**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, staff interviews, and review of facility documents, the facility failed to maintain a clean and homelike environment for one of 24 rooms (Rm 33). Specifically, the facility failed to ensure RM [ROOM NUMBER] privacy curtain was free of brown stains, and a white chalky substance on the curtain. Findings include: Observations on 1/31/2025 at 8:47 am, 2/1/2025 at 8:30 am, and 2/2/2024 at 8:42 am of privacy curtain for RM [ROOM NUMBER] bed A revealed curtain had brown stain on the outer aspect of the curtain and a white chalky substance on the bottom hem of the curtain facing the door. Review of the facility document titled Complete Room Cleaning revealed under Purpose: The complete room cleaning schedule insures that each resident room is discharge-cleaned on a monthly basis. Under section labeled Patient Room (l) Cubicle Curtains- check and report any soil or damage to supervisor. Review of the deep clean schedule for December 2024 revealed room [ROOM NUMBER] was deep cleaned on 12/4/2024, in January 2025 room [ROOM NUMBER] was not on the schedule as being deep cleaned, and for February 2025 room [ROOM NUMBER] was not on the schedule to be cleaned. Conformation walking rounds conducted on 2/2/2025 at 8:45 am with the Administrator and housekeeping Account Manager confirmed observations of privacy curtain for RM [ROOM NUMBER] during rounds. During an interview on 2/2/2025 at 9:00 am with the Account Manager revealed that each resident's room is deep cleaned monthly to include the vents, privacy curtains are removed and replaced if soiled, wiping down the walls, cleaning the windowsills, bed frames, sweeping and mopping the floors. Further interview also revealed that during the daily cleanings there are five steps that are followed that include checking the curtains for any stains so that they can be replaced if needed. During an interview on 2/2/2025 at 9:05 am with Housekeeper HH revealed that she cleaned room [ROOM NUMBER] this morning and did not notice that the curtains were soiled and needed to be changed. During the interview staff member also stated that when she cleans the resident's room, she starts by taking out the trash and then wipe down everything in the room cleaning the bathroom last. Staff member again confirmed that she did not check the privacy curtains when cleaning room [ROOM NUMBER]. During an interview on 2/2/2025 at 9:15 am with the Administrator, housekeeping follows a five and seven step process for cleaning the residents' rooms that included checking the curtains for any stains and to ensure that the curtains are in good repair. It was further revealed that he expected the housekeeping staff to follow those steps to ensure that the residents' environment is clean at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, and review of the facility's policy Transfer/Discharge Outside the Facility, the facility failed to provide a written reason for transfer to the resident or their representative for one of two residents reviewed for hospitalization, resident (R) 17. Findings include: Review of the facility policy titled Transfer/Discharge Outside the Facility , dated February 2015 revealed The resident/patient and/or family/responsible party will be notified of the transfer in writing, except when a transfer is due to an unplanned, acute clinical need. This type of transfer will be communicated verbally, with written documentation to follow in the medical record. R17 was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia, unspecified severity, without behavioral disturbance and type 2 diabetes mellitus with hyperglycemia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R17's Brief Interview for Mental Status (BIMS) score was unable to be determined. Review of medical records revealed R17 was transferred to the hospital from the facility, on 5/13/2024 and again on 12/18/2024. Further review revealed no evidence of the provision of a reason for transfer/discharge provided to R17's representative on either date. Phone interview on 2/1/2025 at 4:26 pm with the resident's representative revealed the facility failed to provide a written reason for transfer/discharge to the representative on 5/13/2024 and 12/18/2024. Interview on 2/2/2025 at 8:17 am with Licensed Practical Nurse (LPN) CC, revealed the facility does not provide anything in writing to the resident or representative as to reason for discharge/transfer. During an interview on 2/2/2025 at 8:41 am, LPN EE revealed that when a resident is discharged to the hospital, she completes a document in the electronic health record and prints that document to give to emergency medical services which includes a reason for transfer. She revealed the facility does not provide a written reason for transfer/discharge to the representative or the resident. During an interview on 2/2/2025 at 8:44 am with the Business Officer Manager (BOM), revealed the facility will call the family representative and notify them of the reason for transfer/discharge but does not provide anything in writing. An interview on 2/2/2025 at 8:51 am with the Director of Nursing (DON) revealed the facility will call family or representative to notify the reason for transfer/discharge. She verified nothing in writing is given to the representative because the facility knows the resident is returning to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility's policy Bed Hold, the facility failed to provide a notice of bed hold for one of two residents (R)(R17) reviewed for hospitalization. Findings include: Facility policy titled Bed Hold, revised on 3/3/2020 revealed Policy: A copy of the bed hold agreement is also provided to the resident or responsible party prior to a resident's transfer to a hospital or start of a therapeutic leave. 2. In case of emergency transfer the resident or responsible party is provided with written notification within 24 hours of the transfer. R17 was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia, unspecified severity, without behavioral disturbance and type 2 diabetes mellitus with hyperglycemia. Review of medical records revealed R17 was transferred to the hospital from the facility, on 5/13/2024 and again on 12/18/2024. Further review revealed no evidence of the provision of a notice of bed hold provided to R17's representative on either date. An unsigned bed hold agreement was located in the resident's record for 12/18/2024. During a phone interview on 2/1/2025 at 4:26 pm with the resident's representative revealed the facility did not provide a written bed hold agreement to the representative on 5/13/2024 or 12/18/2024. Interview on 2/2/2025 at 8:41 am with Licensed Practical Nurse (LPN) EE revealed that when a resident is discharged to the hospital, she completes a document in the electronic health record and prints that document to give to emergency medical services which includes a bed hold agreement. She revealed the facility does not send or give a written bed hold agreement to the representative or the resident. During an interview on 2/2/2025 at 8:44 am with the Business Officer Manager (BOM), it was revealed the facility will call the family representative and notify them of the bed hold agreement but does not provide anything in writing. Interview on 2/2/2025 at 8:51 am with the Director of Nursing (DON) revealed the resident is given the bed hold agreement and facility will call family or the representative. She verified nothing in writing is given to the representative because the facility knows the resident is returning to the facility.