**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to closely monitor a resident receiving continuous oxygen and failed to follow physician's order to ensure a resident was receiving the correct oxygen flow rate for one (R31) out of two residents reviewed for oxygen use in the final sample of 12. Findings Include: On 4/29/25 at 12:03 PM, R31 was sitting on her wheelchair alert and able to verbalize needs. R31 was observed using oxygen (O2) via nasal cannula (NC) and her oxygen concentrator flow rate was set to 2 liters per minute (LPM). R31's oxygen concentrator was located behind her wheelchair and not within R31's reach. R31 stated that somebody comes in in the morning and checks her oxygen. R31 stated she does not know how to change her oxygen setting. R31 stated, I don't even know why I'm on it. The other nurse told me I needed it. Some nurses tell me I don't need it. R31 stated she never touches the dial on the oxygen concentrator because the nurses do it for her and that she can't reach it. On 4/29/25 at 12:09 PM, V9 (Registered Nurse) was asked to verify R31's oxygen order in the electronic health record and the reason why R31 is on oxygen. V9 stated R31 has an order for continuous O2 via NC at 1LPM for acute hypoxia. V9 stated the nurses should monitor the residents' oxygen. On 4/29/25 at 12:12 PM, surveyor and V9 entered R31's room. V9 confirmed the oxygen flow rate was set to 2LPM. V9 changed it to 1LPM. On 4/30/25 at 2:14 PM, V2 (Director of Nursing) stated the oxygen flow rate is followed based on the doctor's order. V2 stated R31 has no order to titrate her oxygen. V2 stated R31 should be on oxygen at 1 LPM via nasal canula. On 4/30/25 at 4:13 PM, surveyor received an email from V2 that reads in part: As mentioned earlier, I conducted my rounds with [R31] and confirmed that she was on 1L/min at that time. I just checked in with her [R31] directly, she shared that she had increased the oxygen flow herself because she was feeling short of breath. When I asked why she [R31] hadn't notified staff, she [R31] explained that the sensation passed and she had planned to return the setting down on her own. I reminded her [R31] of the importance of informing the nursing staff so appropriate support can be provided. She [R31] acknowledged this and assured me she won't make adjustments independently in the future. MD [Medical Doctor] notified, care plan revised and updated. On 5/1/25 at 9:52 AM, V20 (MDS Manager) stated R31's usual performance in locomotion in wheelchair is dependent, meaning she's not able to help at all, and someone needs to push her in the wheelchair. R31's usual performance with transfer from bed to chair is maximal assist meaning somebody needs to help her and R31 can't do it by herself. V20 stated R31's usual performance for personal hygiene is moderate assist meaning she needs assistance and can't do it by herself. V20 stated R31's cognition status is cognitively intact. V20 stated it is not safe for R31 to be reaching her oxygen concentrator and changing the setting herself. V20 stated R31 needs the staff's assistance. R31's clinical records revealed an admission date of 3/27/25 with included diagnoses but not limited to pneumonitis, congestive heart failure, and acute pulmonary edema. R31's Minimum Data Set, dated [DATE] shows R31 is cognitively intact with BIMS (Brief Interview for Mental Status) of 14, and is dependent on staff's assistance for all activities of daily living. R31's order summary report printed on 4/29/25 reads in part: Continuous O2 1 liter via nasal cannula due to acute hypoxia (ordered 3/28/25). The facility's Oxygen Administration policy dated 2001 documents in part: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing).

