Based on observation, interview, and record review the facility failed to administer medications as ordered. There were 30 opportunities with 2 errors resulting in a 6.67 % error rate. This applies to 1 of 5 residents observed in the medication pass. Finding include: R3 admitted to the facility with diagnoses that includes fracture of left femur, hyperlipidemia, hypertension, anxiety, obstructive sleep apnea, (COPD) chronic obstructive disease and asthma. R3's physician orders includes fluticasone-salmeterol 250/50 MCG/ACT (Micrograms/ Actuation) one puff daily for COPD and Metoprolol Succinate 50 MG (Milligrams) on capsule by mouth daily for hypertension. R3's care plan states Actuation/he has asthma/COPD, sleep apnea and will display optimal breathing patterns. Interventions include to give aerosol or bronchodilators as ordered. R3 has hypertension and will remain free of signs, symptoms and complications related to hypertension. Interventions include to give anti-hypertensive medications as ordered. On 11/07/24 at 09:32 AM, during the medication observation V6 (Registered Nurse/RN) did not administer fluticasone-salmeterol 250/50 MCG/ACT one puff daily or Metoprolol Succinate 50 MG to R3. Review of the EMR (Electronic Medical Record) showed V6 (RN) documented fluticasone-salmeterol 250/50 MCG/ACT (Micrograms/Actuation) one puff and Metoprolol Succinate 50 MG (Milligrams) one capsule was administered to R3 that was not administered during the medication pass observation. On 11/08/24 at 11:40 AM, V2 (Director of Nursing) stated nurses should not document a medication was administered if was not administered. If it was not administered, it should be documented appropriately. The outcome for missing a medication depends on the medication. If Metoprolol is missed the resident could have an elevated heart rate or blood pressure. If fluticasone-salmeterol is missed the resident could have increased wheezing and shortness of breath after missing the medication. The facility policy Administering Medications dated April 2019 states medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to discontinue an antibiotic for a resident who did not meet criteria to continue antibiotics. This applies to 1 of 3 residents (R242) reviewed for antibiotic stewardship in a sample of 17. The findings include: On November 7, 2024 at 1:06 PM, V8 (Infection Preventionist/Registered Nurse) said R242 was admitted to the facility from the hospital on antibiotics on October 9, 2024. V8 said he had started Augmentin 875-125 MG (Milligrams) on September 28, 2024, while he was in the hospital. V8 said when R242 was first admitted to the facility, a McGeer's assessment was completed on October 9, 2024, which showed R242 did not meet criteria to continue the antibiotics. V8 said there was no evidence of infection, and his cultures were negative. V8 said she was not sure the doctor saw R242 since he was off the antibiotic by the time she came to the facility. V8 said she was not sure where the Infectious Disease note was. V8 said R242 had only received two days of the antibiotics. R242's POS (Physician Order Sheet) showed an order for Amoxicillin-Pot Clavulanate Tablet 875-125 MG with instructions to Give 1 tablet by mouth two times a day for bacterial infection for 5 days. R242's October 2024 MAR (Medication Administration Record) showed R242 received the following doses: On October 10, 2024 at 9 AM and 6 PM. On October 11, 2024 at 9 AM and 6 PM. On October 12, 2024 at 8 AM and 8 PM. On October 13, 2024 at 8 AM and 8 PM. On October 14, 2024 at 8 AM. R242's Infection Control Data Collection- McGeer tool dated October 9, 2024 at 6:49 PM showed on October 8, 2024 Blood cultures- no growth October 8, 2024 Urine Culture- no growth. Under the comments section, V8 wrote [Patient] has an ileostomy [due to] a colonic obstruction. No evidence of infection, does not meet McGreer's criteria for [antibiotic] stewardship, [Medical Director] referred to [Infectious Disease], will follow up with Infection Control on Thursday, October 10, 2024. R242's Progress Notes were reviewed from October 9, 2024 through October 25, 2024. No note was written by the Medical Director. On November 8, 2024, the facility provided a late entry note created on November 7, 2024 at 6:56 PM (during the survey) by the Infectious Disease Nurse Practitioner, which was backdated to October 10, 2024 at 6:55 PM. The Progress Note documented the following: Patient was admitted from [Hospital] on Augmentin 875 MG BID (Twice Daily) x 5 days. Hospital records are limited. Antibiotics are for bowel obstruction per [discharge] paperwork. Will complete course. Nursing to continue to monitor. R242's face sheet showed he was admitted to the facility on [DATE] and discharged from the facility on October 25, 2024, with diagnoses including ileostomy status, malignant neoplasm of colon, and intestinal obstruction. The facility's Antibiotic Stewardship policy revised December 2016 showed Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. Training and education will include emphasis on the relationship between antibiotic use and: gastrointestinal disorders, opportunistic infections (e.g., C. Difficile, candida albicans, etc.); medication interactions, and the evolution of drug-resistant pathogens. The facility's Unnecessary Drugs-Without Adequate Indication for Use revised February 2023 showed A medication initiated as a result of a time-limited condition .will be discontinued when the condition has resolved, or there is documentation indicating why continued use is relevant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safely store medications for residents who were not assessed or ordered to have medications kept at bedside. This applies to 4 of 4 residents (R24, R13, R7, R19) reviewed for medication storage in a sample of 17. The findings include: 1. On November 6, 2024 at 11:31 AM, R24 had an eye drop bottle of Prednisolone Phosphate 1% Moxifloxacin 0.5% Bromfenac 0.075% on his bedside table. R24 said he was having cataract surgery on November 7, 2024 and needed to apply one drop four times a day. R24 said the nurses set the appointments up for his surgery, but he was not sure if they were aware he was putting the drops in. R24 said he had muscular dystrophy, and he may miss the first drop but there was enough liquid in the bottle to keep trying until he was able to administer the drop. R24's face sheet showed he was admitted to the facility with diagnoses including muscular dystrophy and cognitive communication deficit. R24's MDS (Minimum Data Set) dated September 4, 2024 showed R24 was cognitively intact. R24's POS (Physician Order Sheet) did not show an order for the Prednisolone Phosphate 1% Moxifloxacin 0.5% Bromfenac 0.075%, to self-administer medications, or to store medications at bedside. The Evaluations section of the EMR (Electronic Medical Record) did not have an assessment to show R24 was safe to self-administer medications or to store medications at the bedside. 