the occurrence happened in September, but it was related to another nurse. LPN DD stated she believed LPN EE came in to work and counted the narcotics with another nurse and that was when they noticed there were medications missing. During an interview on 10/05/2022 at 9:18 AM, LPN EE stated Resident #38 had an as-needed order for narcotic pain medication. LPN EE stated that when a narcotic medication was given to a resident, the nurse had to sign it out on the front part of the MAR, in the narcotic book, and then on the back of the MAR. The back of the MAR indicated the time the medication was given, the location of the pain, and the pain level. The MAR was then flagged to remind the nurse to revisit the resident and assess the effectiveness of the pain medication. LPN EE stated she was on call the day she documented there were missing narcotic pills for Resident #38. She had to come in and work a 7:00 PM to 11:00 PM shift. LPN EE stated that when she came in to count the medication cart with the nurse, she advised the nurse that she could not accept the cart because there were missing medications for pills #22, #21, #20, #19, #18, and #17. [The medication bubble-pack cards are labeled with numbers for each pill]. LPN EE stated she notified the Director of Nursing (DON) regarding the missing pills and LPN MM was the nurse she would not accept the cart from. LPN EE stated LPN TT signed with her as a witness that the medication was missing, and LPN TT took over the cart from LPN EE. LPN EE stated she called the pharmacy and notified them of the missing medication. LPN EE stated that per the DON, LPN MM had to provide a urine sample for a drug screening, which was acquired before LPN MM left the facility. LPN EE stated LPN MM was allowed to come back to work after the incident. During an interview on 10/05/2022 at 9:41 AM, DON BB stated when a resident complained of pain and a PRN pain medication was provided, the nurse should document the administration on the front of the MAR that it was given. The nurse also had to document on the back of the MAR the date and time the medication was given and the effectiveness of the medication, as well as document in the progress notes in the resident's EHR. DON BB stated when she was notified of the six missing pills by LPN EE for Resident #38, she had LPN EE and LPN MM write statements, along with other nurses that worked with the resident on 09/10/2022. DON BB stated she had both nurses provide a urine sample before they were allowed to leave the facility. DON BB stated there was no evidence that LPN MM had taken the resident's medication. DON BB stated she never received the actual results of the urine drug screening because the pharmacy would have notified the facility if either staff member were positive for any substance. DON BB stated she did not notify the state agency of the missing medication but stated the incident could be misappropriation of property. DON BB stated the facility's findings were inconclusive, and there was no resolution to the missing medication. At this time, DON BB was shown the resident's September and October MARs, along with the narcotic log that indicated there was no documentation on the MAR for the narcotic. Per the narcotic log, the pain medication was given on 09/04/2022, 09/06/2022, 09/16/2022, 09/30/2022, 10/01/2022, and 10/02/2022. These dates were not listed on the MAR that the medication was provided. DON BB stated if she would have done a thorough audit when the missing medications were missing on 09/10/2022, the undocumented medication on 09/04/2022 and 09/06/2022 would have been identified. DON BB stated that by comparing the MAR and narcotic log, it appeared the medication was punched out of the medication card but not given. DON BB was asked to provide documentation regarding the investigation as well as any in-services provided to staff. DON BB stated the only documentation she had was a copy of the medication card/bubble pack that indicated the date/time of notification to the pharmacy and doctor, as well as the orders for the urine drug screening. No interviews, witness statements, or in-services were provided to the surveyor. During an interview on 10/05/2022 at 10:21 AM, Administrator AA stated she was made aware of the missing narcotic medication for Resident #38 but was unaware of the date. Administrator AA stated LPN MM had been interviewed regarding the incident and also completed a urine drug screen. Administrator AA stated the facility did not receive any notification that LPN MM's drug screen was positive but did not follow up with the lab company to get the paper copy of the drug screen. Administrator AA stated the facility normally did an investigation of the missing medication, drug screened staff that were involved, and the DON would report it to the state agency. Administrator AA stated that missing medication would be considered misappropriation of property. Administrator AA stated the resident's medication did go missing and the facility was unable to find out where it went. At this time, Administrator AA was shown the resident's September and October MARs, along with the narcotic log that indicated there was no documentation on the MAR for the narcotic. Per the narcotic log, the pain medication was given on 09/04/2022, 09/06/2022, 09/16/2022, 09/30/2022, 10/01/2022, and 10/02/2022. These dates were not listed on the MAR that the medication was provided. Administrator AA stated that if there was no documentation on the MAR, then it looked like the medication was probably not given. The Administrator stated if a narcotic medication was given, it should be documented on the MAR and the narcotic book. During an interview on 10/05/2022 at 1:55 PM, LPN MM stated she was unable to recall the exact date the missing medication occurred for Resident #38; however, she stated she arrived at the facility for the 7:00 AM shift around 7:30 AM. LPN MM stated that since she arrived late, LPN UU had already counted the narcotics on the medication cart and LPN MM did not count the medications before accepting the cart from LPN UU. LPN MM stated, My mistake was not counting with her again. I accepted the cart without counting. LPN MM stated that when she was getting ready to leave her shift that evening, she counted the cart with LPN EE, and that was when she noticed the discrepancy with the missing narcotics. She stated LPN EE called the DON and the pharmacy to notify them of the missing narcotics and then she had to provide a urine sample for a drug test. LPN EE stated that as far as she was aware, that was all the facility did, and she was allowed to come back to work a few days later. LPN MM stated she was unaware of any staff member taking the resident's narcotic medication. LPN MM stated that if she did provide any narcotic medication to the resident, she would document it on the front of the MAR, in the narcotic book, and on the back of the MAR, which included the time, medication, route, and what the medication was for. Then, approximately 45 minutes later, she would document the effectiveness of the medication.

