**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure that transfer notices were provided for two of two residents (R) (R50 and R62) reviewed for hospital transfers. This failure created the potential for R50 and R62 to be uninformed about their rights related to hospital transfer and subsequent return to the facility. Findings include: 1. Review of electronic medical record (EMR) for R50 revealed diagnoses that included, but not limited to, acute upper respiratory infection, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and vascular dementia. Review of the EMR under the Census tab indicated that R50 was transferred to the hospital on 5/7/2024 and returned on 5/15/2024. Further review revealed an additional transfer to the hospital on 1/22/2025. There was no documentation found in the EMR to indicate that R50 was provided a copy of the transfer notice upon transfer to the hospital. During an interview on 2/2/2025 at 10:50 am, Agency Licensed Practical Nurse (LPN) BB reported that when a resident was transferred to the hospital, a face sheet, orders, and code status were sent to the hospital. During an interview on 2/2/2025 at 11:10 am, the Assistant Director of Nursing (ADON) reported that when residents were transferred to the hospital the following is provided: demographics sheet, medications, orders, diagnosis, contact information, bed hold information, and transfer notice. However, no transfer notice was found for R50. 2. Review of the EMR for R62 under the Census tab revealed an admission on [DATE] and a billing stop date of 11/17/2024. R62 did not return to the facility once transferred to the hospital on [DATE]. R62 had diagnoses that included, but not limited to, hypertension, congestive heart failure, and hip fracture. Review of Progress Notes dated 11/17/2024 indicated that R62 was transferred to the hospital due to a complaint of difficulty breathing. During an interview on 2/2/2025 at 11:28 am, the Administrator reported that the former company did not provide transfer notices for residents when transferred to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of facility policy titled Bed Hold Acknowledgement Form, the facility failed to ensure that bed hold notices were provided for two of two residents (R) (R50 and R62) reviewed for hospitalization. This failure had the potential to place R50 and R62 at risk of denial of re-admission and loss of their room following hospitalization. Findings include: Review of the facility policy titled Bed Hold Acknowledgment Form, revised 12/6/2022, revealed the Policy: Bed Holds section included . The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. 1.Review of electronic medical record (EMR) for R50 revealed diagnoses that included, but not limited to, acute upper respiratory infection, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and vascular dementia. Review of the EMR under the Census tab indicated that R50 was transferred to the hospital on 5/7/2024 and returned on 5/15/2024. There was a second hospitalization that began on 1/22/2025. There was no documentation found in the EMR to indicate that R50 was provided a copy of the bed hold notification upon transfer to the hospital. During an interview on 2/2/2025 at 10:50 am, Agency Licensed Practical Nurse (LPN) BB reported when a resident was discharged to the hospital, a face sheet, orders, and code status were sent to the hospital. She further reported that she did not provide the bed hold notice and stated Social Services or Admissions may be responsible for the bed hold. During an interview on 2/2/2025 at 11:10 am, the Assistant Director of Nursing (ADON) reported that when residents were transferred to the hospital the following was provided: demographics sheet, medications, orders, diagnosis, contact information, bed hold information, and transfer notice. The ADON reported that when under the previous owners, she was not aware that bed hold notices were sent out with residents. 2. Review of the EMR for R62 under the Census tab revealed an admission on [DATE] and a billing stop date of 11/17/2024. R62 did not return to the facility once transferred to the hospital. R62 had diagnoses that included, but not limited to, hypertension, congestive heart failure and hip fracture. Review of a Progress Notes dated 11/17/2024 revealed R62 was transferred to the hospital due to a complaint of difficulty breathing. During an interview on 2/2/2025 at 11:28 am, the Administrator reported that she did not send a bed hold notice when R62 was discharged to the hospital. The Administrator further reported that the former company did not provide bed hold notices for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled Care Plans, the facility failed to ensure a comprehensive person-centered care plan was developed for the use of psychotropic medications for one of five residents (R) (R12) reviewed for the use of unnecessary medications. This deficient practice had the potential to place R12 at risk for not receiving treatment and/or care according to their needs. Findings include: Review of the facility policy titled Care Plans, revised July 27, 2023, revealed the Policy Statement was It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. The admission Comprehensive Plan of Care section included .3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing, and psychosocial needs, as the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs that are identified in the comprehensive assessment. Review of the clinical record revealed R12 had diagnoses including, but not limited to, major depressive disorder, mood disorder due to known physiological condition, and dementia with other behavioral disturbance. Review of R12's Quarterly MDS dated [DATE] revealed Section N (Medications) documented the resident received an antianxiety medication. Review of the Physician's Orders revealed an order dated 1/15/2025 for mirtazapine 15 milligrams (mg) (a medication used to treat depression), one tablet once a day. Review of R12's care plan revealed there was no care plan developed for psychotropic medication use. During an interview on 2/2/25 at 11:08 am, the MDS coordinator acknowledged that R12 did not have a care plan developed for the use of psychotropic medication and should have one. She stated the normal process was for care plans to be updated during daily morning meetings.

