Based on observations, record review, staff interviews, and review of facility policy titled, Resident Call Lights, the facility failed to ensure one of 30 Residents (R) 22 had their call light in reach during multiple observations. This had the potential for the resident to have unmet care needs. Findings include: Review of the facilities' undated policy titled, Resident Call Lights revealed the purpose was to respond to resident's needs. Further review of the policy revealed resident call lights will be kept within the resident's reach when the resident is in the room. Review of R22's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R22 was admitted to the facility with a diagnosis of cardiac pacemaker. Review of R22's admission Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an admission Reference Data (ARD) of 2/22/2024 revealed R22 had impaired vision and a Brief Interview of Mental Status (BIMS) of seven out of 15 which indicated severely impaired cognition. Reveal of the MDS further revealed R22 needed assistance with Activities of Daily Living (ADLs). Review of R22's admission comprehensive Care Plan dated 2/22/2024 located in the EMR under the Care Plan tab revealed a problem was listed for Visual impairment related to decreased visual acuity. During an observation of R22 on 3/11/2024 at 10:57 AM revealed he was lying in bed in his room on his right side and the call light was to the left of the bed hanging downward to the back of the small bed rail toward the floor past the mattress. During an observation and interview of R22 on 3/11/2024 at 2:18 PM revealed he was in his room and sitting up in a Geri chair and the call light remained on the left side of the bed hanging down the side. A family member of R22 was visiting and said the resident was blind. During an observation on 3/11/2024 at 4:05 PM revealed R22 was in his bed in his room and the call light was hanging down the left side of the bed, not within R22's reach. Observation further revealed when R22 was asked if he could reach his call light, he replied he did not know where it was and took his hands and felt around the bed and could not find the call light. During an observation of R22 on 3/11/2024 at 4:24 PM revealed he was in bed in his room and the call light remained hanging down to the left side of the bed and was not in his reach. During an interview on 3/11/2024 at 4:25 PM with Certified Nursing Assistant (CNA)1 revealed R22 was blind in the left eye and could barely see out of the right eye. CNA1 further revealed she attached the call light to his shirt and would put his hand on it to let him know where the call light was. CNA1 revealed a resident could panic if their call light was not in reach and may try to get up without assistance. CNA1 revealed she had been in with R22 today and thought she attached his call light to his shirt. Interview further revealed after going into R22 room that his call light was not attached to him but was dangling down the side of the bed and was not in his reach. CNA1 revealed the call light should be in his reach and when she asked R22 if he could reach it, he replied no and did not know where it was. During an observation and interview on 3/12/2024 at 9:59 AM revealed R22 was lying in bed on his back and the call light was draped over the bed to the back of R22 dangling down, not attached to him, and not in his reach. Licensed Practical Nurse (LPN)1 who was also in the room confirmed R22 could not reach his call light. LPN1 placed it closer to him and he was able to turn it on. LPN1 further revealed the call light should be attached to his gown. During an interview with the Director of Nursing (DON) on 3/13/2024 at 9:06 AM confirmed call lights should be placed close to the resident and the clip should be attached to the sheets or something that the resident could reach. During an interview on 3/14/2024 at 10:42 AM the Administrator revealed call lights should absolutely be within the residents reach and not dangling down the side of the bed.

Based on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that two residents (Resident (R) 47 and R14) out of 30 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: Review of the RAI Manual, dated 10/01/2023, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Inter-Disciplinary Team] completing the assessment . 1.Review of R47's electronic medical record (EMR) undated, admission Record, located under the Profile tab, indicated R47 was admitted to the facility with diagnoses that included: stroke affecting the right side, and aphasia (loss of ability to speak). Review of R47's annual MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 1/18/2024 indicated the assessment inaccurately indicated R47 took an anticoagulant (blood thinner). Aspirin (antiplatelet/anti-inflammatory) was coded as an anticoagulant. 2.Review of R14's EMR undated, admission Record, located under the Profile tab, indicated R14 was admitted to the facility with diagnoses that included: peripheral vascular disease (PVD), congestive heart failure (CHF) and Type I diabetes. Review of R14's quarterly MDS located in the EMR under the MDS tab with an ARD of 2/13/2024 indicated the assessment inaccurately indicated R14 took an anticoagulant. Aspirin was coded as an anticoagulant. During an interview with the Minimum Data Set Coordinator (MDSC) on 3/12/2024 at 12:30 PM confirmed The assessments were wrong. The facility had an agency MDS nurse at the time and she coded aspirin as an anticoagulant. Interview with the Administrator on 3/14/2024 at 1:20 PM revealed The MDS nurse will be cognizant of what is classified as an anticoagulant and if there are any questions, they will consult with the physician, pharmacist, or the Director of Nursing (DON).