Based on observation, record review, interviews, and document and review of policy titled, Abuse Prohibition/Reporting and Investigation revealed, it was determined that the facility failed to ensure established abuse policies and procedures were implemented after receiving an allegation of abuse for one [Resident (R) #88] of two residents sampled for the implementation of abuse prohibition policies and procedures. Facility staff had not been educated what to do after receiving an allegation of abuse, and as a result, an allegation of physical abuse failed to be reported. Findings included: A review of an undated facility policy titled, Abuse Prohibition/Reporting and Investigation revealed, (revised and updated April 2017) Reporting: 1) Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse including injuries of unknown source/origin and misappropriation of resident property the incident will be immediately reported. The policy also indicated c. The initial report of the incident will be faxed or emailed immediately but no more than 2 hours of abuse or an incident that results in serious injury or within 24 hours when there is no abuse or serious injury to the HFR [Healthcare Facility Regulation Division] Complaint Investigation Intake and Referral Unit and 2) A written report of investigation will be submitted to the HFR Long Term Care Section Complaint Coordinator, within (5) working days of the incident. A review of a Face Sheet dated 10/05/2022 revealed R#88 had diagnoses which included hemiplegia and hemiparesis following cerebrovascular disease (admission), atrial fibrillation, long-term (current) use of anticoagulants, long-term (current) use of aspirin, osteoarthritis, altered mental status, late effects of cerebrovascular disease, cognitive deficits, and age-related osteoporosis without current pathological fracture. A review of R#88's quarterly Minimum Data Set (MDS) assessment, dated 09/06/2022, revealed the resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. A review of R#88's Progress Notes, dated 09/25/2022 at 5:28 PM, revealed that, as reported by a family member to a nurse at 4:45 PM, R#88 alleged a certified nurse aide (CNA) hurt the resident's right hand during morning care. The progress note revealed the nurse assessed the resident's hand, noting the right ring finger appeared swollen. Per the note, a family member and medical doctor (MD) were notified. The note was signed by Licensed Practical Nurse (LPN) CC. A review of R#88's Resident Incident Report, with a Date/Time of 09/25/2022 at 4:45 PM, revealed that, as reported by a family member to a nurse, R#88 alleged a CNA hurt the resident's right hand during morning care. The progress note revealed the resident's right ring finger appeared swollen. Per the report, an Immediate Post-Incident Action was implemented instructing staff to be more careful when rendering care. The report also indicated the physician and family were notified on 09/25/2022. The review revealed the question Reported to Supervisor was answered with No. There was no indication on the report that Director of Nursing (DON) BB or Administrator AA were notified of the reported allegation. A review of a Facility Incident Report Form, dated 09/29/2022, revealed it was submitted by DON BB on 09/29/2022 with the type of incident noted to be staff-to-resident abuse. Per the report form, R#88 alleged an employee picked up the resident's whole hand and rung it like a rag. The report identified blue/green discoloration to the resident's right hand and right fourth finger. Per the report, the facility identified steps taken to prevent further incidents as Investigation pending. On 10/03/2022 at 10:06 AM, during the initial tour, an observation was made of R#88 lying in bed on back. Areas of discoloration were noted to the resident's right index and middle fingers. During a phone interview on 10/05/2022 at 2:07 PM, LPN CC reported she was called to R#88's room by the resident's family, at which time she was informed the resident reported staff hurt his/her finger while giving him/her a bath that morning. LPN CC stated she then checked the resident's finger, which the resident was able to move. LPN CC noted she documented the resident's assessment on Incident and Accident and 24-hour reports. She confirmed she did not report the allegation of abuse to DON BB or Administrator AA or obtain witness statement from staff who cared for the resident that morning because she was unaware of the need to do so. LPN CC confirmed she had not been given instructions regarding what to do when she received an allegation of abuse. During an interview on 10/05/2022 at 2:45 PM, DON BB indicated that if any staff witnessed or received an allegation of abuse, they were to immediately report the allegation of abuse to the Abuse Prevention Coordinator (Administrator/Designee). She indicated new hires and agency staff were supposed to be in-serviced regarding abuse reporting requirements upon hire, annually thereafter, and as needed. She reported she became aware of the incident regarding R#88 when she came to work on 09/26/2022, though the incident had occurred the afternoon of 09/25/2022. She confirmed the incident regarding Resident #88 was not handled according to the facility's Abuse Prevention Protocol. She reported the Administrator, the Assistant Director of Nursing (ADON), and/or the DON should have been notified immediately after receiving R#88's allegation of abuse. She confirmed LPN CC was an agency staff member who had started working a week or two prior to receiving the allegation of abuse, noting LPN CC should have received Abuse Prevention Protocol training prior to her first shift. DON BB indicated that since she could not find a copy of LPN CC's Abuse Prevention Protocol in-service/training, she could not confirm LPN CC received the training. DON BB then indicated that, as LPN CC's supervisor, DON BB should had made sure LPN CC received Abuse Prevention Protocol training prior to working her first shift, which occurred on 09/19/2022. DON BB confirmed she should have been made aware of the incident as alleged by R#88 the day it allegedly occurred on 09/25/2022, but noted she was not made aware of it until the day after, on 09/26/2022. DON BB also confirmed she did not start an investigation into the alleged abuse or submit a report to the state agency until 09/29/2022. DON BB stated she should have started the investigation immediately and should have reported the allegation within two hours since the resident had bruising. During an interview on 10/05/2022 at 3:26 PM, Administrator AA indicated she was not made aware of the allegation of abuse involving R#88 until 09/26/2022. She confirmed DON BB, the ADON, and/or Administrator AA should have been made aware of the allegation of abuse the day it was reported so they could begin an investigation and protect all residents from any further potential abuse. She indicated all staff were supposed to receive abuse prohibition training before their first day, annually, and as needed thereafter. She also confirmed the investigation into the allegation did not begin immediately after being made aware of the allegation and should have been reported within two hours due to Resident #88's injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of policy titled, Abuse Prohibition/ Reporting and Investigation, it was determined the facility failed to ensure an allegation of abuse was investigated for one (Resident #38) of two residents reviewed for abuse. Specifically, the facility failed to investigate alleged misappropriation of Resident #38's narcotic medication. Findings include: A review of facility policy, Abuse Prohibition/ Reporting and Investigation, revised on 04/2017, indicated, 1. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse including injuries of unknown source/origin and misappropriation of resident property the following investigation and reporting procedures will be followed: a. The description of the alleged complaint is written on the investigation form. Any physical evidence and description of emotional state will be documented. The policy further indicated that the investigation should include what occurred, who the alleged victim was, who alleged perpetrator was, description of the occurrence and when/where the occurrence happened, and why the occurrence happened. The facility should conduct interviews of all pertinent parties with written statements, if possible. A review of the admission Record revealed the facility admitted Resident #38 with diagnoses that included polyneuropathy (nerve pain), chest pain, dorsalgia (back/spine pain), and major depressive disorder. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed Resident #38 received as needed (PRN) pain medication and was almost constantly in pain. A review of Resident #38's Physician Orders indicated the resident had an order for an opioid pain medication, hydrocodone/acetaminophen (APAP) 5 milligrams (mg)/325 mg and to take one tablet every six hours as needed for pain, with a start date of 07/20/2022. A review of Resident #38's Medication Administration Record (MAR) for September 2022 revealed the resident received the hydrocodone/APAP on the following dates: 09/04/2022, 09/08/2022, 09/09/2022, 09/13/2022, 09/22/2022, 09/24/2022, and 09/27/2022. The back page of the MAR, where any PRN medication would be documented, included the date/time given, the medication, the route of administration, the reason for administration, the results/response of the medication, the time noted of the results, and the nurse's signature. For the hydrocodone/APAP, the back of the MAR indicated the resident received the medication on 09/04/2022 at 9:00 PM, on 09/08/2022 at 8:00 PM, on 09/09/2022 at 9:00 AM, on 09/13/2022 at 7:00 PM, on 09/22/2022 at 9:15 PM, on 09/24/2022 at 8:00 PM, on 09/27/2022 at 9:00 AM, and on 09/28/2022 at 8:00 PM. The front of the MAR did not indicate any hydrocodone was provided to the resident on 09/28/2022 at 8:00 PM. A review of Control Drug Record for Resident #38 indicated the medication hydrocodone-APAP 5-325 tablet was signed out on 09/04/2022 at 10:00 AM, on 09/04/2022 at 9:00 PM, on 09/06/2022 at 5:00 PM, on 09/08/2022 at 8:00 PM, on 09/09/2022 at 9:00 AM, on 09/13/2022 at 7:00 PM, on 09/16/2022 at 10:45 AM, on 09/22/2022 at 9:20 PM, on 09/24/2022 at 8:00 PM, on 09/27/2022 at 9:00 PM, on 09/28/2022 at 8:30 PM, and on 09/30/2022 at 6:30 PM. The September MAR did not include the medication that was documented on the Control Drug Record for four doses recorded on 09/04/2022 at 10:00 AM, 09/06/2022 at 5:00 PM, 09/16/2022 at 10:45 AM, and 09/30/2022 at 6:30 PM. Three of the four doses were signed out by LPN DD and one dose by LPN MM. The bottom of the document indicated that there were missing doses for doses #17-22. No date was listed next to the note to indicate when the missing doses were noticed. Resident #38's Medication Administration Record (MAR) for October 2022 was reviewed on 10/04/2022 by the surveyor, which indicated the resident did not receive any hydrocodone/APAP from 10/01/2022 to 10/04/2022. However, a review of the Control Drug Record for Resident #38 indicated the medication hydrocodone-APAP 5-325 tablet was signed out on 10/01/2022 at 9:30 PM and on 10/02/2022 at 6:05 PM by LPN DD. The October MAR did not include the medication that was documented on the Control Drug Record for the two doses recorded. A review of an untitled, undated facility incident regarding missing narcotic medication for Resident #38 included a photocopy of the resident's medication card/bubble pack. The medication card had 16 tablets left in the card and handwritten notes that indicated the incident occurred on 09/10/2022 at 7:10 PM for which the Director of Nursing (DON) BB was notified and then the on-call pharmacist was notified at 7:25 PM. A Communication Result Report indicated the pharmacy was faxed a copy of the medication card on 09/10/2022 at 8:00 PM. Two drug screening reports were provided with the incident as well as the Control Drug Record that had the same handwritten information as the medication card/bubble pack regarding notifications. During an interview on 10/05/2022 at 9:41 AM, DON BB stated when she was notified of the six missing pills by LPN EE for Resident #38, she had LPN EE and LPN MM write statements, along with other nurses that worked with the resident on 09/10/2022. DON BB stated the facility's findings were inconclusive, and there was no resolution to the missing medication. The DON stated for allegations of abuse, she would start an investigation and start getting statements from staff members and would report the allegation online in the state's online portal within two hours and then had five days to complete a final report. At this time, DON BB was shown the resident's September and October MARs, along with the narcotic log that indicated there was no documentation on the MAR for the narcotic. Per the narcotic log, the pain medication was given on 09/04/2022, 09/06/2022, 09/16/2022, 09/30/2022, 10/01/2022, and 10/02/2022. These dates were not listed on the MAR that the medication was provided. DON BB stated if she would have done a thorough audit when the missing medications were missing on 09/10/2022, the undocumented medication on 09/04/2022 and 09/06/2022 would have been identified. The DON stated that by comparing the MAR and narcotic log, it appeared the medication was punched out of the medication card but not given. The DON was asked to provide documentation regarding the investigation as well as any in-services provided to staff. The DON stated the only documentation she had was a copy of the medication card/bubble pack that indicated the date/time of notification to the pharmacy and doctor, as well as the orders for the urine drug screening. No interviews, witness statements, or in-services were provided to the surveyor. During an interview on 10/05/2022 at 10:21 AM, Administrator AA stated she was made aware of the missing narcotic medication for Resident #38 but was unaware of the date. Administrator AA stated LPN MM had been interviewed regarding the incident and completed a urine drug screen. The Administrator stated the facility did not receive any notification that LPN MM's drug screen was positive but did not follow up with the lab company to get the paper copy of the drug screen. Administrator AA stated the facility normally did an investigation of the missing medication and drug screened staff that were involved. Administrator AA stated that missing medication would be considered misappropriation of property but did not know why it was not investigated. Administrator AA stated the resident's medication did go missing and the facility was unable to find out where it went.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of policy titled, Oxygen Therapy-Mask and Nasal Cannula, it was determined the facility failed to store the oxygen tubing and nasal cannula in a sanitary manner when not in use for one (Resident [R] #41) of two residents. Findings include: A review of the facility policy, Oxygen Therapy-Mask and Nasal Cannula, dated October 2016, revealed it did not address the storage of oxygen tubing/nasal cannulas when not in use. A review of R#41's Face Sheet revealed the facility admitted the resident with diagnoses which include dementia, shortness of breath, dependence on supplemental oxygen, and dysphagia (difficulty with swallowing). A review of a significant change Minimum Data Set (MDS), dated [DATE], revealed R#41 had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had moderately impaired cognition. Per the MDS, R#41 required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use, personal hygiene, and bathing, and was dependent on staff for locomotion on the unit. The MDS noted the resident received oxygen therapy while a resident at the facility. A review of R#41's Physician Orders Summary, dated 10/01/2022, revealed the following order: Oxygen at 2 liters via nasal cannula for O2 [oxygen]. The following observations were made of R#41's oxygen tubing: On 10/03/2022 at 1:57 PM in R#41's room, the resident's oxygen tubing with nasal cannula was observed on the floor beside the resident's bed, attached to a concentrator. The tubing and nasal cannula were not in a storage bag. On 10/04/2022 at 8:31 AM in R#41's room, the resident was observed lying in bed with eyes closed, and the nasal cannula was in the resident's nose and attached to the concentrator. R#41's wheelchair was beside the bed, and there was another oxygen tubing set with a nasal cannula attached to the oxygen tank on the back of the wheelchair. The tubing was observed on the seat of the wheelchair, not in a storage bag, with clothing and shoes placed on top of the tubing with the nasal cannula. On 10/04/2022 at 1:17 PM, the oxygen concentrator was running in R#41's room, with the tubing and nasal cannula lying across the bed, not in a storage bag. During an interview on 10/04/2022 at 1:33 PM, Certified Nursing Assistant (CNA) NN stated that when oxygen tubing was not in use, staff were to place the tubing, with the nasal cannula, in a storage bag and were to make sure the tubing/nasal cannula did not touch the floor and become contaminated. Per CNA NN, if the tubing was found out of the storage bag, the staff were instructed to replace it. CNA NN further stated surfaces such as a chair, bed, or floor would be considered dirty. During an interview on 10/04/2022 at 1:55 PM, CNA OO stated that when not in use, oxygen should be turned off and the tubing/nasal cannula were to be stored in a provided bag and kept in a safe place, off the floor. CNA OO further stated the tubing/nasal cannula were to be kept clean and not contaminated. Per CNA OO, if the tubing/nasal cannula touched the floor, was left on dirty linen or a table, or was left in the seat of the wheelchair, it would be considered contaminated. During an interview on 10/04/2022 at 2:10 PM, Licensed Practical Nurse (LPN) PP, the unit manager, stated oxygen tubing/nasal cannulas were changed weekly by the night shift staff. Per LPN PP, the tubing/nasal cannulas should be stored in a clear bag when not in use to prevent them from becoming dirty or soiled. LPN PP further stated if a nasal cannula was found on the floor or not placed in the bag and then reinserted in the resident's nares, there was a potential to cause a respiratory infection. LPN PP was asked to look at R#41's oxygen tubing/nasal cannula lying on the resident's bed. LPN PP stated the tubing/nasal cannula should not be stored on the resident's bed, and she would throw away and replace them with clean tubing/nasal cannula. During an interview on 10/05/2022 at 2:02 PM, the Director of Nursing (DON) stated all oxygen tubing, along with the nasal cannulas, were changed weekly by night shift staff. The DON noted when not in use, oxygen tubing and nasal cannulas should be stored in a clear plastic bag to prevent contamination. The DON further stated if left exposed on the floor, bed, or any other surface and if not kept clean, there was a potential for infection when placing the contaminated tubing/nasal cannula in the resident's nose. The DON stated she expected the staff to keep the tubing/nasal cannula in the provided bags. During an interview on 10/05/2022 at 4:29 PM, the Administrator stated the oxygen tubing with attached nasal cannula should be stored in the bags provided for that purpose when not in use. The Administrator further stated the staff knew the process, and it was her expectation that staff kept the tubing/nasal cannulas in the provided bags.