Based on observation and staff interviews, the facility failed to ensure dietary staff pureed fried fish in a manner to avoid compromising the nutritive value. This deficient practice had the potential to place eight of eight residents who received a pureed diet at risk of decreased nutritional intake. Findings include: Observation on 2/1/2025 at 11:30 am of Dietary [NAME] AA preparing puree fried fish for the lunch meal revealed she placed eight fried fish filets in the food processor bowl and began to puree. The cook then added eight slices of bread to the food processor bowl with the fried fish and pureed both together. Dietary [NAME] AA added three cups of vegetable broth to the food processor bowl and pureed the contents until desired puree consistency. Further observation revealed no recipe was available, and no documentation was available to guide the puree production. In an interview on 2/1/2025 at 11:30 am, Dietary [NAME] AA revealed that she always added bread to food items when she prepared puree foods. Dietary [NAME] AA stated that she was trained to add one slice of bread per serving of pureed food. Dietary [NAME] AA revealed that she had never seen a recipe for guidance for puree food preparation and had never seen any documentation regarding adding bread slices when pureeing foods. In an interview on 2/1/2025 at 11:40 am, the Dietary Manager (DM) revealed that bread should not be added to any food items being pureed. The DM stated that there was no recipe for pureed fried fish and no documentation to indicate that bread slices should be added when preparing pureed food items. In an interview on 2/2/2025 at 11:35 am, the DM and the Administrator revealed the facility did not have a policy regarding food preparation.

Based on observations, staff interviews, and review of facility policies titled Food Ordering, Receiving, and Storage, Receipt and Storage of Food & Supplies, and Pot/Pan Washing and Sanitation, the facility failed to discard leftover and expired food, label and date leftover foods, remove dented cans from storage shelves, maintain the cleanliness of the walk-in refrigerator and dry storage areas, and avoid wet nesting of steam table pans to prevent bacterial growth. These deficient practices had the potential to promote foodborne illnesses associated with bacterial growth and cross-contamination for 56 of 58 residents consuming an oral diet from the kitchen. Findings include: Review of the facility policy titled Food Ordering, Receiving, and Storage, revised 6/14/2016, revealed the Procedure section included . 9. Dented cans should be kept in a separate designated area, with a dented can sign, and away from regular stock. Review of the facility policy titled Receipt and Storage of Food & Supplies, revised 3/24/2016, revealed the Procedures section included . 6. All storage areas will be clean, organized, and ready to receive deliveries. 9. Bent and/or damaged cans and/or supplies should not be placed on storeroom shelves or bins. These items are to be placed in a labeled designated area and stored separately to be picked up by the vendor. Review of the facility policy titled Pot/Pan Washing and Sanitation, revised 4/11/2016, revealed the Procedures section included Air dry pots and pans on the drain-board. Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area. 1. Observation on 1/31/2025 at 8:30 am of the walk-in refrigerator revealed the following: - a rectangle-shaped clear plastic container labeled Potato Wedges prepared date 1/26 and use by date 1/29. - a small square clear plastic container labeled peach slices prepared 1/23 - a small square clear plastic container labeled chocolate pudding prepared 1/23 - an open case of four-ounce yogurt cups with a received date of 12/24/2025 and a use-by date of January 13, 2025. - a yellow/light orange liquid substance was on top of three white buckets with lids. Observation on 1/31/2025 at 9:00 am of the clear door reach-in refrigerator in front of the steam table revealed a small clear plastic container with six four-ounce yogurt cups with a best-by date of January 13, 2025. During an interview on 1/31/2025 at 9:00 am, the Dietary Manager (DM) confirmed that the yogurt cups in the reach-in refrigerator had a use-by date of January 13, 2025. The DM stated the dietary staff should have reviewed the date on the yogurt and discarded it. During a continued interview with the DM, she confirmed the case of yogurt cups in the walk-in refrigerator had a received date of 12/24/2025 and a use-by