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, RAI/Care Planning Management, the facility failed to follow the care plan related to providing oxygen as ordered for three of 13 Residents (R) (R12, R7, and R14) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings include: Review of the facility's undated policy titled RAI/Care Planning Management under Interim Baseline Care Plan revealed, Under the section titled, The Care Plan revealed, .The Interim Baseline Care plan will be the guide for the comprehensive care plan Care plans are to be accessible for clinical staff in order to facilitate care plan interventions or to update as indicated due to resident condition change. 1. Record review of Electronic Medical Record (EMR) for R12 revealed diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), hypoxemia and shortness of breath. Review of Physician Orders dated 12/25/2024 for R12 revealed, orders for oxygen (O2) at 3 (three) liters (L) per nasal cannula (NC) for shortness of breath (SOB). Review of care plan with revision date of 11/18/2024 revealed, R12 has DX (diagnosis) COPD with interventions that included, but not limited to: Administer medications as ordered with date initiated, 12/12/2024 and O2 as ordered with date initiated, 8/4/2023. Observation on 1/31/2025 at 8:00 am revealed R12 receiving O2 therapy via (by way of) nasal cannula from the oxygen concentrator set at 7 (seven) L/min (minute). Observation on 2/1/2025 at 10:20 am revealed R12 receiving O2 therapy via nasal cannula from the oxygen concentrator set at 7 L/min. Observation and Interview on 2/1/2025 at 10:30 a.m. with Licensed Practical Nurse EE and the Director of Nursing (DON) revealed, R12 receiving O2 therapy via nasal cannula from the oxygen concentrator set at 7 L/min. LPN EE reviewed R12's physician orders to verify the correct oxygen setting and confirmed that oxygen was to be administered at 3L/min via NC. Interview on 2/1/2025 at 2:18 pm with Minimum Data Set (MDS) Coordinator revealed she was responsible for developing and entering care plans. She reviewed R12 physician orders and verified the oxygen rate was to be set at three liters per minute. She then reviewed the care plan and verified the care plan stated, oxygen as ordered. She confirmed that staff failed to follow the care plan. The MDS Coordinator revealed her expectations of staff were to follow the care plan. She revealed the care plan clearly says, oxygen as ordered. Interview on 2/1/2025 at 2:28 pm DON confirmed the facility failed to follow the care plan for R12 related to oxygen. She revealed she expects her nurses to check the rates during med pass and to provide care per the physician orders and care plans. 2. Review of the medical record for R7 revealed diagnoses that included but are not limited to COPD, unspecified. Review of Physician Orders dated 8/31/2023 revealed orders for oxygen at two liters per minute via nasal canula as needed. Review of care plan with revision date of 8/3/2024 revealed a diagnosis of COPD. Interventions included but not limited to: Administer medications as ordered with date initiated, 10/10/2022 and oxygen via nasal canula with date initiated 10/10/2022. Interview on 2/1/2025 at 2:20 pm with Minimum Data Set (MDS) Coordinator revealed she develops and enters care plans. She reviewed R7's physician orders and verified the oxygen rate was to be set at two liters per minute. Next, she reviewed and verified the care plan stated, administer medications as ordered. She confirmed that staff failed to follow the care plan. The MDS Coordinator revealed her expectations of staff were to follow the care plan. 3. Review of the medical record for R14 revealed diagnoses that included but are not limited to acute respiratory failure without hypoxia. Review of Physician Orders dated 5/1/2024 revealed orders for oxygen at four liters per minute via trach collar. Review of care plan with revision date of 6/1/2024 revealed a diagnosis of acute respiratory failure and respiratory disorder. Interventions included but not limited to: oxygen via trach collar as ordered, initiated on 6/29/2023. Interview on 2/1/2025 at 2:20 pm with the MDS Coordinator who reviewed R14's physician orders and verified the oxygen rate was to be set at four liters per minute. Next, she reviewed and verified the care plan stated, oxygen via trach collar as ordered. She confirmed that staff failed to follow the care plan. The MDS Coordinator revealed her expectations of staff were to follow the care plan. Interview on 2/1/2025 at 2:28 pm DON confirmed the facility failed to follow the care plan for R14 related to oxygen. She revealed she expects her nurses to check the rates during med pass and to provide care per the physician orders and care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Respiratory System Management Standard, the facility failed to ensure that the physician's order for oxygen administration was followed for three of 13 Residents (R) (R12, R7, and R14) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings include: Review of the facility's undated policy titled Respiratory System Management Standard under the section titled Oxygen Therapy Protocol revealed, Procedures to follow in order: 1. Check the physician's orders in the resident's clinical record 10. set the oxygen flow rate as ordered. 1. Review of R12's Electronic Medical Record (EMR) revealed diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), hypoxemia and shortness of breath. Review of R12's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Sections C (Cognitive Patterns)- a Brief Interview of Mental Status (BIMS) of 14; Section J (Health Conditions)-Shortness of Breath (SOB) or trouble breathing when lying flat; Section O (Special Treatments, Procedures, and Programs)- received oxygen therapy while a resident. Review of R12's Physician Orders dated 12/25/2024 revealed orders for oxygen (O2) at 3 (three) liters (L) per nasal cannula (NC) for shortness of breath (SOB). Observation on 1/31/2025 at 8:00 am revealed R12 lying in bed receiving O2 therapy via (by way of) nasal cannula from the oxygen concentrator set at 7 (seven) L/min (minute). Observation on 2/1/2025 at 10:20 am revealed R12 lying in bed receiving O2 therapy via nasal cannula from the oxygen concentrator set at 7 L/min. Observation and Interview on 2/1/2025 at 10:30 am with Licensed Practical Nurse EE and the Director of Nursing (DON) revealed, R12 lying in bed receiving O2 therapy via nasal cannula from the oxygen concentrator set at 7 L/min. LPN EE revealed that she was responsible for making sure the oxygen setting was correct. She revealed that she usually checked the oxygen settings during medication pass however, she had not checked it. LPN EE confirmed the oxygen was set at 7L/min. LPN EE reviewed R12's physician orders to verify the correct oxygen setting and confirmed that oxygen was to be administered at 3L/min via NC. An interview on 2/1/2025 at 10:35 am with DON revealed, her expectations of staff that they ensure oxygen was administered as ordered. She stated they should be checking oxygen settings during their medication pass and as needed. 