Based on observations, record review, staff interviews, and review of Rehab Department Procedures, the facility failed to ensure an order for a resident's palm protector was followed for one of two residents (Resident (R) 47) reviewed for range of motion (ROM). The deficient practice had the potential to inhibit optimal independence for R47 by not applying splints as ordered for contractures. Findings include: Review of a document provided by the facility titled, Rehab Department Procedures (undated), revealed Original orders are placed in a folder in Medical Records office to be signed by the physician. After originals are signed, they are placed in patient's medical hard chart. Review of R47's electronic medical record (EMR) admission Record located under the Profile tab, indicated R47 was admitted to the facility with diagnoses that included stroke affecting the right side and aphasia (difficulty in speaking). Review of R47's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 1/18/2024 indicated R47 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which is indicative of moderate cognitive impairment. Review of R47's Occupational Order dated 1/31/2023 located in the EMR under the Orders tab revealed an order for a right palm protector to be worn as tolerated and removed for hand hygiene/skin check on a daily basis. Review of R47's EMR revealed no evidence the palm protector was put on the resident. During an observation on 3/13/2024 at 11:17 AM revealed that R47 was in the activity room without her right-hand palm protector. Her right hand was folded in and could be pried open, however would not stay open. The palm protector was observed in R47's room on the bedside table. During an observation and interview with R47 on 3/14/2024 at 9:00 AM revealed that R47 did not have her palm protector on. When R47 was asked if she would like to wear her hand splint she stated Yes. During an interview on 3/14/2024 at 9:31 AM with the Director of Nursing (DON) confirmed R47 wore the palm protector on and off. The DON confirmed the order dated 1/31/2023 showed the order was for therapy and not treatment, and that was why the nurses did not know to put the splint on. During an interview on 3/14/2024 at 9:53 AM with the Rehabilitative Occupational Therapist (OT) revealed they put another order in for R47's right hand palm protector (today). The OT revealed the order was put in back in January 2023 and did not know what happened to it. During an interview on 3/14/2024 at 12:09 AM with the Administrator revealed Until we change to a new EMR system, we need daily communication with OT and all orders are to be brought to nursing management. This was a system failure between nursing and therapy.

Based on record review, staff interview, and review of the facility policy titled, Pain & Assessment Control, the facility staff failed to perform a pain assessment prior to administering a narcotic as needed (PRN) pain medication and failed to assess the effectiveness after the medication was administered for one of ten Residents (R) 2. The deficient practice had the potential to prevent the accurate determination of the effectiveness of the pain medication regimen. Findings include: Review of the facility policy Pain & Assessment Control dated 09/22/22 revealed, . The patient's pain is treated promptly accordingly to physician's orders. The patient is reassessed to determine pain relief. a. The patient is evaluated at appropriate intervals after he/she is medicated using the appropriate pain scale. b. All patients receiving medications for pain control are reassessed . Review of R2's undated Face Sheet provided by the facility revealed R2 was admitted to the facility with a diagnosis of acute pain. Review of R2's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/07/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating the resident was cognitively intact. Review of R2's Physician's Orders located under the Orders tab in the electronic medical record (EMR) revealed an order dated 3/08/2024 for Norco 5-325 milligrams (mg) take one table by mouth every six hours PRN. Review of R2's Medication Administration Record (MAR) for March 2024 revealed Norco was given on 3/08/2024 at 5:41 AM, and at 6:49 PM, on 3/09/2024 at 2:01 AM, at 8:15 AM, and 10:19 PM, on 3/10/2024 at 2:55 PM, at 10:49 PM, on 3/11/2024 at 9:50 AM, and at 10:42 PM, on 3/12/2024 at 10:28 PM, on 3/13/2024 at 4:28 AM, and 11:55 AM. Further review of R2's MAR for March 2024 revealed pain assessments once a shift and recorded but no further documentation of pain assessments before and after pain medication being administrated to R2. Review of R2's Progress Notes located under the Notes tab revealed no documentation of pain assessments before and after pain medication administrated to R2 for the dates and times Norco was given to the resident for pain. During an interview on 3/11/2024 at 10:53 AM R2 revealed the pain medication she was given did help her with her pain. During an interview with the Director of Nursing (DON) on 3/14/2024 at 2:00 PM, the DON stated, The nurses did pain assessments twice a day but confirmed they failed to do them before the pain medication was given and then after it was given to check to see if it was effective.

