Based on interview and record review, the Facility failed to ensure residents were receiving the lowest effective doses, recommended by licensed pharmacists, in a timely fashion for 2 of 5 residents (R14, R38) reviewed for unnecessary medications, in the sample of 62. Findings include: 1. On 9/30/2024 at 9:30 AM, R14 stated, They give me a shot of something in the morning. R14's Face sheet dated 10/3/2024 documents, Long term (current) use of insulin. Consultant Pharmacist Recommendation to Nursing dated 8/23/2024 documents, Medication reduction request- Resident is on the following diabetic medications: Metformin ER (Extended Release) 500 mg (Milligrams) 1 tablet in the morning and 2 tablets at bedtime, Basaglar 40 units once daily, and Fiasp 10 units with meals. Recent blood glucose monitoring low. 8/23/2024 54 (normal 70-100). Most recent A1C (Hemoglobin A1C levels indicate the percentage of hemoglobin coated with glucose) 6-2024 (June 20224) 4.5 (Normal: Less than 5.7%). Recommend further reduction of basaglar to 35 units once daily. R14's Physicians Orders dated 10/3/2024 documents, Basaglar (insulin)- inject 40 units subcutaneous in the morning. R14's Care Plan documents, Diabetes Mellitus- (R14) will have no complications related to diabetes through the review dated (12/18/2024). Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. R14's Progress Notes dated 10/2/2024 documents, Updated doctor office on blood sugars. On 10/3/2024 at 9:06 AM, V2, Director of Nursing (DON) stated, On 8/23/2024 the pharmacist recommended (R14's) insulin to be decreased by 5 units. It has not been addressed by the doctor. I had the nurse send the blood sugars to the doctor for review. He also has an appointment to be seen (by the doctor related to his blood sugars). R14's Weights and Vitals Summary documents R14's blood sugar level was low on 9/23/2024 at 57 (normal range is 70-100). 2. R38's Care Plan dated 1/2/2023 documents R38 has the potential for fluid deficient related to diuretic use. Administer medications as ordered. Monitor/document for side effects and effectiveness. R38's Consultant Pharmacist Recommendation to MD (Medical Doctor) dated 6/26/2024 documents, Resident had recent labs with an increased in creatinine from 1.6 to 3.1. Please Evaluate resident and determine if furosemide (diuretic) and or lisinopril dose needs adjusted. It continues to document, Agree- decrease furosemide from 60 mg BID (twice a day) to 60 mg in the AM and 40 mg in the PM. R38's Lab Results Report dated 6/20/2024 documents R38's creatinine level was 3.1 (Reference range 0.7-1.3). R38's Lab Results Report dated 7/2/2024 documents R38's creatinine level was 2 (Reference range 0.7-1.3). R38's Physician's Orders dated 8/2/2024 documents, Lasix- Give 40 mg by mouth in the evening and Lasix- give 60 mg by mouth in the morning for hypertension. R38's Lab Results Report dated 10/2/2024 documents R38's creatinine level was 1.9 (Reference range 0.7-1.3). R38's Weights and Vital Sign Summary documents R38's blood pressure was 97/51 on 8/6/2024 (normal range is 120/80). R38's Weights and Vital Sign Summary documents R38's blood pressure was 94/52 on 8/7/2024. R38's Weights and Vital Sign Summary documents R38's blood pressure was 96/63 on 9/22/2024. On 10/1/2024 at 3:15 PM, V2 stated, We have had a delay in getting the GDRs (Gradual Dose Reductions) addressed. The nurse who was doing them is no longer with our doctor (medical director). (V17, Nurse Practitioner) came and handed me the paper dated 7/11(2024). I made her cross it out and put 8/2/2024. I can't process it (the recommendation) if I don't have it. On 10/3/2024 at 10:08 AM, V18, Licensed Practical Nurse (LPN) stated, When they do them (pharmacy recommendations/monthly medication reviews) they send them to (V2). I don't know how long it takes for her to get them back. Our nurse practitioner (V17) comes every week. On 10/3/2024 at 12:11 PM, V2 stated she should have followed up within a couple days of not receiving orders on the recommendations. The Facility's Pharmacist Medication Regimen Review Policy, Effective: 11/2023, documents, Guidelines: The Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once per calendar month for each resident in certified areas of a skilled long term care facility. For residents residing in long term care facilities licensed for the developmentally disabled or assisted living, pharmaceutical care consultation including medication regimen review will be conducted in compliance with state regulation. Procedure: 1. The Consultant Pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities (defined by CMS as the use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes of pharmaceutical services), exist. Federally mandated standards of care as well as other applicable standards serve as the basis for review to ensure that a resident's medications are promoting or maintaining the resident's highest level of function in congruence with the resident's therapeutic goals and to identify clinically significant risks and/or adverse medication reactions. 2. The review of the medication regimen will include all medications currently ordered, including medications that are ordered on a PRN or as needed basis. The review will incorporate information from the resident's chart concerning the resident's condition, monitoring for side effects, potential for drug-drug interactions, psychotropic medication review including considerations for dose reduction/optimal dosing, review for potentially unnecessary medication usage, as well as review of the medication administration records and ancillary documentation such as the physician's progress notes, nursing notes and laboratory test results. 3. The Consultant Pharmacist will report any irregularities in writing to the attending physician, the Medical Director and the Director of Nursing for follow up. The written documentation will include, minimally, the resident's name, the relevant drug and the identified irregularity. The Consultant Pharmacist will communicate any irregularities that require URGENT action directly to the Director of Nursing or other designated clinical staff for immediate resolution. The Director of Nursing or designee will notify the attending physician of recommendations either in person, by telephone, fax or other secure system of notification within 3 business days of receiving report from the Consultant Pharmacist. If no response is received from the attending physician within 3 business days following notification, the Director of Nursing will make a second attempt to notify the attending physician. If the attending physician does not respond after a second attempt, the Medical Director will be notified of recommendation.