2. Review of the medical record for R7 revealed diagnoses that included but are not limited to COPD, unspecified. Review of 7's Quarterly MDS assessment dated [DATE] revealed, Sections C (Cognitive Patterns)- a Brief Interview of Mental Status (BIMS) of 9; Section J (Health Conditions)-Shortness of Breath (SOB) with exertion or trouble breathing when lying flat; Section O (Special Treatments, Procedures, and Programs)- received oxygen therapy. Review of Physician Orders dated 8/31/2023 revealed orders for oxygen at two liters per minute via nasal canula as needed. Observation on 1/31/2025 at 9:30 am revealed R7 lying in bed receiving oxygen therapy via nasal canula at three liters per minute. Observation on 2/1/2025 at 8:36 am revealed R7 lying in bed receiving oxygen via nasal cannula at three liters per minute. Observation and rounding on 2/1/2025 at 10:30 am with LPN BB revealed R7 lying in bed receiving oxygen via nasal cannula at three liters per minute. LPN BB revealed that she was responsible for making sure the oxygen setting was set on the prescribed rate during morning medication pass. She admitted she did not check the rate and confirmed the oxygen was set on three, not the prescribed rate. LPN BB reviewed R7's physician orders and verified the rate should be set at two liter per minute. Interview on 2/1/2025 at 10:35 am with the DON revealed her expectations are that staff ensure oxygen is administered as ordered. She stated nurses should be checking oxygen settings during their medication pass since oxygen is a medication. 3. Review of the medical record for R14 revealed diagnoses that included but are not limited to acute respiratory failure without hypoxia. Review of 14's Quarterly MDS assessment dated [DATE] revealed, Sections C (Cognitive Patterns)- BIMS of 99, unable to determine Section O (Special Treatments, Procedures, and Programs)- received oxygen therapy. Review of Physician Orders dated 5/1/2024 revealed orders for oxygen at four liters per minute via trach collar. Observation on 1/31/2025 at 8:50 am revealed R14 lying in bed receiving oxygen therapy via trach collar at five liters per minute. Observation on 2/1/2025 at 8:40 am revealed R14 lying in bed receiving oxygen via trach collar at five liters per minute. Observation and rounding on 2/1/2025 at 10:30 am with LPN BB and the DON revealed R14 lying in bed receiving oxygen via nasal cannula at five liters per minute. LPN BB revealed that she was responsible for making sure the oxygen setting was set on the prescribed rate during morning medication pass. She admitted she did not check the rate and confirmed the oxygen was set on five, not the prescribed rate. LPN BB reviewed R14's physician order and verified the rate should be set at four liters per minute. Interview on 2/1/2025 at 10:35 am with the DON revealed her expectations are that staff ensure oxygen is administered as ordered. She stated nurses should be checking oxygen settings during their medication pass since oxygen is a medication.

During the initial screening on 1/31/2025 at 8:55 am, R30 stated that if she does not like the meal that is served, she is not offered, and she does not get an alternate meal. Observations made on 1/31/2025 through 2/2/2025 revealed there were no alternate meals listed on the menu, and there was not an alternate meal on the hot steam tray unit during meal service. 1/31/2025 at 12:03 pm, R30 stated that she has been at the facility for one year. She stated that she never has a choice of meals. R30 stated again that if she does not like what is served, she is not offered, and she does not get an alternate meal. Interview with the Registered Dietician (RD) on 2/1/2025 at 12:53 pm revealed that she was aware that there is not an alternate meal listed on the menu. She stated that residents can have a sandwich or soup, but she was not sure what the sandwich choice was. RD stated that she was not in charge of the budget. She stated that she has never been provided an alternate meal menu. Interview with DON on 2/2/2025 at 8:48 am revealed that she knows that residents are offered a peanut butter and jelly sandwich, she stated that if they're having a meal and they don't want it they offer them sandwiches. Interview with the Administrator on 2/2/2025 at 9:30 am, he stated that he was aware that residents are not offered a hot alternate meal. He stated that they are offered a sandwich or soup. The Administrator stated that residents could get a grilled cheese sandwich. Based on observation, record review, resident and staff interviews, and the facility policy, MENUS, the facility failed to ensure they offered an appealing option of similar nutritive value to residents for lunch and dinner meals and failed to provide preferences for meals for one resident (R) 30. This deficient practice had the potential to affect 50 of 53 residents receiving an oral diet. Findings include: The facility tile, MENUS not dated, revealed, well planned menus aide in meeting the nutritional and psychosocial needs of the residents and are developed, taking into consideration certain budgetary allowances, available personnel, and equipment. When changes in the menus are needed, the changes must provide equal nutritive value. A Resident Council meeting was held on 2/2/2025 during the survey. Residents, specifically R40, revealed that the facility does not have an alternate menu and that if they do not like what is being served their only option is to ask for a sandwich or soup. Other residents expressed concerns regarding lack of choices for food being served. Reveal of the facility's fall/winter 2024 menu revealed no alternate meal choice on the menu for lunch or dinner. Interview on 2/1/2025 at 10:34 am with the Dietary Manager (DM) revealed that the vendor provides menus to the facility and they are without an alternate meal choice. She revealed residents are offered a sandwich, soup, or both as an alternate. Interview on 2/1/2025 at 12:40 pm with Dietary Aid (DA) FF revealed there is no alternate menu for residents. She revealed she offers residents that do not like what is on the menu a sandwich or soup. Interview on 2/1/2025 at 12:45 pm with DA GG revealed there is no alternate choice on the menu for residents. She revealed if a resident did not like what was being offered she would offer them sandwich or soup. Interview on 2/1/2025 with the Registered Dietician (RD) at 12:53 pm revealed that she reviews and signs off on menus that are issued by Sysco. She confirmed there are no alternate choices on the menus that provide two hot entrees but residents can request a sandwich with protein or soup. She revealed she has never been provided an alternate meal menu. She believed due to budget reasons, no one from the facility has ever requested alternative menus from Sysco. Interview on 2/2/2025 at 9:08 am with the administrator revealed he was aware that residents do not have an alternate menu but states a sandwich and soup are always available.

Based on observations, staff interviews, and review of the facility policies titled, Food Storage the facility failed to discard food from the stand-up cooler by the expiration date. This deficient practice had the potential to affect 50 of 53 residents receiving an oral diet. Findings include: Review of the facility policy titled Food Storage, revealed under Procedure: 15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded. The tour of the kitchen on 1/31/2025 started at 8:23 am with the Dietary Manager (DM). The following concerns were identified during the tour in the stand-up cooler: 1. A resealable plastic bag that contained sliced ham with an expiration date 1/29/2025. 2. A plastic container of chicken and noodles with an expiration date of 1/22/2025. Interview on 1/31/2025 at 8:35 am with the DM who confirmed the expired ham and chicken and noodles and discarded them. She stated her expectation was that staff throw away items before they are expired. The risks would be illness to the residents.