Based on observations, interviews, record review, and review of policy titled Dental Services, it was determined that the facility failed to ensure one [Resident (R) #37] of one resident obtained needed dental services after the resident voiced experiencing sore gums. This failure resulted in the resident experiencing gum discomfort and a potential for a diminished quality of life. The facility census was 101 residents. Findings include: A review of a facility policy titled, Dental Services, with a written and approved date of November 2016, indicated It is the intent of [corporation name] facilities that appropriate Dental Services are provided to meet the needs of the residents. The policy also indicated The facility will assist the resident to scheduling [sic] a dental appointment and arrange for transportation to and from dental services locations at the request of the resident. A review of a Face sheet revealed the facility admitted R#37 on 04/08/2019 with diagnoses to include diabetes. A review of the resident's annual Minimum Data Set (MDS) assessment, dated 02/04/2022, revealed R#37 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident had intact cognition. Under section L, the MDS revealed that R#37 had no natural teeth or tooth fragments. Per the MDS, the resident was able to complete own oral care. In an interview with R#37 on 10/03/2022 at 1:03 PM, the resident was observed to be missing all teeth. The resident stated he/she used to have dentures but lost them. R#37 stated his/her gums were sore and tender. R#37 was not sure if or when an appointment would be made with a dentist for treatment. On 10/04/2022 at 1:00 PM, the resident was observed sitting on their bed, eating lunch. The resident was eating mashed potatoes and soup. A review of R#37's Care Plan, with a start date of 02/08/2022, revealed, I'm missing all of my natural teeth, was seen be [sic] in-house dentist, but now wish to see outside dentist. My gums are sore, I use mouth wash frequently. An intervention in the care plan, with a start date of 02/08/2022, directed social services staff to arrange outside appointments with a dentist as needed. During an interview on 10/04/2022 at 3:12 PM, Staff JJ, MDS Nurse, revealed the care plan note regarding R#37's dental status came from the resident's oral assessment that she completed. Staff JJ stated she let nursing and social services know about the resident's need for a dental appointment. During an interview on 10/04/2022 at 2:35 PM, Staff KK, Certified Nurse Assistant (CNA), stated R#37 was able to feed self, sometimes had pain in their mouth, and had difficulty eating hard foods. Staff KK stated she reported the resident's mouth pain to the nurse but did not remember to which nurse it had been reported too, stating, It's been a while. During a follow-up interview on 10/05/2022 at 10:56 AM, Staff JJ, MDS Nurse, stated she was not able to find any information about R#37 being seen or referred to a dentist in February 2022 when the resident voiced a concern about sore gums and expressed a desire to see a dentist. During an interview on 10/05/2022 at 3:35 PM, Staff LL, Social Services, stated, I'll be honest with you, the resident just fell through the cracks. [R#37] is now scheduled to see the dentist. Staff LL indicated it was possible that the previous social worker was supposed to schedule a dental appointment for the resident but didn't. During an interview on 10/05/2022 at 4:43 PM, Staff AA, Administrator, stated when a resident voiced mouth pain, her expectation was for staff to notify the physician first. Staff AA noted the facility had a dental consultant and identified that, if a resident expressed tooth or mouth pain, staff should send a referral and obtain something to ease the resident's pain. During an interview on 10/05/2022 at 4:52 PM, Staff BB, Director of Nursing stated, when a resident voiced mouth pain, she expected CNA staff to report the issue to a nurse. She noted she then expected the nurse to assess the resident for any oral issues, notify the physician, carry out any associated orders, enter documentation, and make a referral.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a clean and homelike environment for residents in three of four hallways in the facility. As evidenced by dark brown stains with a black substance on ceiling tiles (outside of room [ROOM NUMBER], 207, and 208) and four air ventilation grates were covered with an unidentified black substance (on the outside of rooms 202, 215, 216, and 227) on three of four hallways Findings include: During an interview on 10/05/2022 at 8:47 AM, Director of Maintenance (DM) QQ stated his role was to provide the tools necessary to ensure the maintenance staff had what they needed to maintain the building in good shape. DM QQ further stated there was a monthly inspection process to go through the building and determine what needed to be done. DM QQ noted a room inspection checklist was used, and if something did not meet their standards a work order would be placed to have the items repaired. He stated the goal was to get repairs completed within 72 hours, but the maintenance department was short-staffed, and it sometimes took longer as he based repairs on priority to ensure main items such as sinks/lights/faucets were working. DM QQ stated they were trying to get all the ceiling tiles replaced. Per DM QQ, the entire building needed new ceiling tiles, but they were not as important as a toilet overflowing, so they replaced the ceiling tiles as they went. He further stated that when the ceiling tiles were stained due to leaks, he needed to investigate the leak first and then replace any affected tiles, and this was something that happened daily. He noted he only had one maintenance technician, but should have two technicians, and he had to prioritize that person's work. DM QQ was asked to provide evidence of the most recent building inspections and the work orders associated with the inspection. During an interview on 10/05/2022 at 9:07 AM, Maintenance Technician (MT) RR stated he did the maintenance for the building by himself. He noted he received work orders but had to focus on the items that were high priority. MT RR further stated he was responsible for the room inspections but had not been able to do them due to his workload and he depended on staff to let him know of things that needed repair. He stated ceiling tiles should not be stained or falling out of the ceiling. He noted he would like to get all the ceiling tiles replaced but could not get that done at this time. The maintenance technician stated he was aware there were a lot of ceiling tiles to be replaced. During an observation with MT RR at the time of the interview outside of room [ROOM NUMBER], MT RR stated the tile needed to be replaced and he would change the tile immediately. On 10/05/2022 at 10:10 AM, observations of two ceiling tiles in the hallway outside of rooms [ROOM NUMBERS] revealed the ceiling tiles were heavily stained with a black substance noted within the staining. Further observations in the hallway revealed four ceiling air vents outside of Rooms 215, 216, 227, and 202 had a black substance on and around each vent. On 10/05/2022 at 10:16 AM, an interview with the Administrator revealed she had been made aware by DM QQ there were concerns regarding the ceiling tiles and the air vents. The Administrator stated a mock facility survey had been conducted by the corporate office in July of 2022, at which time the recommendation had been made to replace the ceiling tiles and air vents. The Administrator stated the work had not been done. A policy was requested at this time regarding maintenance; however, this was not provided prior to the end of the survey. During an interview on 10/05/2022 at 11:12 AM, DM QQ stated the ceiling tiles and air vents had been repaired following the mock survey, but the problem causing the staining had not been repaired, causing the tiles and air vents to be in the same condition as prior to the repairs. DM QQ explained there had been a roof leak, causing the staining on the ceiling tiles. Per DM QQ, all the duct work needed to be re-wrapped and he was still waiting on a quote for that work. During an interview on 10/05/2022 at 2:04 PM, the Director of Nursing (DON) stated it was her expectation for any stained ceiling tiles to be changed. The DON further stated if there was a little wetness it was one thing, but heavy staining or any black colored substance should be immediately corrected. During an interview on 10/05/2022 at 4:29 PM, the Administrator stated she expected the ceiling tiles would be replaced. The Administrator stated DM QQ was fully aware and should have replaced all the ceiling tiles and air vents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of policy titled, Abuse Prohibition/ Reporting and Investigation, it was determined the facility failed to ensure allegations of abuse and allegations of misappropriation of property were reported to the State Agency for two (Resident #38 and Resident #88) of two residents reviewed for abuse. Specifically, the facility failed to ensure alleged misappropriation of Resident #38's medication was reported and failed to ensure alleged physical abuse for Resident #88 was reported. Findings included: A review of facility policy, Abuse Prohibition/ Reporting and Investigation, revised on 04/2017, indicated, 1. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse including injuries of unknown source/origin and misappropriation of resident property the incident will be immediately reported. a. The Administrator or designee will immediately notify HFR Complaint Investigation Intake and Referral Unit and resident representative of the incident and the pending investigation. The Ombudsman will also be notified as appropriate. The Administrator or designee will direct the investigation. b. If indicated and/or directed notification to the local Police Department should be made. c. The initial report of the incident will be faxed or emailed immediately but no more than 2 hours of abuse or an incident that results in serious injury or within 24 hours when there is no abuse or serious injury to the HFR Complaint Investigation Intake and Referral Unit . 2. A written report of investigation will be submitted to the HFR Long Term Care Section Complaint Coordinator, within five (5) working days of the incident . The report should contain details of the incident, signed statements from pertinent parties, cognitive status of the resident, information gathered during the investigation, and action taken by the facility. If the alleged perpetrator was a certified nursing assistant or licensed nurse, the facility was also to include the personnel file along with the report. 1. A review of the admission Record revealed the facility admitted Resident #38 with diagnoses that included polyneuropathy (nerve pain), chest pain, dorsalgia (back/spine pain), and major depressive disorder. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed Resident #38 received as needed (PRN) pain medication and was almost constantly in pain. A record review of Resident #38's care plan, initiated on 03/01/2022, revealed the resident complained of daily headaches, some severe in nature, and the pain medication relieved the resident's pain. The facility developed an intervention to administer pain medication as ordered and/or indicated. During an interview on 10/03/2022 at 10:40 AM, Resident #38 reported having pain in both feet and ankles, but the resident was not sure if any pain medication for the pain had been received. A review of Resident #38's Physician Orders indicated the resident had an order for an opioid pain medication, hydrocodone/acetaminophen (APAP) 5 milligrams (mg)/325 mg and to take one tablet every six hours as needed for pain, with a start date of 07/20/2022. A review of Resident #38's Medication Administration Record (MAR) for September 2022 was reviewed and revealed the resident received the hydrocodone/APAP on the following dates: 09/04/2022, 09/08/2022, 09/09/2022, 09/13/2022, 09/22/2022, 09/24/2022, and 09/27/2022. The back page of the MAR, where any PRN medication administered was documented, included the date/time given, the medication, the route of administration, the reason for administration, the results/response of the medication, the time noted of the results, and the nurse's signature. For the hydrocodone/APAP, the back of the MAR indicated the resident received the medication on 09/04/2022 at 9:00 PM, on 09/08/2022 at 8:00 PM, on 09/09/2022 at 9:00 AM, on 09/13/2022 at 7:00 PM, on 09/22/2022 at 9:15 PM, on 09/24/2022 at 8:00 PM, on 09/27/2022 at 9:00 AM, and on 09/28/2022 at 8:00 PM. The front of the MAR did not indicate any hydrocodone was provided to the resident on 09/28/2022 at 8:00 PM. A review of the Control Drug Record for Resident #38 indicated the medication hydrocodone-APAP 5-325 tablet was signed out on 09/04/2022 at 10:00 AM, on 09/04/2022 at 9:00 PM, on 09/06/2022 at 5:00 PM, on 09/08/2022 at 8:00 PM, on 09/09/2022 at 9:00 AM, on 09/13/2022 at 7:00 PM, on 09/16/2022 at 10:45 AM, on 09/22/2022 at 9:20 PM, on 09/24/2022 at 8:00 PM, on 09/27/2022 at 9:00 PM, on 09/28/2022 at 8:30 PM, and on 09/30/2022 at 6:30 PM. The September 2022 MAR did not include the medication that was documented on the Control Drug Record for four doses recorded on 09/04/2022 at 10:00 AM, 09/06/2022 at 5:00 PM, 09/16/2022 at 10:45 AM, and 09/30/2022 at 6:30 PM. Three of the four doses were signed out by Licensed Practical Nurse (LPN) DD and one dose by LPN MM. The bottom of the document indicated there were missing doses for doses #17-22. No date was listed next to the note to indicate when the missing doses were noticed. A review of Resident #38's Medication Administration Record (MAR) for October 2022 was conducted on 10/04/2022 by the surveyor, which indicated the resident did not receive any hydrocodone/APAP from 10/01/2022 to 10/04/2022. However, a review of the Control Drug Record for Resident #38 indicated the medication hydrocodone-APAP 5-325 tablet was signed out on 10/01/2022 at 9:30 PM and on 10/02/2022 at 6:05 PM by LPN DD. The October 2022 MAR did not include the medication that was documented on the Control Drug Record for the two doses recorded. A review of an untitled, undated facility incident regarding missing narcotic medication for Resident #38 included a photocopy of the resident's medication card/bubble pack. The medication card had 16 tablets left in the card and handwritten notes that indicated the incident occurred on 09/10/2022 at 7:10 PM for which the Director of Nursing (DON) was notified and then the on-call pharmacist was notified at 7:25 PM. A Communication Result Report indicated the pharmacy was faxed a copy of the medication card on 09/10/2022 at 8:00 PM. Two drug screening reports were provided with the incident as well as the Control Drug Record that had the same handwritten information as the medication card/bubble pack regarding notifications. During an interview on 10/05/2022 at 9:06 AM, LPN DD stated the resident had an order for hydrocodone 5 mg/325 mg and took it as needed. At this time, LPN DD reviewed the MAR and stated the resident received the medication every six hours, as needed. LPN DD then reviewed the narcotic log and stated the last time she provided the resident with the medication was on 10/02/2022. At this time, LPN DD was asked to review the discrepancies for the medication provided in September 2022, and LPN DD stated for every entry on the narcotic log, she provided the medication to the resident. LPN DD stated the documentation at the bottom of the narcotic log indicated missing medication was documented by LPN EE, also the Unit Manager, and the occurrence happened in September 2022, but it was related to another nurse. LPN DD stated she believed LPN EE came in to work and counted the narcotics with another nurse, and that was when they noticed there were medications missing. During an interview on 10/05/2022 at 9:41 AM, the Director of Nursing (DON) stated that when a resident complained of pain and a PRN pain medication was provided, the nurse should document the administration on the front of the MAR that it was given. The nurse also had to document on the back of the MAR the date and time the medication was given and the effectiveness of the medication, as well as document in the progress notes in the resident's electronic health record. The DON stated that when she was notified of the six missing pills by LPN EE for Resident #38, she had LPN EE and LPN MM write statements, along with other nurses that worked with the resident on 09/10/2022. The DON stated she had both nurses provide a urine sample before they were allowed to leave the facility. The DON stated there was no evidence that LPN MM had taken the resident's medication. The DON stated she did not notify the state agency of the missing medication but stated the incident could be misappropriation of property. The DON stated for allegations of abuse, she would start an investigation and start getting statements from staff members and would report the allegation online in the state's online portal within two hours and then had five days to complete a final report. During an interview on 10/05/2022 at 10:21 AM, the Administrator stated she was made aware of the missing narcotic medication for Resident #38 but was unaware of the date. The Administrator stated the facility normally did an investigation of the missing medication, drug screened staff that were involved, and the DON would report it to the state agency. The Administrator stated missing medication would be considered misappropriation of property, and it should have been reported to the state agency but did not know why it was not reported. 2. A review of a Face Sheet revealed Resident #88 had diagnoses which included hemiplegia and hemiparesis following cerebrovascular disease (admission), atrial fibrillation, long-term (current) use of anticoagulants, long-term (current) use of aspirin, osteoarthritis, altered mental status, late effects of cerebrovascular disease, cognitive deficits, and age-related osteoporosis without current pathological fracture. A review of Resident #88's quarterly Minimum Data Set (MDS) assessment, dated 09/06/2022, revealed the resident had moderate cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. A review of Resident #88's Care Plan, reviewed on 09/25/2022, revealed a problem onset regarding injury of the resident's right hand during care. Per the care plan, the resident's right ring finger appeared swollen. The care plan intervention directed staff to obtain an x-ray as ordered on 09/26/2022. A review of Resident #88's October 2022 Physician Orders revealed the resident was taking Eliquis (a blood thinner) 2.5 milligrams two times a day for atrial fibrillation since 07/23/2018 and had an order for an x-ray to the right fourth finger, on 09/26/2022. A review of Resident #88's Progress Notes, dated 09/25/2022 at 5:28 PM, revealed that, as reported by a family member to a nurse at 4:45 PM, Resident #88 alleged a certified nurse aide (CNA) hurt the resident's right hand during morning care. The progress note revealed the nurse assessed the resident's hand, noting the right ring finger appeared swollen. Per the note, the family member and medical doctor (MD) were notified. The note was signed by Licensed Practical Nurse (LPN) CC. A review of Resident #88's Resident Incident Report, dated 09/25/2022 at 4:45 PM, revealed that, as reported by a family member to a nurse, Resident #88 alleged a certified nurse aide (CNA) hurt the resident's right hand during morning care. The progress note revealed the nurse assessed the resident's hand, noting the right ring finger appeared swollen. Per the report, an immediate intervention was implemented instructing staff to be more careful when rendering care. The report also indicated the physician and family were notified. However, there was no indication on the report that Director of Nursing (DON) BB or Administrator AA were notified. A review of a Facility Incident Report Form, dated 09/29/2022, revealed it was completed by DON BB on 09/29/2022 with the type of incident noted to be staff-to-resident abuse. Per the report form, an investigation was pending regarding the alleged perpetrator(s) and steps were taken by the facility to prevent further incidents. On 10/03/2022 at 10:06 AM, during the initial tour, an observation was made of Resident #88 lying in bed on their back. Areas of discoloration were noted to the resident's right index and middle fingers. During a phone interview on 10/05/2022 at 2:07 PM, LPN CC reported she was called to Resident #88's room by the resident's family, at which time she was informed the resident reported that staff hurt the resident's finger while giving the resident a bath that morning. LPN CC stated she then checked the resident's finger, and the resident was able to move it. LPN CC noted she documented the resident's assessment on the Incident and Accident and 24-hour reports. She confirmed she did not report the allegation of abuse to DON BB or Administrator AA or obtain witness statements from staff who cared for the resident that morning because she was unaware of the need to do so. LPN CC confirmed she had not been given instructions regarding what to do when receiving an allegation of abuse. During an interview on 10/05/2022 at 2:45 PM, DON BB indicated that if any staff witnessed or received an allegation of abuse, they were to immediately report the allegation of abuse to the Abuse Prevention Coordinator (Administrator/Designee). She indicated new hires and agency staff were supposed to be in-serviced regarding abuse reporting requirements upon hire, annually thereafter, and as needed. She reported she became aware of the incident regarding Resident #88 when she came to work on 09/26/2022, though the incident had occurred the afternoon of 09/25/2022. She confirmed the incident regarding Resident #88 was not handled according to the Abuse Prevention Protocol. She reported the Administrator, the Assistant Director of Nursing (ADON), and/or the DON should have been notified immediately after receiving Resident #88's allegation of abuse. She confirmed LPN CC was agency staff who had started working a week or two prior to receiving the allegation of abuse, noting LPN CC should have received Abuse Prevention Protocol training prior to her first shift. DON BB confirmed she should have been made aware of the incident as alleged by Resident #88 the day it allegedly occurred on 09/25/2022, but noted she was not made aware of it until the day after, on 09/26/2022. DON BB also confirmed she did not report the allegation to the state agency until 09/29/2022, but should have reported the allegation within two hours, since the resident had bruising. During an interview on 10/05/2022 at 3:26 PM, Administrator AA indicated she was not made aware of the allegation of abuse involving Resident #88 until 09/26/2022. She confirmed DON BB, the ADON, and/or Administrator AA should have been made aware of the allegation of abuse the day it was reported. She confirmed a report should have been made within two hours related to Resident #88's allegation.