2. On November 6, 2024 at 11:26 AM, R13 had Nystatin topical powder 100,000 units per gram, Chlorhexidine gluconate liquid solution 4%, and Triamcinolone acetonide topical aerosol 0.147 mg/gm (Milligram/Gram) with spray on his side table. R13 said the supplies were for his ostomy but the Chlorhexidine was seldom used and was probably for his bed sores. The Chlorhexidine gluconate liquid solution was dated May 17, 2024. On November 7, 2024 at 11:57 AM, the medications were still observed at the bedside. R13's face sheet showed he was admitted to the facility with diagnoses including ileostomy status. R13's MDS dated [DATE] showed R13 was cognitively intact. R13's POS did not have an order for the Chlorhexidine gluconate liquid solution 4%, and no orders to keep the Nystatin powder and Triamcinolone aerosol spray at the bedside. The POS showed the Chlorhexidine gluconate liquid solution was discontinued on June 20, 2024. The Evaluations section of the EMR did not have an assessment to show R13 was safe to self-administer medications or to store medications at the bedside. 3. On November 6, 2024 at 10:39 AM, R7 had a bottle of Phenol 1.4% oral spray on her tray table dated October 16, 2024. R7 said she had the bottle for a while and the facility staff had given it to her. R7 said she would spray it onto the right side of her mouth every once in a while. R7 said the last time she took it as a few weeks ago. R7 said she was not sure if she really needed the medication. On November 7, 2024 at 12:13 PM, R7's tray table did not have the spray on it and she said she did not know where it went. R7 then opened her side dresser drawer, and the Phenol 1.4% oral spray was in the top drawer of her side dresser. R7 said she had used it since the surveyor had asked her about it. R7's face sheet showed she was admitted to the facility with diagnoses including a cough, mood disorder, osteoarthritis, major depressive disorder, and cognitive communication deficit. R7's MDS dated [DATE] showed R7 was cognitively intact. R7's POS did not show an order for Phenol 1.4% oral spray, nor did it show orders for R7 to self-medicate or store medications at the bedside. The Evaluations section of the EMR did not have an assessment to show R7 was safe to self-administer medications or to store medications at the bedside. 4. On November 6, 2024 at 10:24 AM, R19's side dresser table had an unopened tube of hydrocortisone 2.5% cream with adaptor. R19 said she was not sure how or when the cream came to her room. On November 7, 2024 at 12:11 PM (during the survey), R19's tube of hydrocortisone 2.5% cream was no longer in her room. R19's face sheet showed she was admitted to the facility with diagnoses including constipation. R19's MDS dated [DATE] showed R19 was cognitively intact. R19's POS showed an order dated October 29, 2024 for Anusol-HC External Cream 2.5% (Hydrocortisone (Rectal)). R19's POS did not show any orders for R19 to have medications kept at bedside. The Evaluations section of the EMR did not have an assessment to show R19 was safe to self-administer medications or to store medications at the bedside. On November 8, 2024 at 10:18 AM, V6 (Registered Nurse/RN) said if a resident was allowed to self-medicate or store medications at the bedside, they needed an order from the doctor after an assessment for safe administration was done by the resident. V6 said he only had one resident who was allowed to store medications at bedside and self-administer. V6 said if there was a medication at the bedside, there should be an active order for the medication. V6 said the medications should be put in the drawer in their original packaging, and not kept out as another resident could take it or housekeeping could accidentally throw it away. V6 said if the medications did not have orders, it should be kept in the nurse's locked medication cart. On November 8, 2024 at 10:25 AM, V7 (RN) said she did not have any residents who were allowed to have medications at the bedside. V7 said the doctor needed to give an order after the resident demonstrated they were safe to store and self-administer medications. V7 said it was not the facility's practice to keep medications at the bedside. V7 said if a medication was found, there should be an active order for the medication, as well as orders to keep the medications at the bedside. V7 said it was the facility's preference that the nurses were the only ones to administer medications to the residents. V7 said the medications should be stored in the nurse's cart, but if they have an order to keep the medications at the bedside, they should be kept in a locked drawer in the rooms. On November 7, 2024 at 3:45 PM, V2 (Director of Nursing) said residents are allowed to have medications at the bedside if they have been educated on how, a return demonstration was done to show they were able to safely administer and ordered by the doctor. V2 said there was an assessment that gets filled out and an order needed to be put into the POS. V2 said there should be an order for a medication if it is at the bedside. The facility's Medication and Treatment policy dated February 1, 2024 showed An order for medication or treatment must be dated, signed by the prescriber and must be current and consistent with the resident's assessment. The facility's Medication Labeling and Storage policy revised February 2023 showed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, store items, remove expired items, and wear hair restraint while serving food from facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 11/6/24 documents that the total census was 42 residents. On 11/6/24 at 3:20 PM, V2 (DON/Director of Nursing) said there is only 1 NPO (Nothing by Mouth) resident; all other residents eat from the facility kitchen. On 11/6/24 starting at 10:29 AM, the facility kitchen was toured in the presence of V3 (Interim Dietary Manager) and V4 (Executive Chef) and the following was found: In single door reach in cooler: 1. Package labeled Canadian Bacon with expiration date of 8/2/24. 2. Opened, not sealed large tube of ground beef labeled 10/31/24. V4 said the meat is only good for 3 days once opened and expired 11/3/24. Red juices dripping from package. 3. Tubes of ground beef are stored on bottom of refrigerator, not on a pan/tray. Red/brown juices from meat leaked all over the bottom of the cooler. Red liquid dripping on floor of kitchen when expired ground beef was taken out of cooler. In the walk-in Cooler: 4. 2 thawed oven roasted beef pot roasts with pack date of 10/2/24. V3 (Interim Dietary Manager) looked up the expiration date of beef roast said they expired 1 month from pack date- 11/2/24. 