Based on record review, staff interview, review of the Dialysis Agreement, and review of the facility policy titled, Dialysis, the facility failed to have collaboration of care between the facility and the dialysis center for one of three (Residents (R) 45) receiving dialysis treatments. This had the potential for R45 to have unmet care needs. Findings include: Review of the facility policy titled, Dialysis dated 7/10/2023 revealed, . The facility and the dialysis clinic will coordinate and communicate resident needs pertinent to dialysis care and services . Review of the dialysis agreement between the facility and the dialysis center dated 6/05/2007 revealed, . Center shall provide to Facility (sic) information on aspects of the management of the resident's care . Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated (sic) Residents (sic) at the time of the transfer to the Center. This information, shall include, but is not limited to, where appropriate, the following: . (d) Appropriate medical records, including history of the Designated (sic) Resident's (sic) illness, including laboratory, and x-ray findings; (e) Treatment presently being provided to the Designated (sic) Resident (sic), including medications and any changes in a patient's condition (physical or mental), change of medication, diet (sic) or fluid intake . Review of R45's undated Face Sheet provided by the facility revealed R45 was readmitted to the facility with the diagnosis of stage four chronic kidney disease requiring dependence of renal dialysis. Review of R45's Physician Orders under the Orders tab located in the EMR revealed an order for hemodialysis on Mondays, Wednesdays, and Fridays. Review of R45's electronic medical record (EMR) and the hard chart revealed no documentation of communication notes between the facility and the dialysis center on the days R45 received dialysis. During an interview with the Director of Nursing (DON) on 3/13/2024 at 3:05 PM confirmed there was no communication between the facility and the dialysis center for R45.

Based on record review and staff interviews, the facility failed to ensure a psychotropic medication was discontinued when ordered by the physician for one of five residents (Resident (R) 55) reviewed for unnecessary medications. The resident continued to receive the medication for two months after it was discontinued. Findings include: The policy for pharmacy recommendations was requested but not provided by the time of the exit of the survey. Review of R55's Face Sheet in the electronic medical record (EMR) under the Face Sheet tab revealed R55 was admitted to the facility with diagnoses that included Alzheimer's disease, hypertension, non-traumatic brain dysfunction and anxiety. Review of R55's admission Minimum Data Set (MDS) located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 10/03/2023 revealed a Brief Interview of Mental Status (BIMS) was not done due to impaired cognition. Review of the high-risk drug class of the MDS revealed antipsychotics were used on a routine basis. Review of R55's undated Consultant Pharmacist Recommendations in the hard copy chart under the Physician tab the pharmacist recommended an appropriate diagnosis for the use Seroquel (antipsychotic) since the diagnosis of anxiety was not appropriate. Review of the response from the physician revealed the physician discontinued Seroquel on 12/22/2023. Review of R55's Medication Administration Record (MAR) located in the EMR under eMAR tab revealed Seroquel 25 milligram (mg) give ½ tab (12.5 mg) twice a day (bid) had been administered from 12/01/2023 to 02/20/2024, even though it was discontinued on 12/22/2023. During an interview on 3/13/2024 at 1:15 PM the Director of Nursing (DON) confirmed there was a pharmacy review done in 12/2023 to discontinue Seroquel and she did not see where the Seroquel was discontinued until 2/20/2024. The DON confirmed the medication was not discontinued timely because after the physician signed the recommendation it was being put in the medical records slot to be filed in the record and the nurses were not reviewing the orders. During an interview on 3/13/2024 at 4:15 PM the Administrator revealed the pharmacy recommendations and reviews had been reviewed by the physicians but the replies from the physician had been put into the medical records box and filed without the nurses reviewing them. The Administrator further revealed they had identified there was a problem with pharmacy recommendations not being acted upon. During a telephone interview on 3/14/2024 at 12:56 PM with Medical Director (MD)1 revealed he was made aware in February 2024 that some of his physician orders for pharmacy reviews were not being acted upon.