Based on observation, interview and record review, the facility failed to maintain accurate record of usage and accountability for 1 resident (R35) who receives controlled substances from 1 of 2 inspected medication carts. Findings Include: On 4/29/25 at 12:29 PM, a narcotic reconciliation count conducted with V2 (Director of Nursing/DON) for the tenth floor's medication cart. Observed R35's Diazepam 2 milligrams (mg) medication administration blister pack had 39 half tablets in the card. The count on R35's CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM documents 60 half tablets were received on 1/30/25 last entry date showed 4/29/25 at 2:30 AM with 40 tablets remaining. V2 stated the count was incorrect. On 4/30/25 at 2:14 PM, V2 (DON) stated that V9 (Registered Nurse) administered one dose of the Diazepam to R35. V2 stated when administered, the nurse will have to sign off that it was given on the controlled substance accountability form. V2 stated all controlled substances should be accounted for. V2 stated two nurses counting the narcotics at the beginning and end of shift. The nurses have to count if the number of the medications are correct in the bingo card and on the count sheets. V2 stated if the count is wrong the nurses will have to notify V2. R35's clinical records show an admission date of 5/31/24 with included diagnoses but not limited to anxiety disorder. R35's order summary report printed on 4/29/25 revealed an order for Diazepam oral tablet 1 mg by mouth four times a day for anxiety (ordered 4/21/25). The facility's Pharmacy Policy: Controlled Substances dated 4/13/25 documents in part: It is the policy of [facility] to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedure for preventing foodborne illnesses to ensure foods in the walk-in coolers were properly labeled and dated when they were opened and prepared and discarded on the best by date. The facility also failed to ensure kitchen staff was wearing facial hair/beard restraint while in the kitchen and failed to ensure potentially hazardous refrigerated foods were stored at the appropriate temperatures. These failures have the potential to affect 47 residents in the facility who are receiving oral diet. Findings Include: On 4/29/25 at 10:47 AM, during the initial tour in the kitchen (17th floor) with V26 (Chef), surveyor observed the main walk-in cooler external thermometer read 49 degrees Fahrenheit (F) and inside thermometer read 47 degrees F. V26 stated a contracted worker will be coming in to fix the cooler because the thermometers are faulty. Inside the main walk-in cooler was found a container of slices of liver with no label. V26 stated it will be served that day. Inside the second walk-in cooler, a container of opened cow milk ricotta with best by date of 4/17/25 written on the label. On 4/29/25 at 11:27 AM, V3 (Director of Dining) stated that perishable foods that were prepared and stored inside the coolers need to be used or discarded within three days. Everything that is open and cannot be identified needs to be dated and labeled. The label should include the date when it was opened or prepared and last day of consumption is the day it needs to be discarded or use by. V3 stated that the main reason for this is that spoiled foods can get people sick and could cause harm or illness to the residents. V3 further stated that expired foods need to be discarded on the best by or used by date. On 4/30/25 at 11:56 AM, surveyor entered the kitchen and observed V12 (Chef) with facial hair (beard) and was not wearing a beard restraint. As soon as V12 saw this surveyor, V12 immediately applied the beard restraint. V12 stated he is the cook for the day. On 4/30/25 at approximately 11:58 AM, the external thermometer of the main walk-in cooler in the kitchen was observed and read 59 degrees F and the inside thermometer read 59 degrees F. Inside this cooler was a food cart with trays of berry cups, yogurt cups, peeled hard boiled eggs in individual plastic cups, and granola cups with no label of when they were prepared and no use by date. V12 stated they prepared them this morning and will be served to the residents for breakfast tomorrow. V12 stated kitchen staff does not usually label the prepared foods for breakfast. Surveyor also found a container