Based on observations, staff interviews, record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to wash/sanitize hands and change gloves during tracheostomy care for one of one resident (R) (14) reviewed for tracheostomy care, and the facility failed to properly dispose of soiled items. This failure increased R14's risk for infection. Findings include: Review of the facility policy titled, Respiratory System Management Standard, dated August 2021, revealed: Tracheostomy care procedure Nursing actions. 3. [NAME] clean gloves and remove the used tracheostomy dressing being careful to keep the tracheostomy tube in place. 4. Remove used gloves and discard per facility standard. 5. perform hand hygiene. Review of the undated admission Record for R14 located in the Electronic Medical Record (EMR), revealed R14 was admitted to the facility with multiple diagnoses including but not limited to tracheostomy status, acute respiratory failure with hypoxia, respiratory disorder, unspecified, dependence on supplemental oxygen, and cerebral palsy. Review of R14's care plan revealed R14 had a tracheostomy related to diagnosis of acute respiratory failure, respiratory disorder, cerebral palsy, intellectual disabilities, dependence on supplemental O2, and persistent vegetive state. Observations made on 2/1/2025 at 10:00 a.m. revealed R14 lying in bed with head of the bed elevated. R14 was non-verbal. Tracheostomy was in place and secured with ties. Oxygen (O2) via trach collar at 5 liters (L)/minute. Trach care observation on 2/1/2025 at 11:10 am provided by wound care nurse Registered Nurse (RN) AA and assisted by Licensed Practical Nurse (LPN) CC revealed both RN AA and LPN CC washed hands with soap and water, and donned Personal Protective Equipment (PPE) before providing trach care. LPN CC washed her hands with soap and water during the procedure after donning and doffing gloves. RN AA did not wash her hands after donning and doffing gloves. Observation revealed RN AA washed her hands with soap and water before donning gloves before procedure. RN AA placed a pulse oximeter on R14 right fourth digit finger. RN AA removed her gloves, donned gloves and placed a chux pad on the bedside table. RN AA opened the package with the trach collar, opened the inner cannula package, and opened the trach care kit. LPN CC removed inner cannula and 4x4 dressing from R14 trach and placed it in the trash. LPN CC removed her gloves, washed her hands with soap and water, and donned gloves. LPN CC opened a bottle of saline and poured it into trach kit . RN AA removed gloves and donned gloves from the trach care kit. RN AA removed drape from the kit and placed the drape over R14 chest area. RN AA and LPN CC removed the trach collar and threw it in. LPN CC removed her gloves, washed her hands with soap and water and donned gloves. RN AA dipped a Q-tip in saline and swabbed under the right side of the trach collar attached to R14. RN AA wet a 4x4 gauze in the saline and wiped the left side of the trach collar and wiped under the bottom of the trach collar. RN AA cleaned around the trach stoma with a wet 4x4 gauze. RN AA placed 4x4 dressing under trach stoma. RN AA threw chux pad in trash, removed PPE and washed her hands with soap and water. RN AA and LPN CC placed a new trach collar under R14 trach stoma. LPN CC removed PPE and washed her hands with soap and water. RN AA placed soiled towels in a yellow plastic trash bag and placed the bag on the floor next to the plastic container that contained trach supplies. The container of trach supplies was on the floor between a red trash can and the yellow plastic trash bag containing the soiled towels. The yellow plastic trash bag remained on the floor for two hours after trach care was provided. Interview with LPN CC on 2/1/2025 at 11:05 am revealed she does not provide trach care. LPN CC stated that she assists the treatment nurse with trach care. She stated that she has been working at the facility for two years and she has not received an in-service on trach care. Interview with wound care nurse RN AA on 2/1/2025 at 11:30 am revealed RN AA acknowledged that she did not wash her hands before donning and doffing gloves throughout trach care procedure. RN AA stated that she should have washed her hands every time she took her gloves off, but she did not want to leave the resident. RN AA stated that she received a trach care in-service about two years ago. An interview with the Director of Nursing (DON) on 2/1/2025 at 12:35 pm, who stated that her expectations is for the treatment nurse to wash her hands before the procedure (trach care), and to change gloves before, during, and after the procedure. An interview with LPN BB on 2/1/2025 at 1:30 pm revealed LPN BB removed the yellow trash bag from floor in room R14. LPN BB stated that the trash bag should not have been on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and review of the facility policy titled, Use of Restraints. The facility failed to ensure that one of 59 residents (R) (R1) was free from physical restraints while in the facility. The deficient practice had the potential to prevent R1 from attaining and maintaining their highest practicable well-being and ensuring that their dignity and quality of life was maintained. Findings include: Review of the facility undated policy titled, Use of Restraints, under Procedure: This facility will not impose physical restraints for purposes of discipline or convenience. 1. Prior to the initiation of a physical restraint or psychotropic medication(s), clinicians will thoroughly assess the resident's mental/cognitive, behavior and physical status. This assessment will address other interventions that may be symptoms or the cause of the situation. Alternatives, less restrictive measures, to the use of a physical or chemical restraint must be initiated and recorded, including effectiveness of any/all alternatives employed. Clinicians and the attending physician must determine that physical restraint is a measure of last resort to protect the safety of the resident or others. 3. Unless there is an actual emergency, a physical restraint or psychotropic medication will not be initiated until the need for such a restraint is discussed thoroughly with the resident and/or resident representative and written consent is obtained. Observation on 9/9/2023 at 2:19 pm revealed resident was resting in bed with eyes closed. There were no indications of distress noted during observation. Record review revealed resident was admitted to the facility with diagnoses that included but not limited to dementia, major depressive disorder, and intellectual disabilities. Review of Annual Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns) C0500 a Brief Interview for Mental Status (BIMS) score of three indicating resident had a severe cognitive impairment. Section D (Mood) D0200 indicated that resident had trouble concentrating on things, such as reading the newspaper or watching television two to six days during the look back period for the assessment. Section E (Behavior) E0200 indicated that resident did have behavioral symptoms directed towards self and others one to three days during look back period of the assessment. Review of Facility Reported Incident (FRI) investigation dated 5/19/2023 revealed Certified Nursing Assistant (CNA) DD discovered R1 had a sheet tied over her and reported it to the Licensed Practical nurse (LPN) who in turn reported the incident to the Administrator, Director of Nursing, Responsible Party, and the Medical Doctor. According to the report the sheet was thrown over R1 double