**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and facility policy review, the facility failed to send a written notification of hospital transfer to the resident and/or resident representative (RR) for three of three residents (Resident (R) 22, R56, and R62) reviewed for hospital transfer of 27 sample residents. This failed practice had the potential to affect the residents and their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Transfer or Discharge Documentation, an initiation date of 2001 and a revision date of 12/16, indicated .details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider . When a resident is transferred or discharged from the facility, the following information will be documented in the medical record .That an appropriate notice was provided to the resident and/or legal representative. 1.Review of R22's electronic medical record (EMR) located under the Census tab revealed that R22 was discharged to the hospital on 2/6/2025 and returned to the facility on 2/11/2025. There was no record in the EMR of the facility providing a written notice of transfer to the resident or the RR. 2. Review of R56's Census tab in the EMR revealed R56 was originally admitted to the facility on [DATE]. Review of R56's Medical Diagnosis tab in the EMR revealed that R56 had diagnoses including metabolic encephalopathy, Alzheimer's disease, repeated falls, difficulty walking, and other lack of coordination. Review of the Care Plan under the Care Plan tab in the EMR revealed R56 had a focus with interventions related to a risk for falling initiated on 10/7/2022. Review of the MDS [Minimum Data Set] tab in the EMR revealed R56 had Discharge Return Anticipated MDS completed on 1/22/2025. Review of a nurse note, dated 1/21/2025 and located under the Progress Note tab in the EMR, revealed R56 had a witnessed fall in her room. The Occupational Therapist witnessed R56 slide from her bed, in the lowest position, onto her fall mat. The resident had hit her head on the nightstand and complained of hip pain. R56 was sent to the hospital for evaluation. Review of a Nursing Home to Hospital Transfer Form dated 1/21/2025 and supplied by the DON revealed R56 had gone to the hospital due to a fall. This form was given to the transportation personnel upon arrival at the facility. This was not provided to the resident or the RR. 3. Review of R62's undated admission Record located under the Profile tab in the EMR indicated R62 had originally been admitted to the facility on [DATE]. R62's diagnoses include resistance to multiple antimycobacterial drugs, dehydration, atrial fibrillation, dementia, depression, anxiety disorder, hypertension, heart failure, and chronic obstructive pulmonary disease. Review of R62's quarterly MDS located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 5/16/2025 indicated R62 was coded as having a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R62 was moderately cognitively impaired. Review of R62's eInteract-Nursing Home to Hospital Transfer From, dated 4/14/2025 and located under the Assessment tab in the EMR reflected R62 had been transferred to the emergency room (ER) on 6/3/2025 at 10:45 am for altered mental status. Review of R62's eInteract-Nursing Home to Hospital Transfer From, dated 5/5/2025 and located under the Assessment tab in the EMR reflected R62 had been transferred to the ER on [DATE] at 11:12 am for fever. Review of R62's eInteract-Nursing Home to Hospital Transfer From, dated 5/20/2025 and located under the Assessment tab in the EMR, reflected R62 had been transferred to the ER on [DATE] at 7:15 pm for chest pain. Review of R62's eInteract-Nursing Home to Hospital Transfer From, dated 6/3/2025 and located under the Assessment tab in the EMR, reflected R62 had been transferred to the emergency room (ER) on 6/3/2025 at 11:21 am for chest pain. During an interview on 6/12/2025 at 12:23 pm, R62 was unable to recall if a written notification of hospital transfer was received. Review of R62's medical record revealed documentation of written notification of the reason for the transfer to the hospital could not be located. During an interview on 6/12/2025 at 10:31 am, the Director of Nurses (DON) stated that they send the interact form with the emergency personnel. The DON stated that they did not have a form to send to the residents or the family, but they called them. During an interview on 6/12/2025 at 10:35 am, the Social Services Director (SSD) stated that nursing did all of the transfer forms. The SSD also stated that she was not sure about a written transfer notice being sent to the family, but she sent a list of residents transferred to the ombudsman every month. During an interview on 6/12/2025 at 1:28 pm, the Assistant Director of Nurses (ADON) stated they called the resident's representative and documented in the nursing notes in the EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure one 27 sampled residents (R) (R287) was free from significant medication errors when R287 did not receive diltiazem (Cardizem), a blood pressure medication, as ordered by the physician on 10 days. This failure had the potential to cause adverse reactions of high blood pressure. Findings include: Review of the facility's policy titled, Administering Medications, revised December 2012, revealed Medications must be administered in accordance with the orders . Review of R287's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R287 was admitted to the facility on [DATE] for a 14-day respite stay, with diagnoses including heart disease, dementia, and hypertension. R287 discharged home on [DATE]. Review of R287's Physician Orders located under the Orders tab of the electronic medical record (EMR) and dated 10/1/2024, revealed R287 was to receive diltiazem, 120 milligrams (mg), two tablets to equal 240 mg once daily for the treatment of hypertension (high blood pressure). Review of R287's pharmacy Consultation Report, dated 10/2/2024, located under the Scanned Documents tab of the EMR, revealed the recommendation to change the immediate release formulation of diltiazem to the extended-release formulation, diltiazem 24-hour extended release 240 mg once daily. The recommendation was accepted by the physician and signed on 10/3/2024. Review of R287's Physician Orders located under the Orders tab of the EMR and dated 10/3/2024, revealed R287 was to receive diltiazem 24-hour extended release, 240 mg capsule once daily. The medication was entered into the computer by the Director of Nursing (DON) on 10/3/2024 but scheduled not to begin until 10/14/2024 and the old order for diltiazem 120 mg, two tablets (immediate release) once daily was discontinued on 10/3/2024. Review of R287's Medication Administration Record (MAR), dated October 2024, located under the Orders tab of the EMR, revealed no documentation that R287 had received diltiazem on 10/4/2024 through 10/13/2024 as ordered by the physician. It also showed documentation of R287's vital signs that included R287's blood pressure was 128/68 on 10/2/2024 and 10/3/2024 and increased to 140/97 on 10/4/2024. Review of R287's Progress Notes tab revealed no documentation that the medication was discontinued or held by the physician. During an interview on 6/11/2025 at 11:05 am, the Director of Nursing (DON) reviewed R287's clinical record and confirmed that diltiazem 24-hour extended release, 240 mg, should have been started on 10/4/2024 instead of 10/14/2024 and should have been administered once daily. The DON stated that she made an error and entered a start date of 10/14/2024 instead of 10/4/2024, and considered diltiazem to be a significant medication and should have been administered.