5. Cooked beef in a medium silver bin, not covered/sealed with expiration date of 11/5/24. 6. Medium sized silver bin of what V4 says are chicken thighs. Not labeled, dated, or sealed. 7. Medium sized silver bin of shrimp. Not labeled or dated. 8. 2- 16 ounce packages of mozzarella slices with use by date of 10/4/24, expired. 9. 10.5 ounce package of goat cheese best by 10/21/24, expired. 10. 2- 5 pound bags of smoked roasted bacon with expiration date written as 10/31/24, expired. 11. A medium sized bin of dark red sauce that appears to be cocktail sauce. Not labeled, dated, or sealed. 12. Medium plastic bin of what appears to be yogurt. V4 says he thinks it is frosting. Not labeled or dated. 13. A medium sized silver bin of white cream sauce labeled line sauce not sealed. Sauce appears congealed. 14. A small silver bin of what V4 says is white wine tomato sauce, not labeled and not sealed. 15. A medium silver bin of cooked pasta, not sealed and dated 11/4/24. 16. A small silver bin of asparagus, not sealed and wilted, dated 11/3/24. 17. Half an onion, not labeled or dated. In the Dry Storage: 18. Small black flies seen flying around by the canned foods 19. Large plastic container on wheels of white sugar with broken lid. The back half of the lid is missing, so half of the container is not covered. No date or label on the white sugar. 20. Large plastic container on wheels of brown sugar with lid left opened about an inch, exposing the sugar to contaminants. 21. 32 fluid ounce bottle of browning and season sauce opened and sticky on the outside with expiration date of 7/16/23. Small black flies flew off the bottle when it was lifted off the shelf. V3 (Interim Dietary Manager) touched the bottle and commented, sticky and wiped her hands on her pants. 22. 1 gallon Apple Cider Vinegar with use by date of 11/23, expired. Outside of gallon is sticky. 23. 10 pound bag of seedless raisins opened, not sealed. Small black flies flying around the bag. 24. 5 pound bag of toasted couscous opened, not sealed. 25. Dishes stored on rack in dry storage are sticky/dusty and stored right side up instead of upside down. V4 said this is extra storage for our dishes and they do not use these dishes as often. Then 1 minute later, a cook came into the dry storage room and removed two trays from the top of the rack to use for food preparation. 26. Behind the dishes on the storage rack, 3 sweet potatoes were found in a small bowl labeled with expiration date of 10/28. One onion was also found behind the dishes on the rack and V4 said, that's odd, because we keep our onions in the cooler. 27. 6.37 pounds can of sliced water chestnut on circulation rack dented in 3 different spots- 2 dents around the rim and 1 large dent in the side of the can. V3 (Interim Dietary Manager) said we cannot serve that. 28. Opened bag of vanilla wafers, no label or date. 29. 2 boxes of individual zero calorie sweetener packets with expiration date of 3/18/24. In the double door reach in cooler: 30. Medium sized plastic bin of prepared coleslaw with expiration date 11/4/24, expired. 31. 6 prepared bowls of Mediterranean salads with expiration date of 11/4/24. Lettuce has turned brownish red. 32. On 11/6/24 at 12:10 PM, V5 (Server) was seen in kitchenette on the unit serving meals to residents with hairnet only covering half of her head. V5's bangs and hair on the front top half of her head was not restrained and could be seen blowing in the breeze when she walked around in the kitchenette. On 11/8/24 at 10:46 AM, V4 (Execute Chef) said all food items, including items that are prepared in the kitchen, need to be labeled and dated for food safety. V4 said servers who handle resident food in the kitchen areas on the unit are supposed to wear hair restraints covering all the hair on their heads to minimize the risk of contamination from hair falling into the food. V4 said expired foods should be thrown away by or on their expiration date for food safety; to prevent an expired food item from being served to residents with the potential to jeopardize their health. V4 said we don't want any residents getting sick, especially in this environment where many residents are compromised. V4 said all opened food items in the dry storage and coolers should be sealed/covered to avoid cross contamination and debris from getting into the food with the potential to make the residents sick. V4 said dented cans should be removed from the circulation rack because if food is served from a dented can there is a risk for botulism. V4 said if the cans are dented, there is the possibility there is a tiny hole in the can and that creates risk for contamination. V4 said all sticky food packaging should be wiped down prior to being returned to storage because sticky food items can attract bugs/flies that carry diseases and potential to contaminate food items they land on. V4 said cleaned dished should be stored upside down so they don't risk dust particles or any other contaminants falling into the pans. V4 said opened packages of meat should be sealed before being placed back into the cooler to maintain the best quality of the meat and prevent the meat from spoiling quicker. V4 said meat should not be stored on the bottom of the cooler, but instead on a tray or pan to prevent cross contamination of other boxes or food items in the cooler. The facility's policy titled, Food and Supply Storage last revised 1/24 states, Policies: 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 . Procedures: .Foods past the use by, sell-by, best-by. Or enjoy by date should be discarded. Cover, label and date unused portions and open packages . Discard food past the use-by or expiration date . Dry Storage: . Maintain designated area for items that are damaged (such as dented cans) that are to be returned for credit .Store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight-fitting lids. Label both the bin and the lid .Refrigerated Storage: . Store bulk materials in NSF approved containers that have tight fitting lids. Label both the bin and the lid . Foods that are stored on .racks must be fully covered to prevent contamination from airborne contaminants as well as from dripping condensation. Either use a bag that covers the entire cart or cover each tray individually . Sort produce daily to remove spoiled pieces. The facility's policy titled, Storage of pots, dishes, flatware, utensils last revised 1/23 states, Policies: Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means. Procedures: . Store all pots, glasses, and cups in an inverted position on a clean storage surface. Invert the top plate, bowl, or dish of any stacks of dishes . The facility provided undated training papers titled, Personal Hygiene and Uniforms: Important information for all associates states, .Hair Restraints: Associates must wear hair restraints such as hats, hair coverings or nets, beard/mustache restraints, and clothing that covers body hair. Hair restraints must be worn so that hair effectively keep from contacting exposed food, clean equipment, utensils, linens, and single-service articles . The facility's undated policy titled, Cleaning and Sanitation states, Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from littler, rubbish and protected from rodents, roaches, flies and other insects .4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily . 5. Inspections will be conducted but not limited to the following areas: a. Dry Storage .c. Refrigerators .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure peri care was performed in a manner to prevent cross contamination for 1 of 1 resident (R100) reviewed for incontinence in the sample of 12. The findings include: R100's computerized face sheet printed on 12/13/23 shows diagnoses including but not limited to heart disease, malignant breast and liver cancer, chronic kidney disease, diarrhea, and urinary tract infection. R100's facility assessment dated [DATE] shows no cognitive impairment and staff supervision or touching assistance required for toileting hygiene. The same assessment shows R100 is always incontinent of urine and bowel. R100's December 2023 Physician Order Sheet (POS) shows an order start dated 12/11/23 that states: Lomotil tablet 2.5-0.025 milligram (Diphenoxylate-Atropine) Give 1 tablet by mouth every 6 hours as needed for diarrhea. R100's POS shows an order start dated 12/6/23 that states: Azo tabs oral table (Phenazopyridine HCI) Give 2 tablets by mouth as needed for urinary pain for 3 days twice daily. On 12/12/23 at 1:45 PM, R100 was seated on the toilet in her room. R100 said she has been having terrible diarrhea lately and her chemotherapy medication is the cause. R100 said her buttocks skin is sore and irritated from having to go the bathroom so often. R100 said she needs staff to help clean her and put on a protective cream after each episode. At 1:47 PM, V14 (Certified Nurse Aide) entered the bathroom and said R100 has been having watery diarrhea for several days. She needs frequent toileting, and we use an extra absorbent pad inside the brief to keep her skin drier. V14 donned gloves and assisted R100 to a standing position. V14 used peri-wipes to clean R100's buttocks then wiped the vaginal area. V14 wore the same diarrhea contaminated gloves to wipe the vaginal area. V14 applied a barrier cream to R100's buttock then put a fresh brief on her. V14 pulled up her pants and assisted her back into the room recliner. V14 laid a blanket across her lap, then placed the call light, tissues, and coffee cup within reach. V14 was still wearing the dirty gloves. V14 bagged up the garbage in R100's bathroom. V14 exited the room with the same diarrhea contaminated gloves on, walked down the hallway, and coded herself into the soiled utility room to dump the garbage bags. On 12/14/23 at 9:25 AM, V2 (Director of Nurses/Infection Control Preventionist) stated gloves need to be changed after peri care is performed and before a new brief is put on. Aides should be changing gloves between dirty and clean areas. V2 said dirty gloves should never be worn when exiting a resident room. Dirty gloves can cross contaminate clean items, clothing, and skin. It is an infection control concern. Germs can pass from one resident to another resident. Peri care should always be done from the front to the back. Feces can contaminate the urinary tract and cause infections. The facility's Perineal Care policy revision dated 2/2018 states under the steps for procedure section: 1.) b.) Wash perineal area, wiping from front to back . 10.) Remove gloves and discard into designated container. The facility's Glove Use policy dated 2019 states: Sterile gloves and examination gloves are removed: a. As soon as practical when contaminated. d. Before touching uncontaminated surfaces or other area of the same resident's body that may be uncontaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician order was obtained and a care plan was in place prior to oxygen administration for 1 of 1 resident (R96) reviewed for oxygen in the sample of 12. The findings include: R96's face sheet printed on 12/13/23 showed diagnoses including but not limited to acute respiratory failure, acute pulmonary edema, atrial fibrillation, shortness of breath, and dependence on supplemental oxygen. The face sheet showed an admission date of 12/3/23. R96's facility assessment dated [DATE] showed the use of continuous oxygen on admission and within the last 14 days. On 12/12/23 at 10:44 AM, R96 was seated in a wheelchair in her room. Oxygen was running via nasal cannula into her nose. The oxygen setting was at 1 liter per minute. At 12:24 PM, R96 was asleep in bed. The oxygen setting was at 1 liter per minute. On 12/13/23 at 8:36 AM and 12:05 PM, R96 was in bed and the oxygen was running at 2 liters per minute. On 12/14/23 at 8:40 AM, V8 (Registered Nurse) was applying a portable oxygen tank to the back of R96's wheelchair and set the oxygen level to 2 liters per minute. V8 stated she sets the oxygen at the level stated on the daily paper report or per the physician order. This surveyor and V8 viewed the daily report and electronic physician orders together. There were no orders for the use of oxygen. V8 said R96's oxygen needs to be running at the correct level. Too low can cause her to desaturate and not maintain 95% oxygen saturation levels. Too high can over oxygenate her. V8 said there should be orders and a care plan to show how to care for the oxygen system. On 12/14/23 at 9:20 AM, V2 (Director of Nurses) stated oxygen is a medication and needs a physician order. Orders should include the rate, if continuous or intermittent, liters, and oxygen saturation range. Orders should include how to care for the tubing system. V2 said a care plan is a good idea too. It directs staff how to provide that care. Lack of orders and a care plan have the potential for infection control issues and can affect the resident's overall health. Respiratory status can be negatively impacted. V2 reviewed R96's electronic medical record and stated she did not see any orders or care plan for R96's oxygen administration. The facility's Oxygen Administration policy revision dated 10/2010 states under the preparation section: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview, and record review, the facility failed to document and maintain an accurate count of narcotic medications for 1 resident (R6) in the sample of 12 and 1 resident (R95) outside of the sample reviewed for pharmacy services. The findings include: On 12/12/23 at 9:30AM, V8 (Registered Nurse) administered