knotted and tied to the bed on all four corners. An additional sheet was placed over the top of the tied sheet hiding it from plain view. Interview on 9/9/2023 at 3:01 pm with CNA DD revealed that she was scheduled to work the 11-7 shift that night and was assigned to R1 for care. During her rounds at approximately 2:30 am R1 was in bed with a sheet draped over her. When the sheet was pulled back to provide care for resident it was noted that the sheet was tied to the bed on all four corners preventing resident from moving. Further interview also revealed that the incident was reported to the charge nurse and the sheets were removed from the resident by cutting the sheet with scissors. Interview on 9/9/2023 with the Administrator revealed that R1 was physically restrained by tying resident to the bed with sheets that were removed by staff after discovery. The incident was reported to the State Agency, Police, residents' representative, physician, and Adult protective Services (APS). There was an investigation that was completed which included statements from staff, skin assessment of the resident to ensure there were no injuries, and suspension of the staff member that was suspected to have restrained the resident until investigation was completed. Further interview also revealed that there had not been any proof that determined who actually restrained the resident but did acknowledge that the incident did occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Respiratory System Management Standard, the facility failed to ensure the provision of respiratory services in accordance with professional standards for one of one resident (R) (R#19) reviewed for tracheostomy (trach) care. Specifically, the facility failed to provide tracheostomy care supplies to include one size as ordered, and one smaller tracheostomy tube in emergency tracheostomy supplies at bedside. This failure increased R#19's risk for compromise airway and respiratory distress. Findings include: Review of the facility policy titled, Respiratory System Management Standard, dated August 2021, revealed: Tracheostomy care procedure Nursing actions. 3. [NAME] clean gloves and remove the used tracheostomy dressing being careful to keep the tracheostomy tube in place. 4. Remove used gloves and discard per facility standard. 5. perform hand hygiene. Review of admission Record for R#19 located in the Electronic Medical Record (EMR), revealed R#19 was admitted to the facility with multiple diagnoses including but not limited to tracheostomy status, acute respiratory failure with hypoxia, respiratory disorder, unspecified, dependence on supplemental oxygen, and cerebral palsy. Review of the most recent admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R#19 was unable to complete the interview due to cognitive deficits. Review of the care plan for R#19 revealed a tracheostomy related to dx of acute respiratory failure, respiratory disorder, cerebral palsy, intellectual disabilities, dependence on supplemental O2, and persistent vegetive state. Observations made on 9/8/2023 at 8:34 a.m. revealed R#19 lying in bed with head of the bed elevated. R#19 was non-verbal. Tracheostomy was in place and secured with ties. Oxygen (O2) via trach collar at 4 liters (L)/minute (min). Observation revealed there was no same size trach or smaller size trach at the bedside. Further observations revealed there was not an artificial manual breathing unit (AMBU) bag at the bedside. Review of Physician's Orders for R#19 in the EMR revealed no order for an emergency tracheostomy kit at the bedside. Observation and Interview on 9/9/2023 at 8:06 a.m. of tracheostomy care performed by RN AA and assisted by LPN BB revealed RN AA stated she did not know the size of the trach that R#19 had off the top of her head. RN AA stated that she would have to look it up. RN AA stated that she was going to change the inner cannula, trach ties and trach collar today. RN AA donned gloves without sanitizing or washing her hands and begun suctioning using a [NAME]. RN AA stated that the [NAME] was too big, and she placed the [NAME] on a towel that was on R#19's chest. LPN BB entered the room and donned gloves without sanitizing or washing her hands. LPN BB stated that she was not sure what size trach R#19 had. RN AA removed gloves and placed gloves on the bed next to the towel. RN AA opened an oral trach care kit and donned the sterile gloves without washing or sanitizing hands in between. RN AA removed saline from the kit and poured saline into the container and placed the saline bottle on the bed next to the towel. RN AA opened the hydrogen peroxide swabs, placed the drape over R#19 chest, and cleaned around the inner cannula with the hydrogen peroxide swabs. RN AA placed the hydrogen peroxide swabs on the bed on top of the gloves. LPN BB with gloved hands opened the trach tie. RN AA removed the soiled trach tie from around R#19's neck and picked up the [NAME] and began to suction. RN AA cleaned around the inner cannula with saline gauze. RN AA placed soiled gauze on top of the [NAME]. RN AA removed the inner cannula and replaced it with a new inner cannula. RN AA did not remove gloves, wash, or sanitize her hands between procedures. LPN BB assisted RN AA with putting the trach tie on. RN AA and LPN BB each secured an end of the trach tie. RN AA placed a clean gauze under R#19 trach. RN AA gathered up old inner cannula, trach tie, and soiled gauze and placed them in the trash can in room. RN AA removed trach collar and cleaned it with the towel that the [NAME] was placed on. LPN BB and RN AA placed the trach collar over R#19 trach. LPN BB placed the [NAME] in a Styrofoam cup of water, removed the [NAME] then she placed the [NAME] in the pack that it came in. LPN BB then placed the [NAME] on the nightstand by the suction machine. LPN BB and RN AA removed their gloves, neither washed nor sanitized their hands. LPN BB donned gloves turned the concentrator off and removed the humidifier bottle. LPN BB took the humidifier bottle in the bathroom in R#19 room and rinsed the bottle out. LPN BB filled the bottle with sterile water that was at the bedside, placed the bottle back on the concentrator and turned the concentrator back on. LPN BB removed her gloves, exited the room, and stated that she needed to wash her hands. LPN BB walked towards the nursing station. RN AA exited the room with the soiled towel in her hands and walked down the hall with it. RN AA stood in the hall and stated that she needed to wash her hands too. RN AA entered R#19 room and washed her hands in his bathroom sink. Interview with Registered Nurse (RN) AA on 9/9/2023 8:35 a.m. stated she did not know what size trach R #19 had. When asked by the surveyor what would she do if R#19 trach came out, RN AA stated that she supposes she needs to ask and find out before it comes out. RN AA stated that she has been working at the facility for four years as the Weekend RN Supervisor. RN AA stated that she did not know what an obturator was or what it is used for. RN AA further stated that there was normally stuff in the room to care for the trach. When asked by the surveyor what she meant by stuff she stated stuff to clean the trach with. Interview on 9/9/2023 at 8:35 a.m. with Licensed Practical Nurse (LPN) BB stated she received training/ in-service education related to tracheostomy care. LPN BB stated that she was not sure what size trach R#19 had. LPN BB stated that if R#19's trach came out they would send him to the hospital. She stated that it would probably take about three minutes for EMS to arrive because they are just