date of January 13, 2025. She further stated dietary staff should have looked at the date on the case and discarded it. The DM confirmed that the rectangle clear plastic container had leftover potato wedges with a prepared date of 1/26 and a use-by date of 1/29. The DM stated that the dietary cook should have reviewed the dates on the leftover containers and discarded them. The DM further revealed that leftovers should be discarded five days after preparation. The DM confirmed that the sliced peaches and chocolate pudding, both with prepared dates of 1/23, should have been discarded. Further interview with the DM revealed that the facility did not have a policy for leftover food items, and further stated that leftovers should be discarded five days after the prepared date since that was a general practice that dietary was to use. The DM confirmed the yellow/orange liquid on top of several white-colored buckets and stated the liquid was orange juice that leaked from the case stored above the white buckets. The DM stated that dietary staff should have cleaned the spill immediately. 2. Observation on 1/31/2025 at 8:40 am of the walk-in freezer revealed a round chocolate cake layer with no label or date. Observation on 2/2/2025 at 8:10 am of the walk-in freezer revealed that the round chocolate cake layer continued to have no label or date. During an interview on 2/2/2025 at 8:10 am, the DM confirmed that the chocolate cake layer had no label or date. The DM further stated that she was unsure where the cake layer came from since they do not serve residents any round-shaped cakes. 3. Observation on 1/31/2025 at 8:45 am of the dry storage area revealed a large can of baby corn with a dent on the bottom seal. Continued observation of the dry storage area revealed a white powdery substance on the tops of several cans of food and on the floor. During an interview on 1/31/2025 at 9:10 am, the DM confirmed that the can of baby corn had a dent at the bottom seal. The DM stated that dietary staff should have noticed the dent and placed the can in the dented can area. The DM also confirmed that there was a white powdery substance on top of several cans of food, on the food storage shelf, and on the floor. The DM stated that dietary staff should have noticed the white substance and cleaned from the cans, shelf, and floor. The DM revealed that dietary staff cleaned the dry storage area daily. Observation on 2/2/2025 at 8:20 am of the dry storage area revealed a large can of green beans on the food storage shelf with a large dent to the side of the can. Continued observation revealed a white powdery substance was on top of several food cans and on the food storage rack. During an interview on 2/2/2025 at 8:20 am, the DM confirmed that the can of green beans had a dent on the side. The DM revealed that dietary staff had recently put food away and that the dented can should have been placed in the dented can area and not on the storage shelf for usage. The DM confirmed that there was a white powdery substance on top of several cans and on the food storage shelf. The DM revealed she cleaned the cans and the food shelf on 1/31/2025 and did not know where the white substance was coming from. The DM further revealed that dietary staff should be cleaning after any spillage. 4. Observation on 1/31/2025 at 8:50 am of the pot and pan rack revealed a stack of four square steam table pans. The pans were pulled apart, and the top pan had moisture inside. A stack of three medium-sized rectangle pans was pulled apart, and the top pan had moisture inside. During an interview on 1/31/2025 at 9:15 am, the DM confirmed that the square steam table pan and the rectangle pan were stacked and stored with moisture inside. The DM stated that dietary staff should allow pans to dry completely before stacking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and a review of the facility policy's titled, Implanted Venous Port (Mediport) - Accessing, and Implanted Venous Port (Mediport) - De-Accessing, the facility failed to assess the competency of nursing staff caring for implanted venous ports for one of three Resident (R) (#8) receiving Intravenous (IV) antibiotics every four hours. This failure had the potential for residents to have a decline in health status. Findings include: A review of the facility assessment dated [DATE], on page 17 under the heading Competencies, revealed skills of all staff are assessed during orientation with post test for all key clinical areas. New nurses receive an