Norco 5/325mg to R6. V8 documented the medication administration on R6's narcotic count sheet but did not record the administration on R6's medication administration record. On 12/14/23, R6's medication administration record contained no documentation that V8 had administered any Norco to R6. (The only documented dose of Norco for R6 on 12/12/23 was 7:15PM) On 12/13/23 at 1:44PM, Surveyor performed a narcotic count with V8. R95's Norco 5/325mg narcotic count sheet showed R95 had 52 doses remaining. R95's Norco pill card showed 50 tabs remaining. V8 stated she must have forgotten to sign out a dose she gave to R95 earlier in the day. On 12/14/23 at 9:23AM, V8 stated, When we administer any medication to a resident, we are to document it in the medication administration record so there is confirmation that the medication was given. When we administer narcotics, we also have to sign out on the resident's narcotic record, so our counts are accurate. If we don't do both of these steps, our count could be off, and we also can't be sure when a resident last received their medications and that could lead to a medication error. On 12/14/23 at 11:44AM, V2 (Director of Nursing) stated, When staff are administering narcotics, they should first double check the count sheet to make sure the count is correct. After confirming correct count, they should document the amount removed on the count sheet, administer the medication, and then sign off on the resident's electronic medication administration record (EMAR). If a medication is not signed off on the EMAR, that's a problem because we need to know when the medication was last administered. If all of these steps are not followed, there could end up being a medication error. The facility's policy titled, Administering Medications dated April 2013 showed, Medications shall be administered in a safe and timely manner, and as prescribed .19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones . The facility's policy titled, Medication Administration dated 12/1/21 showed, Controlled Substances: Each medication is to be accounted for according to the Agency's procedure as it is removed from the container and before it is administered to the client.

Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 25 opportunities with 3 errors resulting in a 12% medication error rate. This applies to 1of 5 residents (R145) outside of the sample reviewed for medication administration. The findings include: R145's medication administration record for December 2023 showed R145 is to receive memantine 5mg, metformin extended release 500mg, and metoprolol 50mg at 9AM and 5PM. On 12/12/23 at 10:57AM, V7 (Registered Nurse) administered R145's memantine, metformin, and metoprolol. (1 hour and 57 minutes past the scheduled administration time). V7 stated she got a late start on her medication pass today because they were short staffed, and she had to help with patient care. On 12/14/23 at 11:44AM, V2 (Director of Nursing) stated, I wasn't aware that we were short staffed on Tuesday. I would expect the nurses to reach out to me if they are having trouble getting their medications administered in a timely manner or if there are staffing concerns. If a medication is not given within 1 hour before or after the scheduled administration time, then that is technically a medication error. The facility's policy titled, Administering Medications dated April 2013 showed, Medications shall be administered in a safe and timely manner, and as prescribed .4. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on observation, interview, and record review, the facility failed to store medications per manufacturer's directions and facility policy for 2 of 2 residents (R11, R37) outside of the sample reviewed for medication storage. The findings include: R11's physician's orders for December 2023 showed R11 receives Lantus 23 units daily. R37's physician's orders for December 203 showed R37 receives Insulin Glargine 38 units every evening. A review of V8's (Registered Nurse) medication cart on 12/13/23 at 1:44PM showed R11's Lantus pen was unopened with a label stating, Refrigerate until opened. R37's Insulin Glargine pen showed the insulin pen had been accessed and had no opened or use by date. V8 stated she believes that insulin is supposed to be refrigerated until use and that all insulin that has been opened is to have an open and use by date on it per facility policy. On 12/14/23 11:44AM, V2 (Director of Nursing) stated, Unopened vials of insulin should be refrigerated until they are put into use per manufacturer's directions. It should be dated with open date & use by date to ensure we discard it after 28 days. If these directions are not followed it could affect the efficacy of the insulin. The facility's policy titled, Medication Labeling and Storage dated February 2023 showed, The facility stores all medications and biologicals in a locked compartment under proper temperature, humidity and light controls .6. Medications requiring refrigeration are stored in a refrigerator locked in the medication room at the nurse's station or other secured location .5. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorts or longer date for the open vial.

Based on observation, interview, and record review, the facility failed to provide evening snacks for 5 residents (R4, R19, R25, R26, R28). This applies to 5 of 5 resident's outside of the sample reviewed for frequency of meals and snacks. The findings include: On 12/13/23 at 10:00AM, A resident council meeting was held with R4, R19, R25, R26, and R28 who have no cognitive impairment. All resident's stated they do not receive snacks at the facility, and they have not been offered snacks prior to going to bed at night. All residents stated they are not diabetic and do not require any special diet that would prevent them from getting a snack. On 12/13/23 at 1:42PM, V2 (Director of Nursing) stated, We have a snack list posted in the dining area for resident's that want to ask for a snack. We don't routinely pass out snacks or offer them. They know they are there and should ask for them if they want them. We do pass water every shift though. If a resident has an order to receive a snack, then we offer them. I have never heard of a facility offering snacks to residents. The facility's policy titled, Frequency of Meals dated December 2009 showed, Each resident shall receive at least three meals and at least one snack daily .1. The facility will serve at least three meals or their equivalent daily at scheduled times .The following mealtimes have been established by our facility for residents: Breakfast 7:30am-9:30am, Lunch 11:30am-1:30pm, Dinner 4:30pm-6:30pm .6. Evening snacks will be offered routinely to all residents not on diets prohibiting bedtime nourishment .