up the street. LPN BB stated that she would be copying the paperwork to send him out while waiting for EMS to arrive. LPN BB stated that they took everything out of the room, but she was not sure who took it out. The surveyor asked what she meant by everything, LPN BB response was everything like the trach supplies and trach kit. LPN BB stated that R# 19 went out to hospital once because his trach came out. She stated that she had been working at the facility for two years and she was the wound care nurse. LPN BB stated that she had been the wound care nurse since June 2023. LPN BB stated that the wound care nurse usually performs the trach care. LPN BB stated that the respiratory therapist came in and checked them off on trach care. She stated that she knows that they need an AMBU bag at the bed side. She reported that they do not have an AMBU bag at the bedside and did not know why. She stated that she had only seen one AMBU bag in the whole building and that was located on the crash cart. LPN BB stated that she did not know what an obturator was or what it was used for. LPN stated that trach inner cannula change and trach care is a sterile procedure. Interview with the Director of Nursing (DON) on 9/9/2023 at 8:43 a.m. stated that trach supplies are in R#19 room in the closet. DON stated they knew where the supplies were. DON and surveyor walked down to R#19 room. DON opened the closed door and retrieved an AMBU bag. There were no other trach supplies in the closet. DON opened a drawer and retrieved an oral trach care kit. DON confirmed that there was not a trach size ordered or size smaller, or obturator in R#19 room or at bedside. DON stated that R#19's trach came out a week or so ago and she tried to put one back in. She stated that she could not get the trach back in and R#19 was sent out to the hospital for replacement. DON further stated that the nurses knew what to do if R#19's trach came out because they have been in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to wash/sanitize hands and change gloves during tracheostomy care for one of one resident (R) (#19) reviewed for tracheostomy care. This failure increased R#19's risk for infection. Findings include: Review of the facility policy titled, Respiratory System Management Standard, dated August 2021, revealed: Tracheostomy care procedure Nursing actions. 3. [NAME] clean gloves and remove the used tracheostomy dressing being careful to keep the tracheostomy tube in place. 4. Remove used gloves and discard per facility standard. 5. perform hand hygiene. Review of the undated admission Record for R#19 located in the Electronic Medical Record (EMR), revealed R#19 was admitted to the facility with multiple diagnoses including but not limited to tracheostomy status, acute respiratory failure with hypoxia, respiratory disorder, unspecified, dependence on supplemental oxygen, and cerebral palsy. Review of the most recent admission Minimum Data Set (MDS) for R#19 dated 6/27/2023 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R#19 was unable to complete the interview due to cognitive deficits. Review of R#19's care plan revealed R#19 had a tracheostomy related to dx of acute respiratory failure, respiratory disorder, cerebral palsy, intellectual disabilities, dependence on supplemental O2, and persistent vegetive state. Observations made on 9/8/2023 at 8:34 a.m. revealed R#19 lying in bed with head of the bed elevated. R#19 was non-verbal. Tracheostomy was in place and secured with ties. Oxygen (O2) via trach collar at 4 liters (L)/minute (min Tracheostomy care observation on 9/9/2023 at 8:06 a.m. performed by Register Nurse (RN) AA assisted by Licensed Practical Nurse (LPN) BB revealed RN AA donned gloves without sanitizing or washing her hands and begun to suction using a [NAME]. RN stated that the [NAME] was too big, and she placed the [NAME] on a towel that was on R#19's chest. LPN BB entered the room and donned gloves without sanitizing or washing her hands. LPN BB stated that she was not sure what size trach R#19 has. RN AA removed gloves and placed gloves on the bed next to the towel. RN AA opened an oral trach care kit and donned the sterile gloves without washing or sanitizing hands in between. RN AA removed saline from the kit and poured some saline into the container and placed the saline bottle on the bed next to the towel. RN AA opened the hydrogen peroxide swabs, placed the drape over R#19 chest, and cleaned around the inner cannula with the hydrogen peroxide swabs. RN AA placed the hydrogen peroxide swabs on the bed on top of the gloves. LPN BB with gloved hands opened the trach tie. RN AA removed the soiled trach tie from around R#19's neck and picked up the [NAME] and began to suction. RN AA cleaned around the inner cannula with saline gauze. RN AA placed soiled gauze on top of the [NAME]. RN AA removed the inner cannula and replaced it with new inner cannula. RN AA did not remove gloves, wash, or sanitize her hands between procedure. LPN BB assisted RN AA with putting the trach tie on. RN AA and LPN BB each secured an end of the trach tie. RN AA placed a clean gauze under R#19 trach. RN AA gathered up old inner cannula, trach tie, and soiled gauze and placed in trash can in room. RN AA removed trach collar and cleaned it with the towel that the [NAME] was placed on. LPN BB and RN AA placed the trach collar over R#19 trach. LPN BB placed the [NAME] in a Styrofoam cup of water, removed the [NAME] then she placed the [NAME] in the pack that it came in. LPN BB then placed the [NAME] on the nightstand by the suction machine. LPN BB and RN AA removed their gloves, neither washed nor sanitized their hands. LPN BB donned gloves turned the concentrator off and removed the humidifier bottle. LPN BB took the humidifier bottle in the bathroom in R#19 room and rinsed the bottle out. LPN BB filled the bottle with sterile water that was at the bedside, placed the bottle back on the concentrator and turned the concentrator back on. LPN BB removed her gloves, exited the room, and stated that she needed to wash her hands. LPN BB walked towards the nursing station. RN AA exited the room with the soiled towel in her hands and walked down the hall with it. RN AA stood in the hall and stated that she needed to wash her hands too. RN AA entered R#19 room and washed her hands in his bathroom sink. Interview with Registered Nurse (RN) AA on 9/9/2023 9:00 a.m. confirmed that she did not wash her hands before, or during trach care or after removing and changing her gloves. RN AA stated that she washed her hands in R #19 bathroom after she performed trach care. Interview with Licensed Practical Nurse (LPN) BB on 9/9/2023 at 9:05 a.m. revealed LPN BB confirmed that she did not wash her hands before, or during trach care or after removing and changing her gloves. LPN BB stated what do you want us to do stop what we are doing and go in the bathroom and wash our hands? LPN BB stated that she went to the bathroom down the hall and washed her hands after she assisted RN AA with trach care. She stated that she always washes her hands in that bathroom. LPN BB stated that she has been working at the facility for two years and she is the wound care nurse. LPN BB stated that she has been the wound care nurse since June 2023. LPN BB stated that the wound care nurse usually performs the trach care. LPN stated that trach inner cannula change and trach care is a sterile procedure. Interview with the Director of Nursing (DON) on 9/9/2023 at 8:43 a.m. revealed the DON had no response as to why RN AA and LPN BB did not wash or sanitize hands during trach care.