of prepared cream cheese salmon inside a reach in refrigerator with no label when it was prepared or use by. V12 stated it was used this morning and meant to be thrown out. On 4/30/25 at 12:11 PM, V3 stated that anyone entering the kitchen needs to always wear beard net and hairnet if they have hair and/or a beard. V3 stated that the hair could fall in the food and could potentially cause food borne illness. V3 also stated that there is a work order and a contracted worker scheduled to start on 5/2/25 to fix the main walk-in cooler because the temperatures are not going down. V3 provided copies of the work order. On 5/1/25 at 10:22 AM, surveyor observed in the kitchen, the main walk-in cooler's external thermometer read 53 degrees Fahrenheit (F) and inside thermometer read 56 degrees F. While surveyor was looking for a kitchen staff to get food temperatures stored inside the main walk-in cooler, V27 (Dietary Aide) was observed by the dishwashing machine inside the kitchen and noted with facial hair without wearing a hair restraint. On 5/1/25 at approximately 10:25 AM, surveyor and V12 entered the main walk-in cooler. V12 stated the salad dressings were placed inside last night. Surveyor asked V12 to check the following food items stored in the main walk-in cooler: ranch dressing poured in a container read 56.9 degrees F, balsamic dressing poured in a container read 56.3 degrees F, and a large container of cooked pasta read 56.8 degrees F with the label that showed it was prepared on 4/28/25 and used by 5/2/25. V12 stated that the pasta will be served to the residents for lunch tomorrow. On 5/1/25 at 10:50 AM, V10 (Registered Dietician) stated that the walk-in coolers must have the right temperatures for food and safety issues to prevent food borne illnesses. V10 stated temperatures should be below 40 degrees F and perishable food items such as protein, dairy, and fish temperatures should be below danger zone (below 40 degrees F). V10 stated that perishable food should not be left in the danger zone for more than 4 hours. On 5/1/25 at approximately 11:00 AM, V3 entered the main walk-in cooler and asked his kitchen staff to discard all perishable foods and stated all perishable items will be stored inside the second walk-in cooler while the main cooler is getting fixed today and tomorrow. On 5/1/25 at approximately 2:00 PM, an outside appliance and mechanical service technician worked on the 17th floor walk-in main cooler to stabilize the temperatures. Temperatures read 44 degrees F and trending down. Outside contractor will return on 5/2/25 until 5/5/25 to complete the work on the walk-in main cooler. The facility's temperatures logs revealed walk-in main cooler's temperatures as follows: - 4/21/25 - 41 degrees F (external thermometer)/ 42F (internal thermometer) - 4/22/25 - 42F/44F - 4/23/25 - 45F/44F - 4/24/25 - 46F/45F - 4/25/25 - 46F/47F - 4/27/25 - 48F/48F - 4/28/25 - 52F/54F - 4/29/25 - 55F/53F - 4/30/25 - 56F/55F The facility's 4/29/25 residents' roster documents 48 residents in the facility with 1 resident who is NPO (Nothing By Mouth). The facility's Preventing foodborne illness/dating and labeling policy dated 8/7/24 documents in part: It is the policy of [facility name] to protect residents from foodborne illnesses by ensuring food is consumed within a safe timeframe. Label and date food items that require storage and refrigeration. Label and date prepared food. Prepared food must be labeled with the date the food was prepared, and the use by date. The use by date should bot exceed 3 days from the preparation date. The facility's Grooming policy dated 2018 documents in part: It is the policy of [facility name] to prevent hair or other foreign objects from contaminating food and food-contact surfaces. The facility's Preventing Foodborne Illness - Temperature Danger Zone dated 2019 documents in part: It is the policy of [facility name] that food will be stored at a proper temperature, to prevent the risk of foodborne illness. The Danger Zone is the temperature between 41 degrees F and 135 degrees F. In this temperature range, most pathogens multiply rapidly. Cold foods need to be held at or below 41 degrees F. If perishable food (both hot or cold) is left in the Danger Zone for more than 2 hours, must be discarded.