Based on observation, record review, staff interviews, review of Lippincott procedures, and review of facility policy titled, Medication Administration-General, the facility failed to ensure there was less than a five percent (%) medication error rate. Two errors were observed out of 27 opportunities for one Resident (R)6 out of the six residents observed during medication administration resulting in a mediation error rate of 7%. Findings include: Review of the facility policy tilted, Medication Administration-General policy with a revised date of 12/01/2019, revealed the purpose of the policy was to provide resident medication efficacy and safety by following established principles of medication administration. Procedural Guidelines Medication Administration that medications will be administered per the Lippincott Manual of Nursing Practice. Review of the Lippincott procedures - Enteral tube drug instillation, long-term care manual, with a revised date of December 11, 2023, provided by the facility revealed don't mlx different medications intended for administration together through the enteral tube because of the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug response. Review of R6's Physician Orders located in the electronic medical record (EMR) under the Order tab revealed an order for Simethicone 80 milligram (mg) (for relief of gas) via g-tube three times a day (tid) and Dicyclomine Hydrochloride 20 mg (relieves stomach cramping) via g-tube tid. During an observation of the medication administration on 3/12/2024 at 2:15 PM for R6 revealed Registered Nurse (RN)2 crushed Dicyclomine Hydrochloride 20 mg one tab and Simethicone 80 mg one tab into one pill cup and mixed water with it. The RN then administered the two crushed medications together and flushed the g-tube after the medications. During an interview with RN2 on 3/12/2024 at 2:30 PM, the RN revealed that medications can be crushed together and administered by g-tube unless a black box warning was noted. RN2 revealed she had worked in the hospital previously and it was okay to crush the pills together, but she was still learning long term care procedures. RN2 revealed the facility did go over policy and procedures on orientation. During an interview with the Director of Nursing (DON) on 3/13/2024 at 8:46 AM revealed the protocol for g-tube medication administration was to crush each medication individually, add water, and administer separately from other medications. The DON revealed it was not the best practice to crush medications together that were to be given by g-tube. During an interview with the Administrator on 3/14/2024 at 10:48 AM she revealed g-tube medications should not be crushed together.

Based on observation, record review, and staff interviews, the facility failed to maintain infection control during incontinence care during a dressing change for one of five (Residents (R)8) observed for incontinence care. Findings include: Review of R8's undated Face Sheet provided by the facility revealed R8 was readmitted to the facility with the diagnosis of stage three pressure ulcer. During an observation of wound care on 4/14/2024 at 11:23 AM with Registered Nurse (RN)1 revealed as RN1 removed the old dressing to the sacral area and R8 began to have a bowel movement. Certified Nursing Assistant (CNA)2 began to perform incontinence care with a disposable wipe. CNA2 proceeded to wipe from the anal area up towards the sacral pressure ulcer to remove the bowel movement. During an interview, on 3/14/2024 at 1:40 PM with the Director of Nursing (DON) revealed The CNA should never wipe bowel movement up in the direction of a resident's wound as it could potentially contaminate the wound. During an interview with CNA2 on 3/14/2024 at 1:51 PM the CNA was asked when she performed incontinence care to R8 should the resident have been cleaned with a wipe from the anal area up in the direction of the wound, CNA2 stated, I really don't know.