Based on observations, interviews, and review of the policy titled Cleaning and Disinfection of Resident Care Items and Equipment, the facility failed to ensure that it maintained a clean and comfortable home-like environment for two of 30 sampled residents (R) (R54 and R63). Specifically, the facility failed to upkeep the cleanliness of resident wheelchairs related to dirt and hair build up. Findings: Review of the policy titled Cleaning and Disinfection of Resident Care Items and Equipment revised July 2014, revealed the policy is resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogen Standard. Observation on 2/10/2024 at 12:15 pm revealed a thick gray buildup and hair on the undercarriage of the wheelchair for R63. Observation on 2/10/2024 at 1:34 pm revealed R54 sitting in her wheelchair near the front nurse's station. There was a thick gray build-up noted to the wheel spokes and undercarriage of the wheelchair. Interview on 2/11/2024 at 11:17 am, the Maintenance Director stated resident wheelchairs should be cleaned monthly. He reported that night shift staff have washed wheelchairs before, but the Director of Nursing (DON) may be able to provide more information on the schedule. Interview 2/11/2024 at 11:25 am, DON reported that nursing and housekeeping staff are responsible for cleaning resident wheelchairs. During further interview, she indicated that a certain number of wheelchairs should be cleaned weekly on the night shift, but she was unsure of the specific number or which wheelchairs were to be cleaned. During a brief walking tour on 2/11/2024 beginning at 11:26 am, the DON confirmed R63 was observed sitting in her wheelchair with hair, dirt, and thick gray buildup on the undercarriage of her wheelchair; and R54 was observed sitting in her wheelchair in the hallway with thick gray buildup and dirt on the undercarriage and wheel spokes of her wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure the environment was free from potential accident hazards by not ensuring that a portable oxygen tank was stored securely in resident (R) 233's room of 43 resident rooms. Findings include: Review of medical record revealed R233 was admitted to the facility on [DATE] with diagnoses that included but was not limited to chronic congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Observation on 2/9/2024 at 3:35 pm, in R233's room was a free-standing portable oxygen tank sitting unsecured on the floor, near the wall by the television. Observation on 2/9/2024 at 3:55 pm, Licensed Practical Nurse (LPN) LL exited room of R233. During an observation and interview on 2/9/2024 at 3:59 pm, LPN KK confirmed the oxygen tank in R233's room was unsecured. She acknowledged that the oxygen tank should not have been sitting directly on the floor and then removed the oxygen tank from the room. Interview on 2/9/2024 at 4:00 pm, LPN LL stated that she had just exited R233's room but denied that she saw the unsecured oxygen tank sitting on the floor. Interview on 2/11/2024 at 3:43 pm, the Director of Nursing (DON) and the Administrator both denied knowledge of portable oxygen tanks sitting unsecured in any residents' rooms. The DON stated that the portable oxygen tanks should sit in a stand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the policy titled Antipsychotic Medication Use, the facility failed to ensure that psychotropic medications including antianxiety medications were not ordered as needed (PRN) beyond 14 days unless clinically indicated for two of five residents (R) (R8 and R38) reviewed for unnecessary medications. Findings are: Review of the policy titled Antipsychotic Medication Use revised 12/2016, revealed Policy Interpretation and Implementation: Number 15. as needed (PRN) psychotropics medications would not be utilized beyond 14 days unless the healthcare practitioner provided a documented rationale for the extended order and had evaluated the resident for the appropriateness of that medication. 1. Review of the clinical record revealed R8 was admitted to the facility on [DATE] with diagnoses including fibromyalgia, osteoarthritis, congestive heart failure (CHF), hypertension (HTN), hypothyroidism, and anxiety disorder. Review of the Physician Orders (PO) dated 1/18/2023 revealed an order for alprazolam (a medication used to treat anxiety) 0.5 milligram (mg) one tablet by mouth every 24 hours as needed (PRN). Further review of the PO did not indicate that the use of the PRN medication had been re-evaluated by the physician for continued use. The order had no end date. Review of R8's Medication Administration Record (MAR) for January 2024, revealed as needed alprazolam was administered 11 times and February 2024, revealed as needed alprazolam was administered 5 times. 2. Review of the clinical record revealed R38 was admitted to the facility on [DATE] with diagnoses including dementia, urinary retention, dysphagia, gout, hypertension (HTN), and anxiety disorder. Review of the Physician Orders (PO) dated 12/22/2023 revealed an order for lorazepam (a medication used to treat anxiety) 1 mg/milliliter (ml) every 4 hours as needed (PRN). Further review of the PO did not indicate that the use of the PRN medication had been re-evaluated by the physician for continued use. The order had no end date. Review of R38's Medication Administration Record (MAR) for December 2023 revealed PRN lorazepam was administered eight times; January 2024 PRN lorazepam was administered 20 times, and February 2024, revealed PRN lorazepam was administered three times. Interview on 2/10/2024 at 12:11 pm, the Director of Nursing (DON) stated that all psychotropic medications were supposed to have a 14-day stop date. The DON acknowledged there was no stop date for R38s alprazolam and R8s Lorazepam. She stated she was responsible for chart audits to ensure stop-dates were in place, and she stated this was an oversight.