Based on observations, interviews, and record reviews, the facility failed to assess, ientify, and involve the local public health department to determine if their water management plan was adequate to prevent the growth of Legionella or other opportunistic waterborne pathogens. This failure affects five (R22, R28, R30, R204, and R209) out of a total sample of twelve residents reviewed and potentially affects all forty-eight residents residing in the facility. Findings: On 5/1/25 at 10:30 AM, V8 (Director of Plant Operations) stated that the expansion tank does not have enough air pressure and this could possibly cause growth of Legionella, and that the company will be coming next week Friday 5/9/25 to fix the tank, and the mixing valve will be fixed next week Monday or Tuesday 5/5/25 or 5/6/25. On 5/1/25 at 11:50 AM, V14 (Assistant Director of Nursing/Infection Preventionist) stated that when she became aware of the first legionella results, she notified the physician, family members, and staff to monitor the residents for respiratory symptoms. V14 was not sure of the date. She stated she did not report this to the local health authority because there was no case of a resident with Legionella in the facility. V14 stated that residents could potentially get sick after constant exposure to Legionella since 2024. On 5/1/25 at 12:20 PM, V2 (Director of Nursing) stated that she is aware of the rooms that were identified positive with Legionella, the staff monitor all the residents for respiratory symptoms per the facility protocol but V2 was unable to provide any documentation to show that any risk assessment were done until when the surveyor requested for a list. V2 stated that having residents constantly exposed to water with Legionella could expose the resident to contracting respiratory or gastrointestinal disease. On 5/1/25 at 2:44 PM, V1 (Administrator) stated that the outside water management company recommended water flushing in the facility and did not recommend further action. V1 stated the facility follows any recommendations that the outside water management company provides to the facility. There was no testing in January and February of 2024 because the facility switched the testing company in January 2024. V1 stated the previous company stopped coming because of the long distant to get to the facility. V1 stated that she did not report the positive findings to local health authority because no resident tested positive with Legionella Disease. The water in the building was first tested positive for Legionella in 2023. V1 stated that filters were provided for the identified five rooms and the residents are not drinking from the sink. The residents are using the water for mouth wash, and for shower but there is no documentation to show that bottled water was provided for the residents. On 05/01/2025 at 3:03PM V21 (Certified Nursing Assistant/CNA) stated residents receive their drinking water from the faucet located inside of the 12th floor dining room from the designated faucet. V21 states there are two faucets located inside of the dining room, one is for handwashing and the other is for resident's drinking water. Surveyor observes a water cooler dispenser filled with water and ice located in the hall next to the dining room. V21 states this water cooler is filled periodically throughout the day by the dietary staff for residents to drink. V21 states water used to fill the water cooler is also obtained from the designated faucet located in the dining room. On 05/01/2025 at 3:07PM V22 (Licensed Practical Nurse/LPN) stated residents receive their drinking water from the faucet located inside of the 11th floor dining room from the designated faucet. V22 stated when she is performing her medication administration pass, she obtains resident's drinking water from the 11th floor dining room. V22 states there is also a water cooler located by the dining room that is filled with water from the dining room faucet. Surveyor observes a water cooler dispenser filled with water and ice located in the hall next to the 11th floor dining room. On 05/01/2025 at 3:11PM, surveyor located on the 10th floor inside the medication storage room with V23 (Registered Nurse/RN). Surveyor observed a water cooler dispenser filled with water and ice located in the hall next to the 10th floor dining room. V23 states when he is performing his medication administration pass, he obtains resident's drinking water from the faucet located inside of the 10th floor medication storage room. V23 points to the only faucet inside of the medication room and states that's the one he uses to fill a water pitcher for the residents. V23 states there is also a water cooler located by the dining room that is filled with water for residents to drink. V23 states he believes the dietary staff fills this water cooler from the faucet located inside of the 10th floor dining room. On 5/2/25 at 11:37 AM, attempted to conduct a phone interview with V29 (Medical Director) but