Based on observation, staff interview, and review of the facility policy titled, Food and Supply Storage, the facility failed to ensure all pans and dishes were allowed to be air dried before stacked and failed to ensure all food in the freezer was sealed closed. These failures had the potential to affect 63 of 65 residents who consumed an oral diet. Findings include: Review of the facility's policy titled, Food and Supply Storage, dated 1/2024 revealed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Frozen storage: Wrap food tightly to prevent cross contamination. Use food grade plastic bags for food storage. During an observation on 3/11/2024 at 9:58 AM, the following observations in the kitchen were made with and verified by the Supervisor Food/Nutrition (SFN): 1. The freezer contained one bag of chicken and one bag of hamburgers that were not closed shut. 2. There were 12 plastic plate covers being used for lunch that were not allowed to air dry. 3. There were 20 plastic cups that were being used that were wet on the inside and not allowed to air dry. 4. An exhaust fan in the clean dish area was covered in thick, gray dust. During an interview with the Administrator on 3/14/2024 at 1:15 PM revealed My expectation for the kitchen is that they all work together to have the kitchen organized and give the residents good tasting food. We want to do the best job possible. We want to give our staff what they need to do the best job possible.

Based on staff interview, facility document review, and review of the facility policy titled, Quality Assurance/Performance Improvement, the facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program regarding the facility's Performance Improvement Plan (PIP) for Certified Nursing Assistants (CNAs) documentation. This had the potential to affect all residents of the facility. Findings include: Review of the facility policy titled, Quality Assurance/Performance Improvement (undated) revealed, .The facility will implement the Plan-do-Study-Act (PDSA) cycles as its QAPI methodology for testing actions and implementing and evaluating change. The facility will conduct and include Root Cause Analysis in their PDSA methodology. PIPs are evaluated to address gaps/and or effectiveness in systems and processes. Corrective actions may be taken when evaluating effectiveness. Changes identified in PIP action steps may require the development of additional measures for monitoring (audits/checklists), in effort to evaluate PIP effectiveness in achieving desired goals . Review of the facility's PIP dated 4/05/2023 provided by the facility revealed a problem of incomplete and inconsistent CNA Activity of Daily Living (ADL) documentation which was found on 3/23/2023. The PIP consisted of the problem statement, goal, baseline data, root causes, barriers, and established completion date as ongoing. There was no further information provided to the survey team. During the QAPI tasks, the survey team members, the Director of Nursing (DON) and the Administrator were all in attendance which met on 3/14/2024 at 5:45 PM. The Administrator stated, We found this to be a problem of the CNAs not completing their charting in the computer before they left their shift which made the next CNA not able to chart at all unless they finished the charting of the CNA on the previous shift. So, we immediately began having the CNAs document on paper to alleviate the issue we were having. The DON stated, This was something that we did not want to continue, and we did not know of the extent of this problem until we began a PIP on the incomplete CNA documentation. The survey team asked the Administrator and DON if there was any additional information or documentation to support the findings of the audits completed, if there were any barriers found that were unexpected, and when the goal was met and if not the explanation of why it was not met. The Administrator and DON stated they would go and look and bring back any additional information they had to the survey team. At 6:15 PM on 3/14/2024, the administrator returned to the survey team and stated, I know we did each of the steps of this PIP, but we cannot find any more documentation to give to you at this time.