individualized educational program that includes completion of standardized modules through Relias learning. Basic competencies included but were not limited to intravenous care and management (RN Staff), hand hygiene, and infection prevention. A review of the policy titled Implanted Venous Port (Mediport) - De-Accessing, last reviewed January 2014 and updated to competency 6/17/2023, revealed the procedure to remove the port needle is to stabilize the port with thumb and index finger on the sides of port with other hand pull the port needle straight upward and out of port using a steady upward motion the needle will have a safety device covering the needle. A review of policy titled Implanted Venous Port (Mediport) - Accessing, last revised September 2011, made into competency 6/17/2023, revealed the process to set up a sterile field included wash hands, on a clean surface open central line dressing kit or glove packaging to use as a sterile field. Empty all items except saline for injection and heparin onto this field and remove air bubbles from syringes. [NAME] sterile gloves. Record review of the electronic medical record (EMR) revealed R#8 was admitted to the facility with diagnoses listed but not limited to infection and inflammatory reaction due to internal left knee prosthesis subsequent encounter. Record review of the most recent admission Minimum Data Set (MDS) assessment for R#8 revealed a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident was cognitively intact. Record review of the care plan for R#8 indicated a focus of care on infection of the left knee prosthetic. Goals included but were not limited to free from complications related to infections and antibiotic use; infection will resolve. Interventions included but were not limited to maintain universal precautions, monitor left knee for increased pain, swelling, or heat and notify Medical Doctor (MD), monitor temperature/pulse per protocol, monitor/document/report to MD signs/symptoms of delirium. Record review of nursing notes revealed that on 8/19/2023 at 1:53 p.m., the nurse documented a missed dose of antibiotic due to an unsuccessful attempt to change the port needle. Record review of nursing notes revealed that on 8/19/2023 at 10:13 p.m., the nurse documented R#8 called the nurse with concerns about her port access and complained of burning at the insertion site, and the nurse noted minimal swelling; the Nurse Practitioner (NP) was notified, a new order was given to remove the port needle and start a peripheral IV. Observation on 8/19/2023 at 8:50 a.m. revealed Licensed Practical Nurse (LPN) AA entered the room and observation of an IV bag that contained the last dose of antibiotic hanging from the IV pole still connected to R#8's port upon entry to the room. The IV tubing was connected directly to the tubing of the port needle (Huber needle) without a needleless access device. Observed LPN AA remove the IV tubing of the last antibiotic dose and connect a normal saline flush to the end of the port needle tubing without a needleless access device, and she clamped the tubing. LPN AA did not check for blood return, then she attached the antibiotic dose that was currently due to the access device. She then set the rate on the IV tubing to 100 milliliters (ml)/ hour (hr). Interview on 8/19/2023 at 9:10 a.m. with LPN AA revealed that it is a normal occurrence to find the port needle tubing without a needleless access device, and if it does have the device, it is not usually covered. She revealed that the needleless access devices are kept in the facility's locked supply cabinet (cubex) in the medication room and stated that agency nurses do not have access to this system but have to get an employed nurse to access this for them. Observation on 8/19/2023 at 11:40 a.m. with Registered Nurse (RN) BB present observed the Infection Preventionist (IP) remove the port dressing, de-access the port, and attempt to re-access the port. She cleansed the needleless device with an alcohol wipe, she flushed the port with 5 ml of saline and 3 ml of heparin flush and clamped the tubing. She removed the transparent dressing over the port needle. The IP then performed hand hygiene and opened the sterile package for accessing the port. The skin covering the port was again cleansed and allowed to dry; the IP then attempted to access the port unsuccessfully. The port needle was removed, and again the IP did not activate the needle safety device, she placed the needle on the table and access was