no response. At 2:02 she stated that she has been serving the facility for fifteen years, she was informed of positive Legionella test results since 2023 by V1, and V29 does not think the results are harmful even though she is not an expert in water management, but she relies on the water management team. She also stated that the facility is running/flushing the water in the affected rooms and checking the water temperature regularly as recommended, and there are some residents at the facility that are at risk for contracting Legionella' disease. Legionella is a naturally occurring bacterium commonly found in man-made water systems. It can enter through natural water sources like lakes and streams. It thrives in warm, stagnant areas of water systems, multiplying between 68°F and 122°F (20°C and 50°C). The CDC considers a high level of Legionella to be 1 CFU/mL or higher, as this may indicate conditions that could support bacterial growth. However, address extensive colonization to reduce risk, especially in areas that treat or house high-risk populations (such as hospitals or nursing homes) (Water quality frequently asked questions (GSA). The facility Infection Control Policies and Practices dated 2/17/25. The facility Surveillance for Infections dated 2/25/25. Facility untitled and undated document list of residents who are at high risk for Legionella' disease. The facility policy titled: Legionella dated 5/16/24 documents read in part; Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Water Management Environmental Culture Test-Legionella positive result dated 10/9/24 documents in part: L. anisa (Blue-white Legionella sp.) Water Management Environmental Culture Test-Legionella positive result dated 4/02/25 documents in part: L. anisa (Blue-white Legionella sp.) R28 = 0.5 CFU/ML (Colony-Forming Units Per Milliliter), and R204 = 2.0 CFU/ML Water Management Environmental Culture Test-Legionella positive result dated 4/25/25 documents in part: L. anisa (Blue-white Legionella sp.) R22 = 10.0 CFU/ML (Colony-Forming Units Per Milliliter), R30=3.5 CFU/ML, and R209 = 30 CFU/ML

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to conduct a thorough risk assessment to identify why opportunistic waterborne Legionella could grow and spread in the facility water. This failure affects five (R22, R28, R30, R204, and R209) out of a total sample of twelve residents reviewed and potentially affects all forty-eight residents residing in the facility. Findings: On 4/30/25 at 10:39 AM, V8 (Director of Plant Operations) stated that he has been in this facility for almost two years and the facility checks for legionella quarterly. The testing was done on 3/26/25 and 4/18/25 with positive result in five rooms. He also stated that the facility performs daily flushing twice a day on the affected rooms, obtains water temperature log in one room weekly on each floor, and provided water filters for the sink. At 2:35 PM V8 stated that the facility has been positive with Legionella since February 2023 before he joined the facility. V8 said the facility has been cleaning the mixing valve, but he has no documentation. On 5/1/25 at 10:30 AM, V8 stated he tested on ly three rooms in April instead of five rooms as recommended by the consultant. The facility contacted a plumbing company on 4/29/25 .The plumber came on 4/29/25 for onsite visit with recommendation to clean the units, replace the pressure tank, raise the temperature in the tank and rebuild mixing valve. Surveyor asked what took the facility long to check the pressure tank. V8 stated that he is following the water management plan. The surveyor and V8 went to the storage tank room on the Fifty-third floor where the hot water storage tank read 150-degree Fahrenheit (F) and the mixing valve read 134-degree Fahrenheit. V8 also stated that the expansion tank has not had enough air pressure and this could possibly cause growth of Legionella. The company will be coming next week Friday 5/9/25 to fix the tank, and the mixing valve will be fixed next week Monday or Tuesday 5/5/25 or 5/6/25. Hot water temperature of the identified five rooms with filter are as follows: At 11:16 AM, R209 = 109.2F At 11:18 AM, R30 = 103.6F (V8 stated this is low, there is a problem with the mixing valve, this could be a potential for Legionella). At 11:23 AM, R28 = 124.7F At 11:25 AM, R22 = 112.1F At 11:31 AM, R204 = 119.8F On 4/30/25 at 3:06 PM, V1 (Administrator) stated that the facility water has been positive with Legionella since 2023, but in October 2024 some rooms came negative through flushing as recommended by water management company. She stated that the consultant, and the physician did not say anything about the levels or if the levels are harmful. No resident has been tested positive for legionella. The nurses monitor residents for symptoms. V1 was not sure if it was documented and not sure why only three rooms were retested on [DATE] out of the five rooms that were positive on 4/2/25 with significant