Based on observation, interview, and record review, the facility failed to ensure food was kept off the floor, failed to maintain food storage areas in a clean and orderly manner, failed to ensure ice cream freezer temperature was monitored, failed to maintain cleanliness of ice cream freezer, and failed to discard expired food items. These failures have the potential to affect all residents in the facility. The findings include: The facility's resident roster dated 12/12/23 showed 42 residents currently residing in the building. On 12/12/23 at 9:58AM, The facility's refrigerator had multiple pans of food and boxes of food stacked on top of each other. There were boxes filling all racks of the refrigerator, some boxes filled with plastic bags that were packed tightly into each box. Due to the large amount of food stored within the refrigerator, surveyor was unable to move food around to determine what food was present in the refrigerator. A pan of meat was also located on the floor of the refrigerator under a cart. On 12/12/23 10:05AM, The facility's freezer had 12 boxes of food placed on the floor and the shelves were piled with boxes of food so tightly and disorganized that surveyor was unable to move boxes around. On 12/12/23 at 10:12AM, The facility's dry storage room had 2 bags of corn tortillas with an expiration date of 10/19/23, an open container of cherries with no open or use by date, and 6 cans of diced peaches sitting directly on the floor. On 12/12/23 at 10:20 AM, The facility's ice cream freezer area had a bottle of raspberry sauce with an expiration date of 3/23/23 and a bottle of caramel topping with an expiration date of 11/9/23. Surveyor requested to visualize the thermometer for the ice cream freezer and V5 (chef) had to remove 8 containers of ice cream to locate the thermometer that had a large chunk of ice cream stuck to it on the bottom of the freezer. The ice cream freezer had several large scoops of ice cream sitting on the bottom of the freezer surround by crumbs, ice buildup around the entire top portion of the freezer, and large areas of dried, previously melted ice cream located all around the top of the freezer. On 12/12/23 at 10:30AM, V5 stated the temperature for the ice cream freezer is not checked routinely and there is no temperature log for it. V5 stated the kitchen staff have a cleaning list for their respective areas but the ice cream freezer is not on any of those lists. V5 also stated that he is aware that the food storage areas area a bit of a disaster and that is something he will be working on in the near future. The kitchen cleaning schedules were reviewed and showed no schedule for cleaning the ice cream freezer. On 12/12/23 at 11:40AM, V6 (Interim Dietary Manager) stated, I have been the interim director for about a week. I am aware that there are issues in the kitchen and storage is on the top of my list to start working on. We don't have a lot of room for food storage but it's an absolute mess in there right now. There should not be any food or pans on the floor as that is not our policy for food storage. I agree that the food storage situation is chaotic, and I have no idea how they even find anything in there or keep the foods rotated for a first in first out rotation. The ice cream freezer should have the temperature checked every day because that is a dairy product and if it's not kept at the right temperature, it could cause illness potentially. We should be cleaning that freezer out at least weekly and as needed when we identify concerns. The facility's policy titled, Storage of Food and Supplies dated 12/15/2020 showed, 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 .Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date .discard food past the use-by, sell-by, best-by, or enjoy-by date .arrange items neatly on the shelves in the same order as the inventory book .date and rotate items; first in, first out. Discard food past the use-by or expiration date .Refrigerated foods: Space foods on shelves to allow for air circulation. Do not crowd food .store items 6 above the floor, 2 from the walls, and 18 from the ceiling, consistent with local food protection codes .keep all food products at least 6 inches off the floor .Dry Storage: Store dry and staple items at least 6 above the floor and 2 from the walls and 18 from ceiling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care to a resident (R6). This applies to 1 of 1 resident reviewed for activities of daily living in the sample of 13. The findings include: R6's electronic face sheet printed on 1/26/23 showed R6 has diagnoses including but not limited to dementia with behaviors, generalized anxiety disorder, major depressive disorder, hypertension, and type 2 diabetes, constipation, and glaucoma. R6's facility assessment dated [DATE] showed R6 has severe cognitive impairment and is always incontinent of bowel and bladder. R6's nursing care plan dated 4/27/19 showed, (R6) has always been incontinent. History of urinary tract infections. Clean perineal area with each incontinent episode. On 1/24/23 at 1:36PM, V6 & V7 (Certified Nursing Assistants) transferred R6 to her bed with a mechanical lift. V6 pulled R6's shirt down and started to cover her up. Surveyor asked V6 the last time R6 had received incontinence care and V6 replied Earlier this morning when I got her up. It was around 7:30AM. (6 hours had passed since R6 received incontinence care). V6 then removed R6's incontinence brief that was saturated with urine and had a strong odor. V6 stated Incontinence care is provided at least 3 times per shift, residents with lifts are a little different because we have to have 2 people, it's hard to get 2 people when we need it done so they usually have to go a little longer without receiving incontinence care. I would say yes R6 waited too long to receive incontinence care. It could lead to skin breakdown and possibly urinary tract infections if not cleaned & given a clean brief. On 1/25/23 at 12:53PM, V2 (Director of Nursing) stated, We don't have a specific policy regarding how often incontinence care is given. The standard of care is every 2-3 hours whether they are incontinent or not. They should at least be checked and cleaned. 