Based on observation, record review and staff interview, the facility failed to follow Physician's order for a splinting device and for a pureed renal diet for one resident (R) A) of 50 residents reviewed. Findings include: Review of R#A's medical record revealed a Physician's dietary order for a renal pureed diet. There was also a restorative order for splint to bilateral lower extremities for three hours a day as tolerated and splint to right knee for 6 to 8 hours daily. Restorative Supervisor provided a copy of daily restorative care for R# A. Review of the restorative form revealed restorative services 21 days in January and 15 days in February 2020. Further review of the documentation did not reveal that splint devices were applied or refused for R# A. During observations of R#A on 2/25/2020 at 8:53 a.m. and 2:40 p.m., 2/26/2020 at 8:42 a.m. and 1:05 p.m. there was no splinting device observed. During lunch observations on 2/24/2020 at 12:10 p.m. and 2/26/2020 at 12:13 p.m. there were no lunch trays delivered to room for R# A. During an interview with R# A family member 2/26/2020 at 1:05 p.m. revealed that R# A had not received a meal tray since returning from the hospital in December 2019. During an interview with Unit Manager MM on 2/26/2020 at 2:04 p.m. revealed that R# A had not received a pleasure tray since December 2019 when he/she returned from the hospital. Unit Manager then confirmed current dietary order for pureed renal diet for R# A. During an interview with the Director of Nursing on 2/26/2020 at 4:34 p.m. revealed that the nurse should have checked the orders. The DON also reported that the registered dietitian should have followed up on admission on ce it was determined that the order changed for dietary. The DON further revealed that there should have been clarification orders for the splints since the resident no longer was using those. During an interview with the DON on 2/26/202 at 5:18 p.m. revealed that when residents returned from hospital there was no order for the pureed diet, and the order was overlooked during the changeover. DON further reported that the Unit Manager should have checked orders and checked against Physician's orders for January. Once the discrepancy was found a clarification order should have been written and faxed to the pharmacy. Interview with Certified Nursing Assistant (CNA) LL on 2/27/2020 at 2:22 p.m. revealed that she had never seen R# A with splint devices. CNA LL further reported that R# A had not received a pleasure tray since he/she returned from the hospital in December 2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility policy titled, Medication Administration the facility failed to obtain a Physician's Order for one of 26 Residents (R) (R#55) receiving oxygen. Findings include: Review of Medication Administration Policy updated on December 2019 indicated, Medications are administered as prescribed, in accordance with good nursing principles. Guidelines are as follow but not limited to 1) Medications are administered in accordance with a valid prescriber order. 2) All current medications and dosage schedules, except topical medications used for treatments, are listed on the patient's Medication Administration Record (MAR). Review of Most current comprehensive Minimum Data Set (MDS) assessment dated [DATE] in Section O revealed R#55 received oxygen while a resident at the facility. Observations on 2/24/2020 at 11:34 a.m. revealed R#55 receiving oxygen therapy via nasal cannula at 2 LPM (liters per minute). Observations on 2/25/2020 at 9:21 a.m. and 2/25/2020 at 4:57 p.m. revealed R#55 receiving oxygen therapy via nasal cannula at 1.5 LPM. Review of the Medication Administration Record (MAR) charting for 2/1/2020 through 2/29/2020 revealed no oxygen administration orders. Review of Nursing notes during the time period of 12/24/19 through 2/25/2020 revealed R#55 received oxygen administration while at the facility. Review of care plan updated on 12/24/19 revealed R#55 was readmitted back to facility after a five-night hospital stay for diagnosis of pneumonia. She was treated with intravenous (IV) antibiotics during her hospital stay and on continuous Oxygen (O2) by way of nasal cannula at this time. Review of Medication Reconciliation form dated 12/24/19 upon return from hospital stay revealed no oxygen listed under active medication orders. Interview on 2/26/2020 at 3:20 p.m. with Registered Nurse (RN) KK revealed R#55 received oxygen at 2LPM continuously, but she has a history of taking it off on occasions. RN KK confirmed that oxygen should not have been given without an order and that it should have been documented on MAR for R#55. RN KK stated the admitting nurse should have clarified the need for oxygen and written the order upon the resident's return from the hospital. RN KK was unable to locate an order in the resident's records. Interview on 2/26/2020 at 5:19 p.m. with the Director of Nursing (DON) revealed he expects nurses to have an order for oxygen administration. The DON stated the admitting nurse or Unit Manager (UM) are responsible for completing admission orders and medication reconciliation when residents return from the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility's form titled, Control Drug Record, the facility failed to accurately reconcile a medication count with the off going shift for one of four medication carts that was reviewed for correct narcotic count/medication reconciliation. Findings include: On [DATE] at 10:04 a.m. observations were conducted for four of the eight medication carts to check for expired, unlabeled or undated medications. A narcotic count/dose check and review of the medication reconciliation form was also conducted on the four (4) medication carts: on Unit N1 (low side), Unit S2 (low side), Unit N2 (high side) and Unit S2 (high side). During the medication cart check on Unit S2 (low side) on [DATE] at 2:00 p.m. with LPN FF, a narcotic count/dose check was conducted. The narcotic medications were double locked. The medication cart was organized and clean. A review of the facility form titled, Controlled Drug Shift Audit Report revealed that the most recent narcotic reconciliation was documented as conducted on [DATE] from 6:45 a.m. to 7:15 a.m. with two nurse signatures documented; LPN OO, the off going shift nurse and LPN GG, the oncoming shift nurse. This form had documentation on the bottom that indicated that if any error cannot be reconciled, an incident report MUST be completed before reporting off shift and signed by both nurses. Review of the Physician's Orders for R#13 for the period [DATE] through [DATE] revealed a medication order dated [DATE] for Pregabalin (Lyrica) 150 mg capsule, to take one capsule by mouth daily 7AM-10AM for neuropathy. Review of the Medication Administration Record (MAR) for R#13 revealed documentation that the medication ordered was: Pregabalin (Lyrica) one 150 mg capsule by mouth daily for neuropathy; the medication was signed out as given by LPN OO on [DATE] from 7:00 a.m.-10 a.m. During the narcotic count and observation with LPN FF of the 15-medication dose packet ordered by the Physician on [DATE], this revealed two (2) Lyrica 150 mg capsules left in the bubble pack. The facility form titled, Control Drug Record for Lyrica 150 mg capsule documented on [DATE] at 7a.m. that one (1) capsule was left in the packet, signed by LPN OO, indicating a discrepancy. During the narcotic count and observation with LPN FF of a another 15-medication packet ordered by the Physician on [DATE], this revealed 14 Lyrica 150 capsules left in the bubble pack. This second facility form titled, Control Drug Record for Lyrica 150 mg revealed 15 capsules present (none signed out). At this time, LPN FF confirmed that the LPN OO had made a mistake, and confirmed the reconciliation done that morning was incorrect, stating that both Control Drug Records were signed out wrong. An interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 8:35 a.m. the DON revealed that he was not aware of any reported medication discrepancy. The DON confirmed that any medication that is not reconciled is to be reported by the nurse to him. The DON stated that the process for a medication error is that he will investigate, a medication error form is completed, and the pharmacy and/or Physician is contacted. The DON stated that for a transcription/documentation error after investigating it, they will have re-education of the staff. The medication reconciliation procedure/policy was requested but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of a Physician's Do Not Resuscitate (DNR) Order Form for Adult Hospice Patient/Resident Without Decision-Making Capacity With Authorized Person Other Than Durable Power of Attorney for Healthcare Georgia for