Based on staff interviews, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy titled, Antibiotic Ordering, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics. This had the potential to affect all 65 resident of the facility, specifically being prescribed antibiotics that were potentially unnecessary. Findings include: Review of the facility policy titled, Antibiotic Ordering dated 9/01/2023 revealed . 10. The Infection Control Preventionist (lCP) will monitor resident antibiotic use to determine appropriateness.11. The ICP will utilize evidence-based, standard definitions for identifying infections as the criteria in determining antibiotic appropriateness.12. The ICP will review antibiotic surveillance findings during the monthly lnfection Prevention and Control Team (IPCT) meetings. The IPCT will develop antibiotic stewardship action plans, if indicated. 13. The ICP will consult with the Medical Director in the review of antibiotic use and appropriateness. ln the event that unnecessary antibiotics have been ordered, the Medical Director will consult and provide antibiotic stewardship education with the Attending Physicians and/or Nurse Practitioners . Review of a CDC document undated titled, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority.Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use'. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Below are examples of antibiotic use and outcome measures.Process measures: Tracking how and why antibiotics are prescribed.Antibiotic use measures.Tracking how often and how many antibiotics are prescribed.Antibiotic outcome measures.Tracking the adverse outcomes. Review of documents provided by the facility titled, The Revised McGeer Criteria for Surveillance Checklist (a set of criteria if a resident had an infection or not and if an antibiotic might be indicated to treat) had documentation for the months of January 2023 through December 2023, and January and February 2024 which revealed there were infections being treated by the prescriber by ordering antibiotics that did not meet McGeer's criteria for the specific infection to be treated. Review of the Infection Control Book provided by the facility had compiled data that identified the percentage of infections that did not meet McGeer's criteria but was treated as follows: January 2023 - 36% February 2023 - 31% March 2023 - 29% April 2023 - 59% May 2023 - 33% June 2023 - 50% July 2023 - 36% August 2023 - 64% September 2023 - 30% October 2023 - 33% November 2023 contained no data. December 2023 contained no data. January 2024 - 66% February 2024 - 38% During phone interviews on 3/14/2024 between 12:15 PM and 12:45 PM with each of the prescribing physicians (Medical Doctor (MD) 1, MD 2, and MD 3) all three confirmed they had ordered antibiotics for residents before the results or cultures were received back from the laboratory. The Medical Director during this phone interview stated he remembered the infections were discussed in the Quality Assurance Performance Improvement (QAPI) committee meeting but did not recall how in depth the discussion was or if the percentage of infections treated did not meet the criteria were discussed. During an interview on 3/14/2024 at 2:45 PM, the Director of Nursing (DON) stated, I am acting as the infection control nurse until we find one. We had a contract nurse for this, but she just left at the beginning of the month. I didn't know these numbers were broken down like this. During an interview with the Administrator on 3/14/2024 at 5:30 PM, the Administrator stated, I did not know this data existed before this meeting. If I had known, we would have provided this information to the physicians to make them more aware of their ordering of the appropriate antibiotics and when not to order the antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that PRN [as needed] orders for antipsychotic drugs were limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) #10) reviewed for medication management. Findings include: R#10 was admitted to the facility on [DATE] with admit diagnoses of Alzheimer's disease. Review of R#10 Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. Review of the physician orders for R#10 for June 2022 revealed an order for Seroquel 25mg by mouth prn for agitation. The original order dated was 2/16/22. Review of the care plans for R#10 revealed a care plan for the following: Psychotic drug use-receives an antidepressant daily to aid with sleep. 3/4/22 placed on an antipsychotic due to episodes of agitation. Interview on 6/30/22 at 1:01 p.m. with the Director of Nursing (DON) who stated she does not discontinue medications unless the pharmacy makes a recommendation to do so. DON stated the doctor is then notified and he will make that decision. DON stated R#10 was admitted to Hospice of Golden [NAME] on 3/24/22. She stated Hospice did not make any medication changes or recommendations at that time. DON also stated there was documentation of R#10 being agitated in February and in March. DON stated there is no documentation to confirm if R#10 received a prn Seroquel. DON further stated that she has communicated with R#10 doctor today about the prn Seroquel order. She stated the prn order will be discontinued today. Interview with the Assistant Director of Nursing (ADON) on 6/30/22 at 1:30 p.m. revealed prn meds are usually prescribed for 14 days. ADON stated pharmacy sends recommendations to the physician to review to either discontinue or continue use. She stated if the order is written in the chart correctly for 14 days the physician should be contacted to notify of prn. ADON, stated the nurse taking care of that patient should contact the doctor, and they should be putting in a note. ADON further stated that she contacted the doctor today and the doctor stated to discontinue the prn medication today. Interview with the Administrator on 6/30/22 at 2:48 p.m. revealed she would talk to the doctor about getting the Seroquel discontinued. She stated she is not very well versed on antipsychotics, but she knows that they must have a reduction.