Based on observations, staff interviews, and review of the facility's policies, the facility failed to have a hands-free trash receptacle at the hand washing sink, failed to ensure the exhaust hood filters were clean and free from grease build-up, and failed to properly label and date opened food items. These failures had the potential to affect 69 residents receiving an oral diet. Findings include: 1. Observation on 2/9/2024 at 9:45 am during the initial tour of the kitchen with the Dietary Manager (DM), revealed the hand washing sink near the main entrance to the kitchen, adjacent to the dish room, revealed the only trash receptable available to dispose of used paper towels was a large 50-gallon trash can covered with a lid. Continued observation revealed the DM lifting the dirty trash bin lid to dispose of a used paper towel. Interview on 2/9/2024 at 9:45 am, the DM confirmed that the only trash receptacle near the hand washing sink near the main entrance to the kitchen, was a 50-gallon trash can covered with lid, and the lid would need to be touched in order to dispose of used paper towels. The DM could not explain why a hands-free trash bin was not available at the hand washing sink. 2. Observation on 2/9/2024 at 9:48 am, the exhaust hood filters revealed a layer of grease build-up. The exhaust hood was above a four-burner stove and free-standing oven. Interview on 2/9/2024 at 9:48 am, the DM confirmed that there was grease build-up on the exhaust hood filters. She stated that the dietary department recently became responsible for cleaning the filters. She stated maintenance had been cleaning them every two weeks. During further interview, the DM stated that the exhaust hood is scheduled to be cleaned this weekend. Interview on 2/11/2024 at 1:30 pm, the Maintenance Director stated that he is ultimately responsible for cleaning the exhaust hood filters in the kitchen. He stated that the filters should be cleaned at least once a week, and confirmed they have not been cleaned. He stated that he does not keep a log of when the filters had been cleaned. During further interview, the Maintenance Director revealed that he prefers to clean the hood filters himself, due to the need to use a ladder to remove the filters. He stated he does not want to place anyone at risk of falling. 3. Review of the policy titled Food Storage: Dry Goods revised 2/2023, revealed storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the policy titled Food Storage: Cold Foods revised 2/2023, revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation on 2/9/2024 at 9:56 am, during the initial tour of the kitchen, inside the two-door stand up refrigerator revealed a clear plastic container containing Mixed Fruit labeled on the top lid with a date of 1/30/2024. There was also a rectangle shaped steam table pan containing cheese sauce that had a label stating Cheddar Cheese dated 1/28/2024. Interview on 2/9/2024 at 9:56 am, the DM verified the container with the mixed fruit was dated 1/30/2024. She stated that the date on the mixed fruit was wrong, that the fruit was just placed in the container yesterday. The DM confirmed that the pan containing the cheddar cheese sauce was dated 1/28/2024. The DM stated that she thought the discard date for the cheese sauce should be the same as that for shredded cheese, which is to discard three to four weeks after opening. Observation on 2/9/2024 at 10:05 am, in the dry storage area revealed three large clear plastic containers on a shelf containing elbow macaroni, rigatoni noodles, and rice that had no label or open date on them. Further observation revealed a large white plastic bin with wheels containing sugar with no label or open date. Interview on 2/9/2024 at 10:05 am, the DM confirmed that the pasta and rice containers had no label or open date on them. She stated that she expects the dietary staff to label and date food items once taken out of the package and placed in a container. The DM confirmed that the white plastic bin containing sugar had no label or open date on it. During further interview, the DM stated that she does not expect staff to date the sugar bin once the sugar has been taken out of the original package. She stated the sugar bin is cleaned once per month and stated that is when new sugar is placed. The DM verified the last documented date for cleaning the sugar bin was 6/13/2023. Observation on 2/9/2024 at 10:10 am, the outside building with kitchen refrigeration and freezer storage revealed a two door stand up freezer next to the milk chest refrigeration, had a white frosted plastic bag containing a white circular food item with no label or date. Interview on 2/9/2024 at 10:10 am, DM confirmed the white frosted plastic bag with the circular food item did not have a label or date om it. She stated the dietary staff should have placed a label and dated the product before storing the food item. Observation on 2/11/2024 at 9:20 am, the two-door stand up refrigerator inside the kitchen revealed a clear plastic circulator container containing two bags of opened shredded cheese. Continued observation revealed the label on the top lid stated Mixed Fruit 2/8/2024. Interview on 2/11/2024 at 9:20 am, the DM confirmed that the lid to the container storing opened bags of shredded cheese was labeled Mixed Fruit and dated 2/8/2024. The DM stated the dietary staff failed to remove a previous label from the container lid, and she expects staff to place appropriate labels on the containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the Policies and Procedures for Nursing Facility Services, and review of the policy titled Healthcare Management-Legionella Infection Control, the facility failed to develop and implement a water management plan to include policies and procedures for the prevention and spread of Legionella and other opportunistic pathogens in the building water system. In addition, the facility failed to designate a clean and dirty room on the ventilator unit to reduce the cross contamination of respiratory therapy equipment. The census was 93. Findings include: Review of the document titled Healthcare Management-Legionella Infection Control dated 7/22/2021 revealed Legionella bacteria is found in [NAME] environment. The bacteria can become a health concern when it grows in building water systems such as: o Shower heads and sink faucets. o Cooling towers found in centralized air- cooling systems. o Decorative fountains o Hot water tanks and heaters. o Large complex plumbing systems. o Medical equipment such as a C- PAP machine. The facility will implement a water management program to reduce the building's risk for growing and spreading Legionella. Elements of a water management program are to: o Establish a water management program team. The team should include someone who understands accreditation standards and licensing requirements. The infection control person, a clinician with expertise in infectious diseases. Risk management o Describe the building water systems using text and floor diagrams. Be sure to include descriptions of water sources relevant to patient care areas, Clinical support areas, and components and devices that can expose patients to contaminated water. o Identify areas where Legionella could grow and spread. Prevent any water stagnation. o Decide the way control measures should be applied and how to monitor them. Control measures and limits should be established for each control point. And measure your control points weekly. Water should be measured throughout the system to ensure that changes that may lead to Legionella growth are not occurring. o Water heaters should be maintained at an appropriate temperature. (Equal or greater to 124 degrees). o Decorative fountains should be kept free and clear of debris, including biofilm. o Disinfectant and other chemical levels in coolant towers and hot tubs should be continuously maintained and monitored. o Establish ways to intervene when control limits are not met. You should also develop an ongoing dialogue with your drinking water provider so that you are aware of changes that may affect your building's water supply. o Make sure the program is running as designed and is effective. Document and communicate all the activities. 