increase in legionella level. V1 stated she believes the facility should be following the recommendation to resample positive locations. On 5/1/25 at 2:44 PM, V1 (Administrator) stated that the outside water management company recommended water flushing in the facility and did not recommend further action. V1 stated the facility follows any recommendations that the outside water management company provides to the facility. There was no testing in January and February of 2024 because the facility switched the testing company in January 2024. V1 stated the previous company stopped coming because of the long distant to get to the facility. V1 stated that she did not report the positive findings to local health authority because no resident tested positive with Legionella Disease. The water in the building was first tested positive for Legionella in 2023. V1 stated that filters were provided for the identified five rooms and the residents are not drinking from the sink. The residents are using the water for mouth wash, and for shower but there is no documentation to show that bottled water was provided for the residents. On 5/2/25 at 2:50 PM, V28(Water Hygeine Specialist) stated that he has been working on the facility water management for twelve months, and the results as at 4/25/25 were low level positivity per Center for Disease Control (CDC). V28 said that the goal is to eradicate the positive Legionella results through non-invasive and invasive interventions, but now the facility has called a plumber to inspect the mechanical room on the fifty-third floor. Surveyor asked why were they doing the invasive intervention after two years?V28 stated, I do not have an answer to that. The facility did not have documentation of meeting regularly to discuss the results, perform risk assessment to identify why Legionella continue to grow and spread in the facility water, and no documentation that residents' family were notified. Legionella is a naturally occurring bacterium commonly found in man-made water systems. It can enter through natural water sources like lakes and streams. It thrives in warm, stagnant areas of water systems, multiplying between 68°F and 122°F (20°C and 50°C). The CDC considers a high level of Legionella to be 1 CFU/mL or higher, as this may indicate conditions that could support bacterial growth. However, address extensive colonization to reduce risk, especially in areas that treat or house high-risk populations (such as hospitals or nursing homes) (Water quality frequently asked questions | GSA) Facility Water Management Plan dated 3/20/25. Facility Assessment Tool dated 7/24/24. Facility Flushing Log for Positives Location from 4/2/24 to 5/2/25. Facility Water Temperature Log for The Mixing Valves Locations from 4/1/24 to 4/28/25. The facility policy titled: Legionella dated 5/16/24 documents read in part; Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Water Management Environmental Culture Test-Legionella positive result dated from 2/2023 to 12/2023 documents in part: Legionella species (not pneumophila). Water Management Environmental Culture Test-Legionella positive result dated 10/9/24 documents in part: L. anisa (Blue-white Legionella sp.) Water Management Environmental Culture Test-Legionella positive result dated 4/02/25 documents in part: L. anisa (Blue-white Legionella sp.) R28 = 0.5 CFU/ML (Colony-Forming Units Per Milliliter), and R204 = 2.0 CFU/ML Water Management Environmental Culture Test-Legionella positive result dated 4/25/25 documents in part: L. anisa (Blue-white Legionella sp.) R22 = 10.0 CFU/ML (Colony-Forming Units Per Milliliter), R30=3.5 CFU/ML, and R209 = 30 CFU/ML

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff signed the Narcotic Shift Count Log Sheet at the beginning of the shift and at the end of the shift and failed to ensure staff did not sign the Narcotic Shift Count Log Sheet before the end of the shift. These failures affected 5 residents (R7, R29, R30, R50 and R51) reviewed for controlled medications in the total sample of 34 residents. Findings include: On 04/08/2024 at 11:02am during the medication cart observation with V3 (Licensed Practice Nurse) of the 10th floor medication cart, the 10th floor 04/2024 Narcotic Shift Count Log Sheet noted with missing signatures on shift 7A (am) - 7P (pm) columns 'ON' and 'OFF' on DATE: 3. This was pointed out to V3 (Licensed Practice Nurse). V3 stated whoever came in on 04/03/2024 did not sign the narc (narcotic) sheet. We (staff) are supposed to sign after the count. This surveyor requested V3 to provide a copy of the 10th floor 04/2024 Narcotic Shift Count Log Sheet. On 04/08/2024 at 11:04am, V3 provided this surveyor a copy of the 10th floor 04/2024 Narcotic Shift Count Log Sheet. On 04/08/2024 at 11: 06am, V3 and this surveyor completed reconciliation and physical count of controlled medications of R7, R29, and R51. On 04/08/2024 at 12:24pm during the medication cart observation with V6 (Licensed Practice Nurse -Agency) of