Based on observations, staff interviews, and review of the facility policy titled, Disposal of Garbage/Rubbish , the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. Findings include: Review of the facility policy titled Disposal of Garbage/Rubbish review date 1/13/2023 revealed under Procedure: 8. Outside dumpsters provided by garbage pickup services will be kept closed and the surrounding area will be kept free of litter. During the initial observation of the dumpster on 9/8/2023 at 8:50 a.m. with Dietary Manager, revealed the dumpster was open with bags of trash visible. Continued observation also revealed what appeared to be a bag of dirty diapers on the ground around the dumpster as well as gloves, flies, and bugs on top of the open dumpster. The dietary manager confirmed that the dumpster was open and should be closed without trash on the ground around the dumpster. Interview on 9/9/2023 at 8:53 a.m. with the Dietary Manager, she confirmed and agreed that the dumpster was open and should be closed and stated that the dietary staff and Maintenance were responsible for maintaining the dumpster area in a sanitary condition. During a follow up observation of the dumpster on 9/10/2023 at 8:30 a.m. revealed the dumpster was open from the side with trash visible. During an observation of the dumpster area on 9/10/23 at 8:49 a.m. with the Administrator the dumpster was open from the side with trash visible. The Administrator agreed the dumpster is open and should be closed, and trash should not be on the ground around the dumpster. He revealed that the dietary staff is responsible for maintaining and keeping the dumpster area clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, the facility failed to notify the physician in a timely manner of a fall for one of four residents (R#48). Findings include: A review of the facility's Policy titled, Notification of Changes: Procedure 1 revealed the following information: the facility must immediately inform the resident, consult with the residents physician and notify, consistent with his slash her authority, the resident representatives when there is- An accident involving the resident which results in injury and has the potential for requiring physician intervention; R#48 was admitted to the facility on [DATE] diagnoses that included: chronic obstructive pulmonary disease, unspecified sequelae of cerebral infarction affecting right dominant side, displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with nonunion, muscle weakness (generalized) weakness, aphasia, dysphagia, oral phase, essential (primary hypertension), gastro-esophageal reflux disease without esophagitis, unspecified fracture of right pubis, subsequent encounter for fracture with routine healing, unsteadiness on feet. An interview on 3/3/22 at 9:59 a.m. with Certified Nursing Assistant (CNA EE) revealed on 2/14/22 she was going to weigh R#48. Upon entering R #48's room, she heard a cry for help. She discovered R#48 was on the floor next to her wheelchair. CNA EE sent for the nurse, obtained a pillow, and allowed the resident to rest on the floor until the nurse arrived. CNA EE assisted the nurse in putting R#48 back in the bed. CNA EE revealed she did not notice any bruising at this time. CNA EE exited the room while Nurse-GG remained in the room with R#48. An interview on 3/3/22 at 10:05 AM with CNA FF revealed on 2/14/22 she walked into R#48's room to see if CNA EE needed help to weigh R#48. When she entered the room and asked CNA EE did she need help, CNA EE replied, R#48 was on the floor. LPN-GG then stepped from behind the curtains and told her not to say anything about the incident. CNA FF left the room and reported the incident to the DON on the following day. Review of the Progress note dated 2/15/2022 at 3:00 p.m. revealed R#48 was noted to have a bruise from unknown origin and reporting pain to her left hip. MD, DON, Administer notified. Record review revealed there was not any evidence of documentation that the resident's Physician or Responsible Party had been notified prior to 2/15/2022 at 3:15 p.m. An interview on 3/3/22 at 9:20 a.m. with R#48 revealed she did recall the event and stated she did fall to the floor and did not get caught in the handrail on her bed. R#48 revealed she did not recall ever getting caught in the handrail of her bed. An interview on 3/3/22 at 10:32 a.m. with CNA HH revealed she found R#48 on her butt holding on to the bed rail. Resident did not complain of pain after CNA-HH and Nurse placed resident back into bed. An interview on 3/3/22 at 11:06 a.m. with the NA revealed on February 15, 2022, it was reported to the DON and the NHA that a bruise of unknown origin was discovered on R#48's left hip. R#48 does have a Brief Interview score of 13 and is capable of making her own decisions. But secondary to R#48's aphasia it is often difficult to understand her explanation of events. As a result, the investigation into the origin of the bruise was initiated. The residents primary representative and the doctor were notified on 2/15/2022. The investigation showed that LPN-GG had charted that R#48 had entrapped her left hip in the bedrail while attempting to self-transfer to her wheelchair. Witness statements from three CNA's documented that R#48 was found sitting on the floor and that they went and ask LPN-GG to assist R#48 before they transferred her back to bed. The DON, NHA, MD, and RP were not notified at the time of the fall. As a result of conflicting stories from the LPN and 3 CNA's, the MD and the resident representative were called and an order for an x-ray was obtained. The x-ray showed multiple chronic non-healing fractures of the right hip and could not rule out a new fracture without further diagnostic testing. Per MD, R#48 was admitted to a local hospital where she underwent a CAT scan and MRA to further rule out a new fracture. The results showed that the fracture which was chronic in nature and had resulted from a fall more than two years ago. R#48 was then transferred back to the facility with no other indications of pain or discomfort. The NA revealed that their investigation concluded that R#48 did have a fall on 2/14/2022 and it was improperly recorded by LPN-GG. The improper reporting of the incident led to the investigation of a bruise of unknown origin on R#48. The bruise was determined to be caused by the fall that had not been reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual the facility failed to correctly code one Minimum Data Set Assessment (MDS) for Dialysis for one of 16 residents (R#24) reviewed. Findings include: The facility follows the RAI manual for policies and procedures. Review of R#24's medical record revealed diagnoses that included but not limited to end stage renal disease (ESRD) and dependence on renal dialysis. Review of R#24's quarterly MDS dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status score of five (5) indicating poor cognition; Section G-Functional Status: resident was totally dependent on staff for most Activities of Daily Living (ADL's); Section O-Special Treatments: Was not coded as receiving dialysis. Review of R#24's care plans revealed: Resident has peripheral vascular disease (PVD). Resident has renal insufficiency related to ESRD and secondary to hyperparathyroidism. Resident needs hemodialysis related to ESRD An observation of R#24 on 3/1/22 revealed resident was not in the facility and was at dialysis. An interview on 3/2/22 at 11:00 p.m. the Registered Nurse (RN) RN AA Wound Care nurse revealed resident is on Hospice, is very contracted, she had already completed the residents wound care with Hospice this AM. She does the wound care daily, Hospice does it when they come in. She has multiple wounds. She is very difficult to turn, positioning pillows and wedges used. She is on a pressure relief mattress. She is on supplements and gets all nutrition via g-tube bolus feedings. They have a wound care Nurse Practitioner (NP) that comes into the facility weekly and sees all the wounds in the facility. Adjustments in orders are done as needed. Resident has dialysis shunt in left arm. She checks it during wound care. An interview on 3/03/22 at 8:10 a.m. with the RN MDS Coordinator verified the MDS dated [DATE] did not indicate under section O that resident was on dialysis. She indicated it was an error and will do an attestation right away. An interview on 3/03/22 at 8:30 a.m. with the Director of Nursing (DON) revealed she would expect the MDS to reflect the resident's status and would expect the resident on dialysis to be coded correctly.