6 hours is way too long for a resident who is completely incontinent and cannot tell you when she needs to go or is wet. It is important to keep resident's skin dry to promote skin integrity and those kinds of things. On 1/26/23 at 11:40AM, V2 stated, (V6) said he did check (R6) every 2 hours, but she was dry. I can't confirm that he did or didn't check her but she is hospice and doesn't have a lot of fluid intake so that might be why he didn't change her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pressure ulcer prevention measures for a resident (R8) and failed to initiate treatment for a resident (R8) with a pressure ulcer. These failures apply to 1 of 4 residents reviewed for pressure ulcers in the sample of 13. The findings include: R8's electronic face sheet printed on 1/26/23 showed R8 has diagnoses including but not limited to osteomyelitis, Parkinson's Disease, pneumonitis, dysphagia, peripheral vascular disease, and chronic kidney disease stage 3. R8's facility assessment dated [DATE] showed R8 has no cognitive impairment. R8's nursing care plan dated 1/16/23 showed, (R8) is at risk for the development of pressure related injury due to advanced age, multiple disease processes, polypharmacy, impaired mobility, generalized weakness, bladder incontinence, bowel incontinence. If (R8) refuses the treatment, confer with the resident, interdisciplinary team and family to determine why and try alternative methods to gain compliance. Document alternative methods. R8's skin/wound note dated 1/16/23 showed, Wound type: FULL THICKNESS WOUND Acquired date: CHRONIC; PRESENT ON admission Location: RIGHT LATERAL TOE/FOOT Drainage: NONE Size: 5.3 cm X 4.2 cm Wound bed: Dry stable eschar .Recommendations: Cleanse with gentle soap/water or wound cleanser, apply (brand name antiseptic) to (brand name gauze dressing) and secure with roll gauze; daily dressing change. R8's physician's orders showed, 1/16/23 heel suspension boots every shift; utilize at all times while in bed R8's physician's orders dated 1/25/23 showed, Dressing change right lateral foot every day shift; full thickness eschar wound; cleanse, pat dry, apply (brand name antiseptic) to gauze dressing, apply on eschar wound, secure with roll gauze. No previous wound care orders were present in R8's medical record from 1/16/23 thru 1/24/23. On 1/24/23 at 1:20PM, R8 stated, I don't wear the heel boots because they hurt my heel. They haven't put my feet up on pillows or anything yet today. (R8's feet were resting flat on the air mattress during this observation). On 1/25/23 at 9:57AM, V8 (Registered Nurse) stated, (R8) has a sore on his right foot, he wears heel suspension boots most of the time. Not sure when his treatment was started. Treatment should begin as soon as a wound is identified to prevent wound from worsening. On 1/25/23 at 12:34PM, R8 stated, They usually have 1 or 2 pillows under my legs to keep my feet up, but they haven't been doing it for some reason. I won't wear the boots they want me to wear because it rubs on the back of my foot where I have a sore, but I let them put the pillows underneath because then my heels don't rub on the bed. On 1/26/23 at 9:32AM, V5 (wound care nurse) stated, (R8) came in with a wound that was eschar on the right lateral aspect of his foot. He's getting (brand name gauze dressing) done daily and that started on admission. We were doing the dressing changes, but they weren't documented. The only place it would be documented would be in a note or on the treatment administration record. If it's not documented, then it wasn't done. I think it just got missed. Pressure ulcer prevention for (R8) includes low air loss mattress, heel suspension boots or pillows under his feet. These are prevention measures in place for him because his skin is so fragile, and he is a higher risk for further skin breakdown. On 1/26/23 at 11:40AM, V2 (Director of Nursing) stated, When a pressure sore or any other skin condition is identified an assessment should be completed, initiate repositioning & heel boots or pillows. Treatment should be initiated right away and documented on the treatment administration record. If the orders are not in the system, then the nurse will not know what the orders would be and if it's not documented then we can't always assume it's not done. I'm sure this wound care was done they just didn't document it. The facility's policy titled, Skin Maintenance-Pressure Injury-Prevention and Maintenance dated 01/20/2022 showed, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. To eastablish guidelines to prevent development of avoidable pressure injury for residents in our community .2. Interventions .c. Interventions will be documented in the resident care plan and revised based upon ongoing assessment and evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide range of motion (ROM) exercises for a resident with a muscle wasting disease. This applies to 1 of 1 resident (R18) reviewed for restorative services in the sample of 13. The findings include: R18's Face Sheet showed he was admitted to the facility on [DATE] with diagnoses to include Inclusion Body Myositis (progressive muscle weakness that can cause muscle damage); left fibula and tibia fracture (lower leg bones), and spinal stenosis. R18's 11/25/22 Minimum Data Set (MDS) showed he was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. The MDS showed he was totally dependent on two staff for bed mobility and transfers as well as requiring extensive assistance of two people for dressing. On 1/24/23 at 11:18 AM, R18 was in his bed and laying on his back. R18 was wearing a hospital gown and he was covered with a sheet. R18's hands were contracted into a claw type grip. R18 stated, I used to have range of motion exercises at the facility I was at prior to here. I really think that would help with my legs. Someone told me that someone from OT (Occupational Therapy) would come to me and see if I needed PT (Physical Therapy) or ROM therapy, but that was a week or so ago. When the CNA's take care of me throughout the day they don't do any extra ROM exercises with my legs. I have a rare muscle wasting disease, so I do have some contractures to both hands . The range of motion exercises would help to keep them (legs) more mobile, if they stay in this position 24/7 (24 hours a day, 7 days a week) and they are going to stiffen up .I think I should get ROM exercises at least once a day. On 1/25/23 at 2:22 PM, V10 (Certified Nurse Assistant/CNA) was R18's CNA and she was not aware of any residents requiring ROM exercises; however, V10 stated she provided ROM exercises for all of her residents while she got them dressed. (R18 wore a hospital gown on 1/24/23 through 1/26/23.) On 1/25/23 at 2:32 PM, V9 (Restorative Nurse) stated ROM is a part of restorative responsibilities. V9 stated passive ROM is ROM that is performed by the staff for the resident. V9 said active ROM is when the resident does the ROM them self. V9 stated she is responsible for entering ROM orders and she is responsible for updating the electronic charting which. V9 said ROM is more deliberate than assisting a resident with dressing. V9 said, [R18] is not on a ROM program. I don't know why he is not on a ROM of program. He would benefit from the ROM program. He would benefit from ROM program because he is going to atrophy (muscle wasting) and his muscles will suffer. It (ROM) can help prevent