unsuccessful. Interview on 8/19/2023 at 11:00 a.m. with the IP and the Treatment Nurse revealed the needleless access devices are kept on the treatment care, and all nurses have access to the cart. Interview on 8/19/2023 at 12:10 p.m. with the Director of Nursing (DON) revealed that the Assistant Director of Nursing (ADON) normally changes the port needles, flushes ports, and changes the dressings on the ports. The DON further revealed that the facility has no competency check off for port care, accessing/de-accessing, or dressing changes of ports. She stated that the IP was a new nurse, and she assumed that she learned about port care in nursing school and was competent in port care because of this. The DON stated that the ADON was not working on 8/19/2023. She stated that she does not possess the skill/knowledge to access/de-access ports or change the dressings properly.

Based on observations, staff interviews, record review, and review of the facility policy titled, Administering Medications, the facility failed to ensure one of three Resident (R) (#8) is free of significant medication errors. Findings include: A review of the policy titled, Administering Medications, revised December 2012, revealed the policy statement was medications shall be administered in a safe and timely manner, and as prescribed. Under section title Policy Interpretation and Implementation, number 7 revealed the individual administering medications must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medications. Record review of the care plan for R#8 indicated a focus of care on infection of the left knee prosthetic. Interventions included but were not limited to administering antibiotics as ordered by the Medical Director (MD). Record review of the Electronic Medical Record (EMR) for R#8 revealed a physician order for oxacillin sodium in dextrose intravenous solution 2 gram (GM)/50 milliliters (ml) (oxacillin sodium in dextrose). Record review of the Electronic Medication Administration Record (E-MAR) revealed oxacillin sodium in dextrose intravenous solution 2 GM/50ML (oxacillin sodium in dextrose) use one dose intravenously every four (4) hours for osteomyelitis for 42 days, (start date 8/2/2023). 100 doses were signed off as given. Observation on 8/19/2023 at 8:50 a.m. of a medication pass with LPN AA revealed LPN AA mix and administer oxacillin 2GM/ 100 ml NS at 100 ml/hrs, via dial-a-flow tubing. Interview on 8/19/2023 at 4:45 p.m. with the Director of Nursing (DON) confirmed and verified that the IV medication oxacillin on hand was oxacillin sodium 2 GM attached to a 100 ml bag of normal saline, which the nurse mixes prior to administration. The DON verified and confirmed that the physician ordered oxacillin sodium in dextrose intravenous solution 2 GM/50 ml. She verified that this was not the same as the order and that the nurses should have caught this. She stated she expected the nurses to read the medication label verify the dilution solution and compare these with the MAR and the physician's order, and if these differ, the nurse should contact the physician for direction/clarification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and a review of the facility's policy titled, Infection Control, Implanted Venous Port (Mediport) - Accessing, Administering Medications and the facility assessment, the facility failed to implement infection control practice during the care of a resident receiving medications via a port and during change of needle device to access the port for one of three Resident (R) (#8) receiving intravenous (IV) antibiotic therapy every four hours. These failures had the potential of exposing patients to infections due to cross contamination. Findings include: A review of the policy titled Infection Control, not dated, revealed the objective of infection control policies and practices are listed as but not limited to prevent, detect, investigate, and control infections in the facility. A review of the policy titled Implanted Venous Port (Mediport) -Accessing, last revised September 2011, made into competency 6/17/2023, revealed the process to set up a sterile field was described as wash hands, on clean surface open central line dressing kit or glove packaging to use as a sterile field. Empty all items except saline for injection and heparin onto this field, remove air bubbles from syringes. [NAME] sterile gloves. Cean port area with antiseptic cleaning solution. Hold the saline syringe with sterile gauze (to preserve sterile gloves), attach syringe to