1. The facility could not provide any documentation regarding the water management plan, including an assessment for the identification of where Legionella could grow and spread or measures to prevent the growth of opportunistic waterborne pathogens, and how to monitor. Review of the daily water temperature logs provided by the Maintenance Director revealed there were no temperatures logged for the months of January 2023 through January 2024. The facility did not have a log for flushing water lines in areas that had increased risk for the growth of Legionella. Interview on 2/10/2022 at 9:40 am, the Maintenance Director revealed he checks the water temperature in resident rooms monthly. He presented a book titled [facility name] Treatment that had pictures of a temperature stick dated 2/10/2024. There were no other dates or pictures of temperatures in the [facility name] Treatment book. The Maintenane Director was asked for the policy and procedures for measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems, and he reported it should all be in the book. He confirmed there was no plan in place for prevention of Legionella or other bloodborne pathogens in the [facility name] Treatment Book. 2. Review of the document titled Part II - Policies and Procedures for Nursing Facility Services; Georgia Department of Community Health, Division of Medical Assistance dated July 1, 2014, Chapter 800, Section 804: Mechanical Ventilation Services, 804.5 Nursing Facility Staffing, Equipment and Requirements revealed in order to maintain quality standards and reduce cross contamination, the facility policy and procedure for cleaning and maintaining equipment must include a designated soiled utility room which will be used to clean soiled Respiratory Therapy equipment, as well as a separate area to store clean equipment. The ventilator unit must have a designated clean and dirty room. This area may not be a mixed use area. It must be separated from storage and or office space. Observation on 2/9/2024 at 11:53 am of the ventilator unit revealed the facility does not have a dirty and clean room for disinfecting and cleaning equipment. Observation of dirty respiratory equipment is the respiratory office. Interview on 2/9/2024 at 1:30 pm, Registered Respiratory Therapist (RRT) AA indicated the dirty equipment from the ventilator unit is brought into the respiratory department to be cleaned, and then taken back out for use. During further interview, RRT AA revealed there was not a separate door to take the cleaning equipment from the department, back on the unit. She stated the room in the respiratory department was used by all the staff. Interview on 2/9/2024 at 1:00 pm, Administrator stated the respiratory equipment was cleaned in the respiratory department, on the opposite side of the room. He confirmed there was only one entrance to the room to bring the dirty equipment in and to take clean equipment out. Interview on 2/10/2024 at 12:30 pm, Director of Respiratory Therapy (DORT) stated the dirty respiratory equipment was now being covered with a plastic bag and moved from the vent unit through the hall to a room designated for cleaning. He stated the room still does not have a separate dirty and clean side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and review of facility policy titled, admission Criteria, the facility failed to perform PASARR Level II screening for two of two residents (R), R#68, R#5, diagnosed with mental disorders. These failures to prescreen residents prior to admission to the facility may result in the failure to identify residents who have or may have mental disorders (MD), intellectual disorders (ID), or a related condition. Findings include: Review of the facility policy titled, admission Criteria, dated March 2017, revealed the following: Policy Interpretation and Implementation: #8) Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable. #9) Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through preadmission screening program) that the individual has a physical or mental condition that requires the level of services by the facility. Review of the electronic medical record (EMR) for R#68 revealed he was a [AGE] year old male admitted to the facility on [DATE] with diagnoses to include post-traumatic stress syndrome (PTSD) and adjustment disorder with anxiety. Review of the EMR for R#68 revealed a PASARR Level I assessment was approved before admission [DATE]) but there was no Level II PASARR assessment on file. Review of the EMR for R#5 revealed she was a [AGE] year old female admitted to the facility on [DATE] with diagnosis to include schizoaffective disorder. Review of the EMR revealed a PASARR Level I assessment was approved before admission but there was no Level II PASARR assessment on file. In an interview with the Social Services Director (SSD) on 1/4/2023 at 6:20 p.m., she stated the facility had five residents with PASARR level II approvals. She confirmed neither R#68 nor R#5 had a PASARR Level II assessments but should have based on their diagnoses. She stated she has only been on staff since September of 2022 and had not done an audit to determine which residents should be assessed. She stated she would conduct an audit when the new psych services company starts this month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 Respiratory Care 01/03/23 10:30 AM Resident resting quietly with eyes open, Oxygen at 3.5 lpm via NC with no humidification, oxygen tubing not labeled, brief record review revealed no order for oxygen. 1/4/23 08:40 AM R 12 observed sitting up in bed after eating breakfast states he enjoyed his breakfast. Bed linens appeared clean, resident reports he is about to get his bath. Clean linens, towels, and clothing stacked neatly on residents night stand. 01/05/23 08:50 AM Observed resident resting quietly with eyes closed, oxygen at 3 lpm via NC no humidification, oxygen tubing not labeled. 01/05/23 10:25 AM Interview with [NAME] LPN revealed residents on oxygen have an order for the intervention, states they check O2 saturations every shift as ordered by the physician. States the respiratory therapy is responsible for maintaining the oxygen concentrator and changing filters. 01/05/23 10:29 AM Interview with [NAME] RT confirmed that respiratory therapist is responsible to maintain concentrators and change filters weekly. She confirmed there is no order on chart for R #12. 