or minimize contracture. V9 said she does not need a physician order to provide ROM services and she was not certain why R18 was not placed on ROM exercises from admission. On 1/26/23 at 10:26 AM, R18 said he was evaluated for ROM on 1/25/23 and he was given an exercise band for the upper body, and he will be receiving passive ROM for his legs. R18 said 1/25/23 was the first day either of those interventions occurred. R18 said, I have very little movement with my legs. I can bend my right knee a little, but I can't lift it off the bed, my left leg I broke some bones so all I can do is wiggle the foot. I cannot do ROM with my lower body at all; I need help with that. R18 said, Applying the hospital gown is very little ROM. I have to lift my arms a little but that's really all I have to do; it's very minimal. I don't recall anyone assessing my ROM from this facility but maybe they did it at the other facility. I am not able to manually stretch my hands apart (his contracted fingers.) No one ever stretches my hands apart, but that sounds like a good idea I would really like that. The facilities Restorative Census (dated 2023) showed R18 is not in any restorative program to include active ROM, passive ROM, bed mobility, or transfers. R18's care plan showed Provide gentle range of motion as tolerated with daily care. (Initiated 11/18/22, the type of range motion, extremities included, repetitions, and frequency was not specified.) The facility's Rehabilitative/Restorative- Mobility and Range of Motion policy (revision 12/29/21) showed, Mobility training can improve the range of motion (ROM) of a resident joints and muscles by increasing flexibility and stamina. [The facility] works with our residents to improve their mobility reducing the risk of injuries .as part of the resident's comprehensive assessment, the nurse will identify the resident's: current range of motion of his or her joints .opportunities for improvement . The policy showed, The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to transfer a resident (R13) with a gait belt. This applies to 1 of 2 residents reviewed for safety and supervision in the sample of 13. The findings include: R13's electronic face sheet printed on 1/26/23 showed R13 has diagnoses including but not limited to history of falls, dementia with behaviors, delirium, major depressive disorder, and peripheral autonomic neuropathy. R13's facility assessment dated [DATE] showed R13 has severe cognitive impairment and requires 2 staff member assistance for transfers. R13's fall risk assessment dated [DATE] showed R13 is a high fall risk. R13's care plan dated 1/2/22 showed, (R13) is high risk for falls related to gait/balance problems, history of falls secondary to fall with right femur distal end distal fracture. R13's care plan dated 1/2/22 showed, (R13) has an activities of daily living (ADL) self-care performance deficit related to dementia, limited mobility, and musculoskeletal impairment secondary to fall with right femur distal end fracture. Transfer program: (R13) will transfer with 1 staff assist, gait belt and walker, stand pivot transfer. On 1/24/23 at 9:33AM, V7 (Certified Nursing Assistant) was transferring R13 from the toilet to her wheelchair. V7 had R13 hold onto the metal bar next to her toilet, lifted her up by the back of her pants. R13 did not have a gait belt around her waist during the transfer. V7 stated, It's my fault for not using a gait belt, I should know better, but I didn't have one. If (R13) began to fall I would have to try and catch her because I don't have a gait belt on her to try and keep her steady. On 1/26/23 at 9:46AM, R13's ADL care guide in her room showed R13 requires 1 staff member assistance with a gait belt for all transfers. On 1/25/23 at 9:57AM, V8 (Registered Nurse) stated, Gait belts should be used for any resident that requires assistance with transfers or walking in case they become weak and need to be lowered to the floor or chair. If these are not used a resident could become injured if staff, try to catch them. On 1/26/23 at 11:40AM, V2 (Director of Nursing) stated, (R13's) transfer status depends on her level of cooperation. If she's having a difficult time following direction, we would use 2 assist for transfers. A gait belt should definitely be used for her because she's not always cooperative with transfers. The facility's policy titled, Positioning/Moving-Safe Resident Handling revised on 12/29/2021 showed, It is the policy of (facility) and its affiliates to ensure the safe physical transfer of residents using the identified transfer method that promotes the appropriate level of independence and safety for the resident and associate care givers .2. Gait belt usage: a. Gait belt usage is recommended for all 1 person transfers with the exception of bed mobility and/or medical contraindications.

Based on observation, interview and record review the facility failed to wear hair nets while working in the kitchen, thaw foods in a manner to prevent a food borne illness and failed to cover bulk foods. This applies to all residents in the facility. The finding include: The Centers for Medicare and Medicaid Services Resident Census and Resident Conditions 672 form dated 1/25/23 shows there are 40 residents residing in the facility. On 1/24/2023 at 9:20 AM the dietary staff were observed entering the kitchen without wearing a hair net. When this surveyor entered the kitchen and applied a hair net, several dietary staff were observed putting on a hair net. In the dry storage room, the bulk containers containing the sugar and the panko breadcrumbs were observed to be uncovered. At 1:00 PM the same day the storage containers were still uncovered. On 1/24/2023 at 9:30 AM, a dietary worker was observed placing a tray of frozen ground sausage on top of the convection oven. This surveyor at 9:45 AM asked V4 (Executive Chef), why that pan of frozen meat had been placed on top of the oven. V4 said that should not have been put there to thaw. There is a better way. V4 took the pan and placed it into the refrigerator. 01/25/23 10:00 AM V4 and V3 (Director of Dining) said they expect staff to thaw all meats in the refrigerator, wear hair nets while in the kitchen and close the lids to all storage bins when not in use. The facility policy with a revision date of 1/2022 for Uniform Dress Code shows: wear the approved hair restraint when on duty regardless of length or presence of hair. The policy provided to this surveyor for food storage dated 10/1/22 for storage facilities shows food storage containers with tight-fitting covers should be used for storing bulk foods such as flour, sugar ., the undated food handling guidelines for thaw frozen meats shows meat to be thawed under refrigeration, under running water, as part of the cooking process or in the microwave.