the 11th floor medication cart, the (04/2024) 11th floor Narcotic shift Count Log Sheet has missing signatures on shift 7a(m) - 7p(m) columns 'On' and 'OFF' on date: 6. This was pointed out to V6. V6 stated it means whoever worked in the morning shift did not sign it. This surveyor requested V6 to provide a copy of the (04/2024) 11th floor Narcotic shift Count Log Sheet. On 04/08/2024 at 12:26pm, V6 provided this surveyor a copy of the (04/2024) 11th floor Narcotic shift Count Log Sheet. On 04/08/2024 at 12:30pm, V6 and this surveyor completed reconciliation and physical count of controlled medications of R30 and R50. On 04/09/2024 at 11:22am, V2 (Director of Nursing) stated the expectation is to sign right after they counted the controlled medications. The purpose of signing right after they counted is to acknowledge the count is okay. R7's (04/2024) Physician Order sheet documented, in part Diagnoses: (include but not limited to) pain in limb and aftercare traumatic fx (fracture) hip. Medication(s) Hydrocodone 5mg-acetaminophen 325mg. Order date: 1/11/2023. R29's (04/2024) Physician Order sheet documented, in part Diagnoses: (include but not limited to) pain, unspecified and pain in left hip. Medication(s) Oxycodone 15mg. Order date: 3/11/2024. R30's (04/2024) Physician Order sheet documented, in part Diagnoses: (include but not limited to) fracture of left femur and encounter for orthopedic aftercare. Medication(s) Dilaudid oral solution 4m/ml (0.25ml). Order date: 1/16/2024. Lorazepam 2mg/ml (0.25ml). Order Date: 2/20/2024. R50's (04/2024) Physician Order sheet documented, in part Diagnoses: (include but not limited to) encounter for other orthopedic aftercare and polyneuropathy. Medication(s) pregabalin 75mg capsule. Order Date: 3/21/2024. Oxycodone 5mg (2.5mg) Order Date: 3/21/2024. R51's (04/2024) Medications documented, in part Location: 1009 (10th floor room [ROOM NUMBER]). Diagnoses: (include but not limited to) wedge compression fracture of first lumbar vertebra and subsequent encounter for fracture with routine healing. Order. Oxycodone 5mg tablet (0.5) tablet oral. Order Date: 4/3/2024. Discontinued: 04/05/2024. On 04/11/2024 at 2:45pm, in reference to discontinued controlled medication, V2 stated the nurse will remove the medication in the narcotic box and try to ask another nurse to come so they can destroy the medication together. But we (facility) need to do this if both nurses have the time to do it. Resident's safety is first. Further review of the (04/2024) 11th floor Narcotic shift Count Log Sheet also noted a signature on shift 7a(m) - 7p(m) column 'OFF' on date: 8. Of note, this document was received prior to the end of the shift of V6. The (04/11/2024) email correspondence with V1 (Administrator) and V2 (Director of Nursing) documented, in part When do you expect your staff to sign the Narcotic shift count log sheet? Once the count is right. Are staff expected to pre sign? e.g. before the end of the shift? and why? No(,) they are not expected to pre sign before the end of the shift. The off going nurse is signing to say I am leaving the count right and the upcoming nurse is signing to say I received the count right. The (04/08/2024) Staff In-Service/Education sign-In Log documented, in part Given by: V2 (Director of Nursing). Narcotics must be counted and signed at the beginning and end of shift. The (1/26/2024) Licensed Practical Nurse Position Description documented, in part Responsible for the independent supervision of the delivery of care to a group of residents on a nursing unit. Assesses residents(') needs, develops individual care plans, administers nursing care, evaluates nursing care and supervises RCAs /CNAs and other personnel in the delivery of nursing care. Essential Job Duties: 7. Demonstrates knowledge of policies governing medication administration and documentation. The (1/26/2024) Registered Nurse Position Description documented, in part The Registered Nurse provides direct nursing care to the residents and supervises and coordinates the activities performed by the CNAs to ensure a high degree of quality care is maintained. Is responsible for admission, transfers, and discharges of residents. Administers medication and treatments and maintains proper charting for the unit in all accordance with federal, state, and local standards and regulations and department policies and procedures. Essential Job Duties. 4. Ensures facility nursing policies and procedures are consistently and properly followed. The (Reviewed/Revised Date: 07/13/2023) Pharmacy Policy: Controlled Substances documented, in part POLICY: It is the policy of the 'Facility' to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. PURPOSE: the purpose of these guidelines is to ensure the controlled substances are accessed, stored(,) and handled by authorized personnel. PROCEDURE: 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must count together and report any discrepancies to the Director of Nursing Services.