Based on record review, staff interview, and review of the facility policy titled, 'Physician Services', the facility failed to follow Physician's orders for one of 26 residents (R#157). Findings include: Review of policy titled, 'Physician Services' dated August 2021 revealed page six 'Physician's Orders: Procedure 1. All Physicians' Orders for each resident shall be entered into the electronic medical record immediately upon receipt. Paper orders are also acceptable.' Record review revealed R#157 was admitted to the facility 2/10/22 with diagnoses including but not limited to acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, cardiomyopathy, hypertension, type 2 diabetes mellitus, hypertension, and atherosclerotic heart disease of native coronary artery. Review of R#157's hospital discharge orders dated 2/9/22 revealed an order for metoprolol 50 milligrams (mg) twice daily. Review of February 2021 medication administration record (MAR) revealed no order for metoprolol 50mg twice daily. During an interview on 3/02/22 at 3:25 p.m. with the DON confirmed R#157 order for metoprolol 50mg twice daily was not carried forward on admission. States she is not sure why the admitting nurse did not add the medication. Revealed it is her expectation for nurses to follow physician orders or write progress notes to explain why medication was not started.

Based on observation, record review, staff interviews, and review of the facility policy titled, Medication Administration Guidelines the facility failed to ensure the medication error rate was less than five percent (5%). There were 12 medication errors with 32 opportunities for three residents observed (R#45, R#14, and R#41) by two nurses on two of five halls observed for a medication error rate of 37.5%. Findings include: Review of the facility policy titled Medication Administration Guidelines dated September 2019 revealed: Safe Medication Administration Medication Administration Staff administering medications must know or be able to locate medication information on the intended purpose, side effect, dosage, and special instructions. A. b. The resident's Medication Administration Record (MAR) is reviewed to determine what medications are to be administered and then staff removes those medications from the medication cart. h. After administration, staff will document the administration on the Medication Administration Record (MAR) or document refusal if indicated. A. o. Additional guidelines for the administration of inhaled medications No guideline to rinse mouth after use p. Additional guidelines for administration of nasal sprays i. Staff will request resident to blow nose prior to spray Documentation of Medications Review each MAR after each medication administration is completed and prior to the end of the shift to ensure documentation is complete and supports services provided, including, but not limited to, the following: Identification of omissions or inconsistencies within the MAR documentation. Review of the package insert for Symbicort inhaler indicated After inhalation, the patient should rinse the mouth with water without swallowing. A medication administration observation on 3/2/22 at 7:42 a.m. with Licensed Practical Nurse (LPN) LPN CC on R#45 revealed the nurse administered the following medications: Keppra 500 milligrams (mg) one (1) tablet by mouth (PO) Coreg 6.25mg 1 tablet po Lasix 40mg 1 tablet po Gabapentin 300mg 1 capsule po Dexilant delayed release (DR) 30mg 1 capsule po Fluticasone Nasal Spray 5 Micrograms (mcg) 1 spray into each nostril. Prasugrel 5mg 1 tablet po Vitamin E 400 Individual units (IU) 1 capsule po Zoloft 100mg 1 tablet po Tegretol 50mg 1 tablet po Review of R#45's 3/2/22 medication orders revealed the following errors and omissions: Colace 100mg 1 capsule 2 times a day (BID) scheduled for 8 a.m. and 8 p.m. was not given. Ferrous Sulfate 325mg 1 tablet BID scheduled for 8 a.m. and 8 p.m. was not given. Refresh Tears Solution instill 1 drop in both eyes BID scheduled for 8 a.m. and 4 p.m. was not given. LPN CC did not have R#45 blow her nose prior to administering the Fluticasone nasal spray. A medication administration observation on 3/2/22 at 7:52 a.m. with LPN CC on R#14 revealed the nurse administered the following medications: Acidophilus 1 capsule po Amlodipine 10mg 1 tablet po Aspirin 81mg 1 tablet po Symbicort inhaler 2 puffs inhale orally, rinse mouth after use. Carvedilol 3.25mg 1 tablet po Cranberry 450mg 1 tablet po Ferrous Sulfate 325mg 1 tablet po Ursodiol 300mg 1 capsule po Fexofenadine 180mg 1 tablet po Gabapentin 600mg 1 tablet po Review of R#14's 3/2/22 medication orders revealed the following errors and omissions: Nexium DR 40mg 1 capsule po BID scheduled for 8 a.m. and 8 p.m. was not given. LPN CC did not have resident rinse mouth after inhalation of the Symbicort inhaler. A medication administration observation held on 3/3/22 at 8:22 a.m. with LPN DD on R#41 revealed the nurse administered the following medications: Carbidopa 25mg 1 tablet po crushed Duloxetine 60mg 1 capsule po capsule opened and poured on applesauce (not crushed) Midodrine 5mg 1 tablet po crushed Memantine 10mg 1 tablet po crushed Raloxifene 60mg 1 tablet po crushed Senna 8.6mg 1 tablet po crushed Acetaminophen-Codeine half (1/2) tablet po crushed Medications were crushed all together and mixed in applesauce. Duloxetine capsule was opened and poured over the applesauce. Review of R#41's medication orders revealed no order to crush medications. An interview held on 3/2/22 at 7:52 a.m. with LPN CC revealed she has received education on medication administration. She knew to have resident blow nose before giving the nasal spray and to rinse mouth after use of an inhaler. She was nervous and forgot. An interview held on 3/3/22 at 8:22 a.m. LPN DD revealed she has received education on medication administration. She verified the resident did not have an order to crush her medications. An interview held on 3/03/22 at 10:26 a.m. with the Director of Nursing (DON) revealed she would expect the nurses to give medications as ordered and to follow the policy on rinsing mouth after use of an inhaler and blowing nose before giving a nasal spray. She would expect a resident to have a crush medication order. She has done education and training on medication administration.