R#118 revealed that an authorized person signed the DNR form on 7/3/19, and the attending physician only signed the form on 7/6/19. No concurring physician signature was noted. The instructions at the bottom of order form documents the signature of a concurring physician is not required if the authorized person completing Parts 1 and 2 is an agent appointed by the Patient under Durable Power of Attorney for Health Care or Advance Directives for Health Care executed by the Patient. No Durable Power of Attorney for Health Care or Advance Directives for Health Care executed by the Patient noted in medical records. Review of Minimum Data Set (MDS) admission assessment dated [DATE] revealed received hospice and Brief Interview of Mental Status (BIMS) score of nine indicating moderate cognitive impairment. Review of R#118's Physician Orders revealed that she was listed as a DNR. Review of Social Service assessment dated [DATE] revealed Resident #118 was under hospice care with a code status of DNR. Interview with the DON on 2/26/2020 at 4:46 p.m. confirmed that Resident # 118 only had one physician signature. The DON stated there should have been a concurring physician signature included. Based on record review, staff interviews, and review of the policy titled, Advance Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician Orders for Life Sustaining Treatment (POLST) for Do Not Resuscitate (DNR) consents for three of five Residents reviewed for Advanced Directives. (R) (R#67, R#120, R#118). Findings include: Review of the facility's policy titled, Advanced Directives documented the following: C. Procedures for periodically reviewing resident choices and preferences related to health care decisions after admission: 7. During Advanced Care Planning (ACP) conversations, education may be provided to residents on the Georgia Physician Orders for Life Sustaining Treatment (POLST). The POLST is a physician's order that provides directions regarding end of life care. a. A POLST that has been appropriately completed will be accepted and followed by the facility. Review of the Advanced Directives policy related to residents without any advance directive revealed the following: B. The physician will have his/her medical decision concurred with by another physician when possible. 1. Review of medical record for R#67 revealed a POLST with a choice to allow natural death/DNR. The form was signed by one Physician and a family member that was not the residents Power of Attorney, but there was no concurring Physician's signature nor was the form dated. Further review of the Medical Record for R#67 revealed that there was not a Health Care Agent for R#67. 2. Review of medical record for R#120 revealed a POLST with a choice to allow natural death/DNR. The form was signed by a family member on 1/22/2020 but the form was not signed by a Physician. Further review of the medical record revealed that R#120 did not have a health care agent. During an interview with the Director of Nursing (DON) on 2/26/2020 at 2:18 p.m. revealed that on admission the nurse asks resident and family member regarding code status. It was further reported that Social Services was responsible for following up with the resident and family member regarding code status and Advanced directives. The DON also revealed that the Admissions Director discusses the healthcare agent information during the Admissions process. The DON revealed that if a resident wants to change code status after being in the facility that this information was discussed with the nurse and by social services. Further interview with the DON revealed that if a resident is cognitively intact, he/she can sign the POLST for self, otherwise a family member or health care agent signs the form. The DON revealed that if a non-health care agent signs the form that two physician's signatures would be needed, and Social Services would have been responsible for assuring that the POLST form is completed and had the appropriate signatures. Review of the POLST for R#67 with the DON revealed that the DON confirmed the missing concurring Physician signature and dates. Review of the POLST for R#120 the DON confirmed that it did not have a Physician signature.

Based on observation, interview and review of the facility policy's titled, Pharmacy Services- Medication Storage in the Care Center and the facility policy titled, Pharmacy Services- Medication Administration-General, the facility failed to maintain temperature logs for 4 of 4 medication refrigerators, and failed to ensure food was not stored with medications in 2 of 4 medication refrigerators. In addition, the facility failed to ensure food was not stored in 1 of 8 medication carts and failed to ensure multi-dose medications were labeled with an open date to assist in determining a discard date in 4 of 8 medication carts. Findings include: A review of the facility policy titled, Pharmacy Services- Medication Storage in the Care Center, updated 10/2019, documented that medications and biologicals are stored safely, and properly following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. At section No. 16, policy documented that refrigerated medications are kept in closed and labeled containers with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods are not stored in this refrigerator. A review of the facility policy titled, Pharmacy Services- Medication Administration-General, documented that the intent is that medications are administered as prescribed, in accordance with good nursing principles. At section No. 5, policy documented that medications dispensed for multi-use, e.g. blister/punch cards, large volume liquids, multidose vials, shall be labeled by the nurse as to the date of first use or first administration. Check expiration date of the medication. Under no circumstances should an expired medication be administered to a patient. Observations and medication storage checks were conducted with nursing staff for four of four medication storage rooms and in four of eight rolling medication carts as follows: Medication Rooms An observation was conducted on 2/26/2020 at 10:22 a.m. with Licensed Practical Nurse (LPN) GG of the Unit S2 medication room where a small package of cheese was found in the medication refrigerator, in the freezer section. The freezer had a large amount of frost. The LPN confirmed she had never noticed it before and stated she did not know who it belonged to. LPN GG stated that the Maintenance Department was responsible for defrosting the refrigerator. A review was conducted of the requested forms titled, Refrigerator Temperature Log for January 2020 and February 2020. The review revealed that two temperature logs provided by the LPN for the month of 1/2020 documented discrepancies in temperature documentation (varying temperatures) for the dates from 1/1/2020 through 1/15/2020, and discrepancies in the nurse staff initials (varying initials) documenting the temperatures for those days. Review of the February 2020 Refrigerator Temperature Log revealed a missing temperature recording for the 2/25/2020 morning shift and the 2/26/2020 morning shift. An observation was conducted on 2/26/2020 at 10:50 a.m. with LPN KK of the Unit S1 medication room where a review was conducted of the provided Refrigerator Temperature Logs for January 2020 and February 2020 which revealed missing temperature recordings as follows: no recordings were found for the period 1/1/2020 to 1/6/2020; duplicate documentation was found for 1/13/2020, with a temperature discrepancy; for 1/14/2020 no evening shift recording; for 1/18/2020 no morning or evening recording found; for period 1/23/2020 to 1/31/2020 no temperature is documented for the morning shift. For review of the month of February 2020, no morning shift temperature recordings are documented for dates from 2/1/2020 to 2/3/2020, for 2/15/2020, 2/16/2020 and 2/26/2020. No temperatures were documented for the evening shift for the dates of 2/4/2020, 2/5/2020, 2/7/2020, 2/11/2020, and 2/23/2020. An observation was conducted on 2/26/2020 at 11:07 a.m. of the Unit N1 medication room with Registered Nurse (RN) NN. A review was conducted of the provided temperature logs for January 2020 and February 2020 that revealed missing temperature recordings on the Refrigerator Temperature Log. Missing temperature recordings were as follows: no temperature recording for the morning shift for 1/13/20 and 1/27/20; no temperature recording for the evening shift for 1/16/2020, 1/17/2020, 1/26/2020, and 1/29/2020. An observation was conducted on 2/26/2020 at 11:17 a.m. of the Unit N2 medication room with LPN HH. Observation of the medication refrigerator revealed no expired or unlabeled medications or biologicals/vaccines, however, in the freezer compartment a frozen 