Based on observation, interviews, record review, and review of facility policy titled Infection Prevention and Control Program Overview the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The facility census was 53. Findings include: Review of facility's undated policy titled Infection Prevention and Control Program Overview 5. The facility will ensure the following elements are incorporated within the IPCP management activities. Elements may include, but are not limited to: IPCP Coordination, Communication, and Oversight Written Policies and Procedures Surveillance and Data Analysis Antibiotic Stewardship Community Acquired and Healthcare Associated Infections Outbreak Control Vaccinations and Screening Employee Health and Safety 6. The facility will designate a licensed nurse, who meets the infection control training requirements, to be the facility's Infection Control Preventionist (ICP). The ICP's role and responsibilities will include: Coordinating and overseeing the facility's IPCP Leading the facility's Infection Prevention and Control Team (IPCT) Reporting IPCP management activities to the facility's Quality Assurance /Performance Improvement (QAPI) Team, at least quarterly. 9. The facility's ICPT responsibilities will include, but not be limited to: Assisting in the development of IPCP policies Establishing and maintaining an active and effective IPCP Monitoring the implementation of the facility's IPCP Collecting, reviewing, and analyzing infection control surveillance data (monthly and annually with the IPCP Risk Assessment) Determining and implementing action plans as a result of the infection control surveillance data and approved by the QAPI Team Evaluating the effectiveness of infection control action plans Review of the Infection Control Book from 6/2021 to 6/2022 revealed the facility did not collect surveillance data for six months (January 2022 through June 2022). During interview with Director of Nursing (DON) / Infection Control Preventionist (ICP) on 6/30/22 at 1:24 p.m., revealed the facility's ICP left the position in December 2021. DON stated the ICP role was handed down to her by the administrator because she has the ICP certification. DON stated the administrator gave her that task after the ICP left but that was not her primary responsibility, and it was not her primary focus. DON stated she have not been able to complete the task or do anything with it as far as tracking or surveillance because of her other responsibilities to include daily overseeing of the Nurses and CNAs, reporting to NHSN, monthly update of the matrix, and reporting to NRChealth.com formerly called my interview. Further interview with the DON about the infection rates for the last six months, she stated she does not know what the rates were because she has not been documenting them. DON re-stated that she assumed the responsibility of Infection Control in January 2022, and that infection control was not her primary focus. Interview with the Administrator on 6/30/22 at 2:28 p.m. revealed the DON is the Infection Preventionist, and she is responsible for the Infection Control Program. Administrator stated infections are extremely important, she stated she expects it to be tracked. She stated she would expect for the DON to assign the task to the Assistant Director of Nursing (ADON) or another licensed nurse if she was not able to complete it.

Based on staff interviews, and review of facility documents, the facility failed to establish an Antibiotic Stewardship Program that included antibiotic use protocols and a monitoring system to track and trend antibiotic use. The facility census was 53 residents. Findings include: Interview with Infection Control Preventionist (ICP)/ Director of Nursing (DON) on 6/30/22 at 1:24 p.m. revealed she has completed the CDC Nursing Home Infection Preventionist Training Course. DON stated the facility uses the McGeers Criteria to determine if there was an infection and if it was community or facility acquired. She stated she have not used this criterion because she has not been monitoring. Continued interview with the DON revealed there has not been anyone tracking the antibiotics since the last IP left in December 2021. DON stated the IP role was handed down to her after the previous ICP stopped working at the facility. However, she has not been able to do anything with it as far as tracking the antibiotics and maintaining the Antibiotic Stewardship program. She stated she has other duties and responsibilities and has not been able to address Antibiotic Stewardship. DON stated antibiotics are discussed in care plan meetings, and pharmacy sends a daily and monthly list of antibiotics. DON stated care plans are updated with any new antibiotic. DON stated she and the Administrator are the only two who are certified with the ICP certificate. DON stated Infection Control was not her primary focus. She stated her other jobs were her primary focus which includes reporting NHSN monthly, update matrix and staffing report to NRChealth.com formerly called my interview, oversee daily nursing and CNAs. She stated the ADON oversees wound care and falls program, serve as a resource to the nurses when they are on the floor. She stated she get pulled to the med cart to work sometimes but not too often. She further stated the Interview with the Administrator on 6/30/22 at 2:28 p.m. revealed she is aware that there has not been any tracking and trending of antibiotic use since December 2021. She stated the Antibiotic Stewardship is familiar to her. Administrator stated she would look for the Antibiotic Stewardship book. Administrator reported that she would not know of trends with infections if it were not tracked and documented. Administrator stated infections are extremely important, and she expected them to be tracked. Administrator expressed that she would expect for the DON to assign to the ADON or another licensed nurse if she is not able to complete the task. Administrator was unable to provide any documentation of an Antibiotic Stewardship Program Administrator confirmed there was no tracking and trending of antibiotic use in the facility.