needleless connection device and [NAME] tubing and the port needle with saline. A review of policy titled Administering Medications, revised December 2012, revealed the policy statement was medications shall be administered in a safe and timely manner, and as prescribed. Under section title Policy Interpretation and Implementation number 22 revealed staff shall follow the established facility infection control procedures (e.g. handwashing, antiseptic techniques, gloves) for the administration of medications as applicable. A review of the facility assessment dated [DATE], on page 17 under heading Competencies revealed skills of all staff are assessed during orientation with post test for all key clinical areas. New nurses receive an individualized educational program that includes competition of standardized modules through Relias learning. Basic competencies included but not limited to intravenous care and management (RN Staff), hand hygiene, and infection prevention. Requested policy specific to administering IV medications, the corporate nurse Registered Nurse (RN) BB stated the policy titled Administering Medications, revised December 2012, included administration of IV medications. Record review of the electronic medical record (EMR) revealed R#8 was admitted to the facility with diagnoses listed but not limited to infection and inflammatory reaction due to internal left knee prosthesis subsequent encounter. Record review of the EMR revealed for R#8 revealed a physician order for RN to change port needle weekly and as needed and change dressing to port (right chest) every Friday and as needed. Observation on 8/19/2023 at 8:50 a.m. revealed Licensed Practical Nurse (LPN) AA performed hand hygiene in the hallway and Director of Nursing (DON) a pair of gloves upon entering the room. LPN AA removed the previous antibiotic dose and left the room. Upon her return, she had obtained a needleless access device. She donned a pair of gloves (no hand hygiene) and opened the needleless access device package, removed the saline flush from the end of the tubing on the port needle, and then attached the needleless access device to the tubing of the port needle. She then placed the access device on the resident's chest. She obtained a new saline flush and flushed the port without cleansing the end of the access device. Interview with LPN AA on 8/19/2023 at 9:10 a.m. revealed she stated she should have performed hand hygiene when she returned to the room and re-gloved her hands prior to removing the saline flush and attaching the needleless access device. She stated she should have cleansed the end of the needleless access device with an alcohol wipe prior to flushing and connecting the antibiotic tubing to the port needle tubing. She stated she was in a hurry, and she was very tired. Observation on 8/19/2023 at 11:40 a.m. with RN BB present observed the IP, with gloved hands after performing hand hygiene, prepared a table for her supplies by cleaning it with a facility approved disinfectant and allowed the table to dry. She doffed her gloves, performed hand hygiene, and donned clean non-sterile gloves. She then placed supplies needed to de-access the port onto her table. The IP then performed hand hygiene and opened the sterile package for accessing the port. Using a non-sterile gloved hand, the IP removed the drape from the package and placed it on the table to create a sterile field; she donned non-sterile gloves and began adding supplies to the sterile field by picking up items and placing them on the field. She dropped the port needle onto the sterile field; then, she attached an extension set with a needleless access device to the tubing of the port needle. The IP placed the clear dressing on the sterile field with a gloved hand, opened the saline and heparin-flush, dropped it onto the sterile field, donned sterile gloves, without performing hand hygiene, and then cleansed the skin over the port with the cleaning device from the sterile field. RN BB stepped in and began instructing the IP. The table was cleansed again with facility approved disinfectant and allowed to dry. A sterile field was prepared appropriately with the assistance and direction of RN BB. Interview on 8/19/2023 at 12:10 p.m. with DON revealed the Assistant Director of Nursing (ADON) had worked with the IP one day the previous week to train, but she stated the IP did not demonstrate to the ADON setting up a sterile field and maintaining the sterile field or access a port utilizing sterile technique.