01/05/23 10:32 AM Interview with Director of Nursing confirmed respiratory therapist (RT) is responsible for maintain concentrators and change filters weekly, the RT is also responsible for reviewing orders and make recommendations to physician regarding oxygen needs and humidification for oxygen. She confirmed R #12 does not have an order for oxygen. Confirmed oxygen is not care planned. Record Review: admission MDS dated [DATE] C - Cognitive Patterns: BIMs score of 03 indicating severe impairment. G - Functional Status: Total Dependence with 2 person assist for bed mobility, toilet use, dressing, bathing; Extensive assistance with personal hygiene with 2 person assist; Independent with eating J - Health Conditions: no shortness of breath recorded on this MDS. O - Special Treatments, Procedures, and Programs: treatments, procedures, and programs that were performed during the last 14 days prior to MDS assessment: Oxygen was marked as received while resident of the facility. Respiratory therapy not received in previous 7 days of MDS assessment. Physician’s orders: Evaluate resident for SOB with laying flat, attempting to lay flat, or with activities, new or worsening malaise (general feeling of discomfort, illness, or uneasiness), new dizziness, diarrhea, sore throat, or new loss of smell or taste every shift. Pertinent diagnoses: Acute on chronic diastolic (congestive) heart failure, chronic atrial fibrillation, chronic obstructive pulmonary disease (COPD) Care plan dated 11/10/22 no findings on care plan to support use of oxygen. Nurses Notes Reviewed: On 10/25/22 Nurse note entry by [NAME] LPN at 1512 recorded spo2 of 82% and a call to physician (Dr. [NAME]) and new orders received and implemented at this time. 02 on at 2 lpm. Stat neb tx ordered, legs elevated and lasix ordered and given. Resident is stable and resting comfortably at this time. VSS Spo2 at 95%, P 69, r16, bp 115/89. There after multiple intermitted entries recorded by various nursing staff of Resident on O2 at 2LPM via NC. Resident #14 Activities of Daily Living 1/3/23 11:10 am Observation and interview of R#14 , revealed resident propelling self in a wheelchair into his room. Was dressed and had facial hair visible on chin, cheeks, and upper lip. Observed fingernails to be long, jagged, and with brown discoloration. Resident revealed he does have his face shaven when receives a shower and revealed receives a shower two times a month. Revealed would like a shower more often and for face to be shaved at least two times a week and fingernails to be trimmed. 1/4/23 8:45 a.m. Observation and interview of R#14 revealed sitting in his room in a wheelchair. Was dressed and had visible facial hair on chin, upper lip and cheeks. Observed fingernails to be long, jagged, and with brown discoloration under nails. Toenails observed to be within normal length and smooth. Resident revealed cannot remember the last time he had a shower or face was shaved and would like for his face to be shaved at least two times a week. Revealed he required assistance with bathing and personal cares. 1/4/23 11:15 a.m. Observation and interview of R#14 revealed resident sitting in a wheelchair in his room. Dressed and groomed with facial hair observed on chin, upper lip and cheeks. Fingernails observed to be long, jagged, and with brown discoloration. Resident revealed he did get a shower this morning but did not have his face shaved or fingernails trimmed or cleaned. R#14 is a [AGE] year old male admitted on [DATE] Quarterly MDS dated [DATE] revealed: C - BIMS score of 13 E - no behaviors exhibited G - required limited assistance of one person for bed mobility, transfers, dressing; supervision of one person for locomotion, eating, personal hygiene; extensive assistance of one person for toileting; ambulation did not occur; required physical assistance of one person in part of bathing activity. J - did not receive scheduled or prn pain medication and no pain was reported during the 5 day look back period. O - received occupational therapy for 5 of 7 days Physician’s orders include (not all inclusive): 10/14/22: Behavioral Monitoring: Has resident had behaviors of yelling, cursing, resisting care, delusions, hallucinations, hitting this shift? Monitor for and document if noted adverse reactions - every day and night shift 10/11/22: Skilled OT to tx 5-7 x week x 4 weeks for therapy exercise, therapy activity, neuro [NAME] and self care/ADLS Diagnosis include (not all inclusive): MUSCLE WEAKNESS (GENERALIZED) OTHER LACK OF COORDINATION DIFFICULTY IN WALKING UNSPECIFIED DEMENTIA TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA Care plan dated 11/1/22 revealed (not all inclusive): Focus: The resident has an ADL self-care performance deficit r/t recent lengthy hospitalization. Had a fall with fracture and had surgical nailing repair to rt hip. Here for therapy and regain as much of prior function as possible. Goal: The resident will improve current level of function in transfers and ambulation through the review date. Interventions: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. DRESSING: Allow sufficient time for dressing and undressing. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. EATING: The resident is able to feed self with set up assist ORAL CARE ROUTINE SPECIFY brush rinse mouth with wash. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self care. PT/OT evaluation and treatment as per MD orders. Focus: The resident has Diabetes Mellitus Goal: The resident will have no complications related to diabetes through the review date. Interventions include: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Fasting Serum Blood Sugar as ordered by doctor. Offer substitutes for foods not eaten. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Record review of the nurses notes revealed no documented refusal of ADLS or showers. 1/4/23 at 3:00 p.m. a record review of the shower log in the electronic medical record (EMR) revealed resident did not receive a shower from 12/25/22 to 1/3/22. Revealed one refusal of a shower on 11/25/22. 1/4/23 at 9:25 a.m. an interview with [NAME], CNA revealed she had worked at the facility for 3 weeks. Revealed during orientation, she received training to include ADL cares, abuse and neglect, PPE use, infection control, fire safety. She revealed there was a shower team of CNAs who provide showers and baths. Revealed residents have scheduled shower/bath two times a week and as needed. Revealed she provides bed baths to bed bound residents daily as needed. 1/4/23 at 11:25 a.m. an interview with [NAME], CNA revealed she had worked at the facility for 3 weeks. Revealed during orientation, she received training to include ADL cares, infection control, PPE use, abuse, and revealed she had completed multiple training modules in the Relias program. She further revealed she is on the shower/bath team and follows the schedule for resident showers. She revealed residents are scheduled for shower/bath two times a week and may receive shower/bath as requested on other days. She revealed males are offered to have their face shaved and hair and fingernail care is included in cares received with showers. She further revealed ADL cares and refusal of cares are reported to the nurse and documented in the (EMR). 1/4/23 at 11:30 a.m. an interview with [NAME], RN revealed residents are scheduled for showers/baths two times a week and that males should be offered to have their face shaved and hair and fingernail care is provided for all residents on shower days. She further revealed ADL cares are to be documented in the EMR and refusal of cares are to be documented and reported to the nurse. Observation of R#14 with RN [NAME] verified him to have obvious facial hair on chin, upper lip and cheeks and fingernails to be long, jagged and to have brown discoloration. 