16.9 ounce of Aloe Vera Juice with Honey was found lying in a large amount of frost. In the medication room, on a storage shelf containing IV supplies, two BD Vacutainers used for specimen blood tests was found; one 8.0 ml BD Vacutainer had an expiration date of 11/30/2019. LPN HH confirmed she did not know who the juice belonged to; she then asked another nurse to put it in the pantry refrigerator. LPN HH stated she did not know who was responsible for defrosting the refrigerator. LPN HH stated that they rarely draw blood and didn't know where the specimen tubes came from. A review was conducted of the provided Unit N2 Refrigerator Temperature Log for 2/2020 that revealed missing temperature recordings on the log for the morning shifts for 2/25/2020 and 2/26/2020. The LPN confirmed she could not locate the log for 1/2020. A brief interview as conducted on 2/26/2020 at 11:28 a.m. with LPN FF from Unit S1 where she explained that a new Refrigerator Temperature Log was initiated two months ago that now reflects temperature recordings twice daily, for each twelve-hour shift. She confirmed prior to that they were only recording temperatures once daily. Review of the Refrigerator Temperature Log that was revised 1/13/2020, documented that refrigerator temperature must be between 36 degrees Fahrenheit (F) - 46 degrees F. Documentation areas for recordings were as follows: date, time AM temp, initials, time PM temp, initials and comments. General guidelines located at the bottom of the form instruct that associates will monitor temperature of the medication refrigerator at least twice per day to keep temperature between 36 degrees F-46 degrees F. No food items will be stored in medication refrigerators. Refrigerators and freezers will be kept clean and neat, free from spills. Medications will be dated when opened. Expired medications will be removed from the refrigerator for destruction per policy. Medication Carts An observation with a medication check was conducted on 2/26/2020 at 1:50 p.m. of the Unit N1 (low side) medication cart with LPN II that revealed an opened stock multi-dose medication as follows: 1. MiraLAX Powder (for constipation)- the 17.9 ounce/30 dose multi-use container was not dated when opened for use and did not name a resident; the container had 2/3 of the contents remaining. A faded room number (109) was on the container written with a Sharpie type pen. LPN II was unable to determine if the medication belonged to a resident currently in that room. An observation with a medication check was conducted on 2/26/2020 at 2:00 p.m. of the Unit S2 (low side) medication cart with LPN FF that revealed opened stock multi-dose medications as follows: 1. Certa-Vite (vitamin with minerals)- the 300 tablet multi-dose container was not dated when opened for use; the container had 9 tablets remaining. 2. Acetaminophen (mild pain reliever) 500 mg tablets- the 100 tablet multi-dose container was not dated when opened for use; the container had 1/8 of the contents remaining. 3. Senna (for constipation) 8.6 mg tablets- the 100 tablet multi-dose container was not dated when opened for use; the container had 1/2 of the contents remaining. 4. Antacid (no trade name) 500 mg tablets- the 150 tablet multi-dose container was not dated when opened for use; the container had 1/2 of the contents remaining. An observation with a medication check was conducted on 2/26/2020 at 2:20 p.m. of the Unit S2 (high side) medication cart with LPN GG that revealed opened medications as follows: 1. Acetaminophen (mild pain reliver) 325 mg tablets- the 100-tablet container was not dated when opened for use; the container had 1/2 of contents remaining. 2. Nitroglycerine (for chest pain) 0.4 mg sub lingual tablets- two open containers (of 25 tablets each) had a resident label for Resident (R) #73- both opened containers had a small orange label attached documenting to discard after 180 days once opened; however, no open date was recorded, unable to determine the use by date. 3. Nicotine Lozenges (to reduce nicotine cravings) 4mg lozenges- the 27 lozenges container was not dated when opened for use and did not have a resident's name label attached- 5 lozenges remained in the box. The LPN was unable to determine which resident was taking this medication. An observation with a medication check was conducted on 2/26/2020 at 3:00 p.m. of the Unit N2 (high side) medication cart was conducted with LPN HH that revealed an opened multi-dose stock medication and a food product as follows: 1. Loperamide Hydrochloride (treatment of diarrhea) 2mg caplets- the 12-caplet container was not dated when opened for use; the container had two caplets remaining. 2. A pre-packaged bowl of Raisin Brand breakfast cereal was found- the food container was not labeled for resident use; was removed and taken to the food pantry by the LPN who confirmed she had kept it there in case any of her residents got hungry. During an interview on 2/27/2020 at 8:35 a.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON revealed they had their Nurse Consultant assist them in revising their Refrigerator Temperature Log for temperatures to be checked twice daily to maintain required temperature for medications, vaccines and biologicals. The DON stated they had a new policy initiated. The DON confirmed that they have a protocol for medication room refrigerators, that night shift nurses are responsible for defrosting the medication freezers as needed. The DON confirmed that nurses were responsible for maintaining their medication carts.

Based on observation, staff interview, and review of the facility policy titled, Ice Machines Policy & Procedure the facility failed to maintain the cleanliness and sanitation of the ice machine in the resident pantry. This had the potential to effect 123 residents receiving an oral diet. Findings include: Review of the facility policy titled Ice Machine Policy & Procedure revealed Policy: The following procedure will be followed check water filter, check air filter, clean coils, sanitize interior, and clean interior. Observation on 2/24/2020 at 11:20 a.m. of the ice machine of the south two pantry revealed yellow and brown stain on the outside door. Inside of the ice machine had a same yellow and brown debris. The metal joints (hinges that holds the door on) were brown in color. The side of the ice machine had grayish color debris going down the side. Inside the ice machine noted the metal joints brown in color was running into the ice. Inside the ice machine the upper inner splash panel has small specks of black debris Observation and interview on 2/26/2020 at 10:30 a.m. with the Maintenance Supervisor (MS) revealed a leaky brown rusty substance dripping into the ice machine. Interview at the time of the observation with the MS revealed that his expectations are for the ice machine to be cleaned thoroughly and free from grime and debris. He states it's his responsibility to check the ice machine on a monthly basis and that the ice filter is to be changed every ten years. He reported he didn't feel the residents could get sick from the leaky substance. Interview on 2/26/2020 at 1:44 p.m., the Maintenance Director (MD) revealed that it's his expectation is for the ice machine to be put on a preventative maintenance work log that is reviewed and checked off every six months. The MD described the filmy and flaky substances as a product of corrosion which resulted from water residue and calcium deposit built up, The MD further stated that he has since contacted the equipment service company to come out and clean/replace the water filter for the ice machine. Interview and observation on 2/26/2020 at 2:45 p.m. with the MD regarding the schedule of cleaning the ice machine. The MD revealed the ice machines are cleaned every six months by a reputable company. The ice is dumped the machine is taken apart cleaned with a food grade sanitizer and the filter is changed. After the ice is made after cleaning, the ice is dumped again. Every four months the ice machine is cleaned with a nickel bath. The ice is dumped, the ice machine is placed on a cleaning cycle and the inside box is sanitized. After the machine makes ice, it is dumped again before use. The MD revealed he is aware of the yellow stain on the outside of the ice maker but has not been able to remove the stain. Interview and observation on 2/27/19 at 1:00 p.m. with the Administrator regarding the ice machine in the pantry. The Administrator revealed she was not aware of the condition of the ice machine. The Administrator stated that her expectation is for all ice machines to be cleaned under scheduled equipment, including the internal components of ice machines that are not drained, cleaned, and sanitized as needed and according to manufacturer's specifications.