Based on observation, staff interviews, and review of facility policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles the facility failed to ensure that expired medications were removed from two of four medication carts. Findings include: Observation on 1/16/2019 at 3:13 p.m. during an inspection of medication carts revealed A hall medication cart had a bottle of MiraLAX for resident R#47 that had expired on 10/2018. R#47 has an order for MiraLAX 17 grams (gms) mixed in water or juice daily. The Director of Nursing (DON) verified the medication was expired. Review of the residents Medication Administration Records (MAR')s for 10/2018, 11/2018, 12/2018 and 1/2019 revealed the resident received a dose daily. Observation on 1/16/2019 at 3:30 p.m. during an inspection of medication carts revealed C hall medication cart had an expired vial of Novolog Insulin for R#51 that had the date 12/4/2018 written on the vial. The vial stated to discard after 28 days after opening. The DON verified the medication should have been discarded after 28 days of use (December 31, 2018). She stated it is the responsibility of the nurses to check the carts daily for expired medications. Review of R#51's Medication Administration Record (MAR) revealed the Novolog insulin was given on the following days: 1/1/2019 9:00 p.m. 2 units 1/2/2019 4:30 p.m. 2 units, 9:00 p.m. 2 units 1/3/2019 11:30 a.m. 2 units, 4:30 p.m. 2 units 1/4/2019 11:30 a.m. 2 units 1/7/2019 9:00 p.m. 2 units, 9:00 p.m. 2 units 1/8/2019 11:30 p.m. 6 units 1/9/2019 9:00 p.m. 2 units 1/11/2019 9:00 p.m. 4 units 1/12/2019 9:00 p.m. 2 units 1/14/2019 9:00 p.m. 4 units Interview on 1/17/2019 at 10:22 a.m. with Licensed Practical Nurse (LPN) AA revealed she checks the resident's medications before giving them for the expiration dates. When insulin is opened she stated she dates it with the opened date and the use by date. If it is expired she stated she removes it from the cart and discards it in the drug room, logs it and puts it in the discard box. Interview on 1/17/2019 at 10:32 a.m. with the DON revealed her expectations are the medication carts should not have any expired medications in them. She expects all nurses to check the medications before giving them. She has started a binder titled Cleaning Log and the 7pm-7am nurses on the weekend are responsible to check all the medication carts and treatment cart on the weekends. She started this audit on 1/1/2019. Review of the binder titled Cleaning Log revealed a Medication Cart Cleaning Log. The log on 1/17/2019 at 10:39 a.m. revealed A hall cart was audited on 1/1/2019 7 pm-7 am. The B hall cart was audited on 1/6/2019. Further review revealed the C hall cart was not audited and the D hall cart was audited on 1/6/2019. The tasks included: Wipe down cart, remove debris from drawers, wipe out drawers, remove expired medications. Interview on 1/17/2019 at 10:48 a.m. with the Pharmacy Consultant revealed that insulin can lose its effectiveness if given past the manufacturer's recommendations. He stated the nurses should be following the manufacturer's recommendations on the medication package. Review of the policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles dated effective 12/1/2017 and revised 1/1/2013 revealed: 4. Facility should ensure that medications and biologicals have an expiration date on the label and has not been retained longer than the recommended by the manufacturer/supplier. 5. Once any medication/biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. The facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. The facility may record the calculated expiration date based on date opened on the medication. Review of the document titled Recommended minimum Medication Storage Parameters Injectable Medications last revised 9/29/2016 revealed multi-dose vials for injection are recommended to date when opened and discard unused portion after 28 days or in accordance with manufacture's recommendations. Review of the Novolog package insert under Recommended Storage revealed Novolog once opened may be stored at room temperature for 28 days. This prevents contamination and/or infection, or leakage of insulin and will ensure accurate dosing.