1/4/23 at 1:50 p.m. an interview with [NAME], Director of Nursing (DON) revealed residents are scheduled to have a shower two times a week and as needed or requested. She further revealed males should have their face shaved as requested and that fingernail care is provided on shower days and as needed. She revealed residents with diagnosis of diabetes mellitus have fingernail care provided by the nurse and toenail care provided by a podiatrist. She revealed her expectations are for residents to receive showers and ADL cares as scheduled and for cares and refusal of cares to be documented in the EMR. 1/5/23 at 9:00 a.m. during an interview with [NAME], DON, the shower log documentation was reviewed and she verified R#14's documentation revealed he did not receive a shower from 12/25/22 to 1/3/22. She further stated she thinks he did receive a shower during the time frame and contacted a unit nurse and stated R#14 received a shower on 12/28/22 and printed a shower log to contain 12/28/22 documented as resident received a shower. Further interview verified resident had obvious facial hair on chin, upper lip and cheeks and long, jagged, brown discolored fingernails on 1/3/23/and 1/4/23. Based on observation, resident and staff interviews and record, the facility failed to provide ADL care, specifically fingernail care and facial grooming related to shaving for R#14. Based on observations, record review, resident and staff interviews, and review of the facility policies titled Care Planning-Interdisciplinary Team and Care Plans, Comprehensive Person-Centered the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical needs and included the resident's goals and desired outcomes in regards to oxygen administration for two of two residents (R) (R#82 and R#12) and failed to implement care plan interventions for one resident (R#14) related to Activities of Daily Living (ADL) fingernail maintenance. Findings include: Review of the undated facility policy titled, Care Planning-Interdisciplinary Team revealed the policy statement of: Care Planning/Interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident and A comprehensive care plan for each resident is developed with seven (7) days of completion of the resident assessment Minimum Data Set (MDS). Review of the policy titled, Care Plans, Comprehensive Person-Centered with a revision date of December 2016, revealed the policy statement of: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy interpretation and implementation section revealed: 8.b. The comprehensive, person-centered care plan will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. A review of the clinical record for R#82 revealed an admission date of 8/4/2022 with diagnoses including but not limited to: hemiplegia and hemiparesis following cerebral infarction, hypertension, chronic kidney disease, muscle weakness. Review of the most current quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating a moderate cognitive impairment. In addition, MDS revealed the resident was receiving oxygen before living at the facility. Review of physician orders revealed an order for oxygen with a start date of 11/21/2022 to use as needed for shortness of breath (SOB) at 2, 3, or 4 liters per minute (LPM) via nasal cannula (NC). An observation on 1/3/2023 at 10:35 a.m. revealed oxygen on at 3.5 LPM via NC, with the NC on his forehead, 1/4/2023 at 10:55 a.m. revealed R#82 lying in bed with oxygen on at 3.5 LPM via nasal cannula (NC) with NC on upper right corner of mattress, and on 1/5/2023 at 9:50 a.m. revealed R#82 lying in bed with oxygen on at 3.5 LPM via NC with the NC lying in the bed beside R#82. During an interview on 1/5/2023 at 2:40 p.m. with Licensed Practical Nurse (LPN) DD, she revealed she looks at the Medication Administration Record (MAR) and physician orders for oxygen needs and looks at the care plan maybe once a month if she sees a change written in the Pertinent Charting 24-hour Report notebook kept at the nurse's station. During an interview on 1/5/2023 at 2:50 p.m. with LPN FF, she revealed she checks the MAR for oxygen needs and looks at the care plan maybe every two weeks. She checks the Pertinent Charting 24-hour Report notebook every day prior to beginning work. During an interview on 1/5/2023 at 3:20 p.m. with the Director of Nursing (DON), she revealed it is the Unit Manager's responsibility to initiate the care plan on admission and auditing care plans. The nurses and interdisciplinary team can update the care plan. The DON also revealed the clinical team has a morning meeting every day where missing or incorrect interventions should be discussed if needed. 2. Review of the clinical record for R#12 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to acute on chronic diastolic (congestive) heart failure, chronic atrial fibrillation, and chronic obstructive pulmonary disease (COPD). Review of the admission MDS dated [DATE] revealed a BIMS score coded as 3 indicating severe cognitive impairment. Further review revealed section O for special treatments documentation of oxygen use while in the facility was answered positively. Review of care plan dated 11/10/2022 did not address the use of oxygen. Review of physician orders revealed new orders for oxygen were written on 1/5/2023. No orders for oxygen prior to this date were found. Nurses' notes dated 10/25/2022 revealed an entry, recorded by LPN GG, at 3:12 p.m. revealed a drop in oxygen saturation to 82% for R#12. LPN GG called the physician and documented receiving a verbal order for oxygen at 2 LPM via NC but did not write the verbal order received. Further review of nurse's notes dated 10/25/2022 through 1/4/2023 revealed multiple entries recorded by various nursing staff of R #12 being on oxygen at 2 LPM via NC. An observation 1/3/2023 at 10:30 a.m. revealed R #12 with oxygen on at 3.5 LPM via NC without humidification. The oxygen tubing was not labeled. An observation 1/4/2023 at 8:40 a.m. revealed R#12 sitting up in bed, stating he enjoyed his breakfast, and they were about to bathe him. Observed clean linens neatly stacked on the nightstand. Observed R#12 was receiving oxygen at 3.5 LPM via NC without humidification and the oxygen tubing was not labeled. An observation 1/5/2023 at 8:50 a.m. revealed R#12 receiving oxygen at 3 LPM via NC without humidification and the oxygen tubing was not labeled. During an interview on 1/5/2023 at 10:25 a.m. with LPN GG, she revealed that all residents who are receiving oxygen must have an order for the intervention, states nurses check residents' oxygen saturation every shift as ordered by physician. She went on to indicate that the respiratory therapist is responsible for maintaining the oxygen concentrator and changing of filters but was uncertain of how often this should occur. During an interview on 1/5/2023 at 10:29 a.m. with Registered Respiratory Therapist (RRT) HH, she confirmed that it is the responsibility of the respiratory therapist to maintain and change filters for all the oxygen concentrators on a weekly basis. She was not certain what day of the week this facility does this. She confirmed that every resident receiving oxygen has an order. She also confirmed there was no order for oxygen recorded in the medical record for R#12. During an Interview on 1/5/2023 at 10:32 a.m. with the DON, she confirmed that the respiratory therapists are responsible for maintaining oxygen concentrators and change filters on a weekly basis. She further stated the respiratory therapists are responsible for reviewing orders and making recommendations to the physician regarding oxygen needs and humidification for oxygen use. She confirmed R #12 did not have an order for oxygen and the care plan did not address use of oxygen. 3. A review of the clinical record for R#14 revealed an admission date of 6/23/2022 with diagnoses including muscle weakness, other lack of coordination, difficulty in walking, unspecified dementia, type 2 diabetes mellitus with hyperglycemia. Review of the most recent quarterly MDS dated [DATE], revealed a BIMS score coded as 13, indicating R#14 is cognitively intact. The MDS revealed R#14 required supervision of one person for personal hygiene. Review of the care plan dated 11/1/2022, revealed R#14 had an ADL self-care performance deficit and required assistance with care to meet her needs. Interventions included to check nail length and trim and clean on bath day and as necessary and to report any changes to the nurse. Observations on 1/3/2023 at 11:10 a.m., 1/4/2023 at 8:45 a.m., and 1/4/2023 at 11:15 a.m. revealed R#14 with long, jagged fingernails with brown discoloration on all fingernails and to have facial hair on chin, upper lip, and cheeks. Interviews on 1/3/2023 at 11:10 a.m., 1/4/2023 at 8:45 a.m., and 1/4/2023 at 11:15 a.m. with R#14 revealed he would like to have his face shaven at least two times a week and would like to have fingernails trimmed and cleaned weekly. R#14 revealed he had asked for his face to be shaved and his nails to be trimmed. During an interview on 1/4/2023 at 9:25 a.m. with Certified Nursing Assistant (CNA) AA, she revealed the shower team provides showers/baths and included facial shaving and nail care. She revealed she provides bed baths to residents that are bed bound and nail care and facial shaving was provided with the bed baths. She revealed refusal of cares are reported to the nurse and documented in the electronic medical record (EMR). During an interview on 1/4/2023 at 11:25 a.m. with CNA BB, she revealed she was part of the shower/bath team. She further revealed male residents are offered to have their face shaven on shower/bath days and that fingernail care is included in cares received on shower/bath days. She revealed refusal of cares, including ADL cares, are documented in the EMR and reported to the nurse. During an interview on 1/4/2023 at 11:30 a.m. with Registered Nurse (RN) CC, she revealed residents are offered a shower/bath two times a week and facial shaving and nail cares are provided on shower/bath days and as needed. She revealed refusal of cares should be documented in the EMR and reported to the nurse. An observation on 1/4/2023 at 11:30 a.m. of R#14 with RN CC, verified R#14 to have obvious facial hair on their chin, upper lip, and cheeks and to have long, jagged fingernails with brown discoloration on all fingers. R#14 revealed to RN CC he would like to have his face shaved and his fingernails trimmed and cleaned. Record review of the shower log for October, November, and December 2022 revealed documentation that R#14 received a shower two times a week during the last three months. There was no specific area for nail care or facial shaving documentation. During an interview on 1/5/2023 at 9:00 a.m. with the DON, she revealed her expectations are for residents to have fingernail care provided and for male residents to be offered to have face shaved on shower/bath days and as needed. She further revealed residents with a diagnosis of diabetes mellitus receive fingernail care provided by a nurse and that nail care should be provided and documented as provided or refused. She revealed her expectations are for care plans to be followed. The DON verified that R#14 had obvious facial hair on chin, upper lip, and cheeks and fingernails were long, jagged with brown discoloration. She also verified the care planned interventions for R#14 including ADL and nail cares should be provided. Cross reference F677

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to provide activities of daily living (ADL) cares, specifically nail care and facial shaving, for one of 48 residents (R) (R#14) sampled that required assistance for ADLS, including showers and nail care. These failures caused R#14 to go unshaven and to have long, unkept/unclean fingernails. Findings include: The facility did not provide a policy, procedure, or formal guidelines for ADL cares. A review of the clinical record for R#14 revealed admission date of 6/23/2022 with diagnoses including muscle weakness, other lack of coordination, difficulty in walking, unspecified dementia, type 2 diabetes mellitus with hyperglycemia. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed Brief Interview for Mental Status (BIMS) coded as 13, indicating R#14 is cognitively intact. The MDS revealed R#14 required supervision of one person for personal hygiene. Review of the care plan dated 11/1/2022, revealed R#14 had ADL self-care performance deficit and required assisted care to meet needs. Interventions included to check nail length and trim and clean nails on bath day and as necessary and to report any changes to the nurse. Observations on 1/3/2023 at 11:10 a.m., 1/4/2023 at 8:45 a.m., and 1/4/2023 at 11:15 a.m. revealed R#14 with long, jagged fingernails with brown discoloration on all fingernails and to have facial hair on chin, upper lip, and cheeks. Interviews with R#14 on 1/3/2023 at 11:10 a.m., 1/4/2023 at 8:45 a.m., and 1/4/2023 at 11:15 a.m. revealed he would like to have his face shaven at least two times a week and would like to have his fingernails trimmed and cleaned weekly. R#14 revealed he had asked for his face to be shaved and his nails to be trimmed. Interview on 1/4/2023 at 9:25 a.m. with Certified Nursing Assistant (CNA) AA revealed the shower team provides showers/baths and includes facial shaving and nail care. She revealed she provides bed baths to residents that are bed bound and nail care and facial shaving is provided with the bed bath. She revealed refusal of cares are reported to the nurse and documented in the electronic medical record (EMR). Interview on 1/4/2023 at 11:25 am with CNA BB revealed she is part of the shower/bath team. She further revealed male residents are offered to have their face shaven on shower/bath days and that fingernails care is included in cares received on shower/bath days. She revealed refusal of cares, including ADL cares, are documented in the EMR and reported to the nurse. Interview on 1/4/2023 at 11:30 a.m. with Registered Nurse (RN) CC revealed residents are offered a shower/bath two times a week and facial shaving and nail care are provided on shower/bath days and as needed. She revealed refusal of cares should be documented in the EMR and reported to the nurse. Observation on 1/4/2023 at 11:30 a.m. of R#14 with RN CC verified R#14 to have obvious facial hair on chin, upper lip, and cheeks and to have long, jagged fingernails with brown discoloration on all fingers. R#14 revealed to RN CC he would like to have face shaved and fingernails trimmed and cleaned. Record review of the shower logs for October, November and December 2022 revealed documentation that R#14 received a shower two times a week during the last three months. There was no specific area for nail care or facial shaving documentation. Interview on 1/5/2023 at 9:00 a.m. with the Director of Nursing (DON) revealed her expectations are for residents to have fingernail care provided and for male residents to be offered to have face shaved on shower/bath days and as needed. She further revealed residents with a diagnosis of diabetes mellitus receive fingernail care provided by a nurse and that nail care should be provided and documented as provided or refused. The DON verified that R#14 had obvious facial hair on chin, upper lip, and cheeks and fingernails were long, jagged with brown discoloration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and the facility policy titled, Oxygen Administration Level III, the facility failed to ensure that one of 21 residents (R) #12 with oxygen in use had an order in their medical record. Due to this failure, R#12 was administered oxygen without a written physician order. Findings Include: Review of policy titled, Oxygen Administration Level III revealed the first step in administering oxygen was to verify that there is a physician's order and review the physician's order. Equipment and supplies needed had a humidifier bottle listed. Review of the clinical record for R#12 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to acute on chronic diastolic (congestive) heart failure, chronic atrial fibrillation, and chronic obstructive pulmonary disease (COPD). Review of the admission Minimum Data Set (MDS) dated [DATE] for R#12 revealed a Brief Interview for Mental Status (BIMS) was coded as 3 indicating R#12 had severe cognitive impairment. Further review revealed section O for special treatment (oxygen use while in the facility?) was answered positively. Review of care plan dated 11/10/2022 did not address the use of oxygen. Review of physician orders revealed new orders for oxygen were written on 1/5/2023. No orders for oxygen prior to this date were found. Nurses' notes dated 10/25/2022 revealed an entry, recorded by Licensed Practical Nurse (LPN) GG, at 3:12 p.m. indicating a drop in oxygen saturation to 82% for R#12, nurse called the physician and documented in this note a verbal order was taken for oxygen at 2 liter per minute (LPM) via nasal cannula (NC) but did not write the verbal order received. Further review of nurses notes dated 10/25/2022 through 1/4/2023 revealed multiple entries found recorded by various nursing staff of R#12 receiving oxygen at 2LPM via NC. On 1/3/2023 at 10:30 a.m., R#12 was observed wearing oxygen at 3.5 LPM via NC without humidification and the oxygen tubing was not labeled. On 1/4/2023 at 8:40 a.m. R#12 was observed sitting up in bed, stated he enjoyed his breakfast, and the staff were about to bathe him. Observed clean linens neatly stacked on the nightstand. Observed R#12 was receiving oxygen at 3.5 LPM via NC without humidification and the oxygen tubing was not labeled. On 1/5/2023 at 8:50 a.m. R#12 was observed receiving oxygen at 3 LPM via NC without humidification and oxygen tubing was not labeled. An interview on 1/5/2023 at 10:25 a.m. with LPN GG, revealed that all residents who receive oxygen must have an order for the intervention. She stated that nurses check resident's oxygen saturation every shift and as ordered by physician. LPN GG further states that the respiratory therapist is responsible for maintaining the oxygen concentrator and changing of filters but was uncertain of how often this should occur. An interview on 1/5/2023 at 10:29 a.m. with Registered Respiratory Therapist (RRT) HH confirmed that it is the responsibility of the respiratory therapist to maintain and change filters for all the oxygen concentrators on a weekly basis, however she was not certain what day of the week this facility does this. She confirmed that every resident receiving oxygen should have an order. She confirmed there was no order for oxygen in the medical record for R#12. An interview on 1/5/2023 at 10:32 a.m. with the Director of Nursing confirmed that the respiratory therapists are responsible to maintain oxygen concentrators and change filters on a weekly basis. She further stated the respiratory therapists are responsible for reviewing orders and making recommendations to the physician regarding oxygen needs and humidification for oxygen use. She confirmed R#12 did not have an order for oxygen and the care plan did not address the use of oxygen.

Based on observations, interviews, and review of the policies titled, Storage of Medications and Administering Medications, the facility failed to ensure that one of four medication carts was locked and secured when the carts were out of view of the nurse and failed to ensure that six containers of multi-use ophthalmic drops on one of four carts were labeled with the open date. The Deficient practice had the potential to allow unauthorized staff, visitors, and residents access to unsecured medications. Findings include: Review of the undated policy titled Storage of Medications revealed the policy statement for the facility is to store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation number 7 stated: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the policy titled Administering Medications with a revision date of December 2012, revealed the policy statement of: Medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation number 9 stated: The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. An observation on 1/3/2023 at 10:05 a.m. on the Springs Hall revealed that one medication cart located in the hallway outside of the nursing unit to be unlocked. The cart was facing the hallway with the drawer handles facing the hallway. One resident was observed propelling themself in a wheelchair past the cart. At 10:35 a.m. Licensed Practical Nurse (LPN) DD approached the cart and verified she was responsible for the cart and that she left it unattended and unlocked. LPN DD stated she had left the cart for a few minutes. An observation on 1/4/2023 at 2:30 p.m. of a medication cart on the Meadows Hall with LPN EE, revealed the cart to contain six open containers of multi-dose ophthalmic drops without open dates labels. The following were open and without an open date label: 1. latanoprost ophthalmic solution .005% 2. Timolol GFS ophthalmic solution 0.5%, 3. fluorometholone 0.1% ophthalmic solution 4. Tobramycin 0.3%/Dexamethasone 0.1% ophthalmic solution 5. Tobramycin 0.3%/Dexamethasone 0.1% ophthalmic solution 6. Tobramycin 0.3%/Dexamethasone 0.1% ophthalmic solution On 1/4/2023 at 2:35 p.m., LPN EE verified the ophthalmic solutions were open and without an open dated labeled on the container or box. LPN EE revealed she was unaware that ophthalmic medications should have an open date written on them when opened. An interview on 1/4/2023 at 3:15 p.m. with the Director of Nursing (DON) revealed her expectations are for all medication carts and medication storage rooms to be locked and secured when unattended and only accessed by authorized nurses. Further revealed her expectation are for ophthalmic medications containers to be labeled with the open date when opened. She also revealed she provided education on 11/2/2022 that included medication cart audit (date opened OTC, medication refrigerator dates, nurses to lock the medication cart when not in use, medication door must be locked). Record review of the in-service sign in sheet revealed 54 signatures. The DON revealed she plans to provide further in-service about security of the medication carts and labeling of opened multi-dose ophthalmic solutions to nursing staff.