Based on observation, interview and record review, the facility failed to ensure food was at the proper holding temperature at the steam table for 4 of 12 residents (R8, R21, R23, R35) reviewed for food temperatures in the sample of 62. Findings include: On 10/1/2024 at 11:55 PM, during the lunch service R8 was served mechanical hot dog meat and tater tots. On 10/1/2024 at 11:56 PM, R35's meal ticket documented a mechanical diet. On 10/1/2024 at 11:58 AM, during the lunch service R35 was served a mechanical hot dog meat on a bun. On 10/1/2024 at 11:59 AM, during the lunch service R21 was served a mechanical hot dog meat on a bun and tater tots. On 10/1/2024 at 12:00 PM, R21's dietary ticket documents he was on a mechanical diet. On 10/1/2024 at 12:03 PM, during the lunch service R23 was served a mechanical hot dog meat on a bun and tater tots. On 10/1/2024 at 12:04 PM, R23's dietary ticket documents he was on a mechanical diet. On 10/01/2024 at 12:12 AM, after the last lunch plate had been served, food temperatures were taken on the steam table with a calibrated metal thermometer and the following temperatures were below 135 degrees Fahrenheit (F), tater tots 130.0 F, and the mechanical hot dog meat was at 112.0 F. On 10/1/2024 at 1:11 PM, V11, Dietary Manager provided a list of male residents who were on mechanical meat and the following residents were documented as being on mechanical meat R8, R21, R23, and R25. On 10/1/2024 at 1:14 PM, V11 stated we feed the male residents first at 11:30 AM, and then after they leave the dining room then we feed the female residents. On 10/1/2024 at 1:20 PM, the Food temperature book did not record any temperatures for the first lunch service. The areas were blank. On 10/1/2024 at 1:22 PM, V12, cook stated, I took the temperatures but I did not record them in the book. I have the temperatures somewhere around here. On 10/1/2024 at 4:01 PM, V11 stated, I would expect all the food on the steam table to be at least 165 degrees or higher when holding. I heard that when you took temperatures today, they were below 112.0 F and I know that is. I am in the middle of my training for my certification for the dietary manager. On 10/1/2024 at 4:11 PM, V14, Dietician stated, I would expect all items on the steam table to be held at 135 degrees Fahrenheit or higher. If the temperature is less than 135 degrees, bacteria can grow if the temperature is between 41-135 degrees F, which could lead to food borne illness. The Monitoring Food Temperatures for Meal Service Policy dated 2020 documents, Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. The temperature for each food item will be recorded on the Food Temperature Log. Foods that required a corrective action (such as reheating); will have the new temperature recorded with a notation of the corrective action intervention. If the serving/holding temperature of a hot food item is not at 135°F or higher (check your state specific regulations: some states require 140°F minimum hot holding temperature) when checked prior to meal service, the item will be reheated to at least 165°F for a minimum of 15 seconds. The item may be reheated only once and must be discarded or consumed within two hours. Any reheated item that is left after meal service or held longer than two hours is discarded.

Based on interview and record review, the Facility failed to ensure a Registered Nurse (RN) was working at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 62 residents living in the facility. Findings includes: The facility's partial August 2024 Daily assignment sheets for 8/30/2024 and 8/31/2024, documented that there was not consecutive 8 hours of consecutive RN coverage. The facility's September 2024's RN staffing documented that there was not consecutive 8 hours of consecutive RN coverage on 9/9/24, 9/10/24, 9/11/24, 9/13/24, 9/14/24, 9/15/24, 9/17/24, 9/18/24, 9/19/24, 9/23/24, 9/24/24, 9/25/24, 9/27/24, 9/28/24, 9/29/24. On 09/30/2024 at 4:00PM, V2, Director of Nurses, stated that she was told by her corporate nurse that as long as it was a consecutive 8 hours then her night RN would count as the RN. V2 stated that that RN works 10 pm to 6 am and that the new day starts at 12:00 AM. V2 continued to state that she guessed then the new day would start at 12 am and that only 6 of the 8 hours would be on the new day. On 10/02/204 at 3:10 pm, V1, Administrator, stated that they do not have a RN Coverage policy and that they follow CMS (Center for Medicare and Medicaid Services) guidelines. The Facility's Long Term Care application for Medicare and Medicaid, CMS 671, dated 9/30/2024 documented that the facility had a census of 62 residents.

Based on interview and record review, the facility failed to obtain lab draws as ordered by the physician for monitoring therapeutic drug levels for 1 of 7 residents (R11) reviewed for unnecessary medications in the sample of 64. Findings include: R11's Face Sheet documents her diagnoses to include Post Traumatic Seizures and Personal History of Traumatic Brain Injury. R11's Physician Order Summary dated 9/19/23 documents the following orders: 8/31/23: Trileptal Oral Tablet 300 milligrams (mg) (Oxcarbazepine) Give 1 tablet by mouth in the evening related to Post Traumatic Seizures. Give with 150 mg tab to equal 450 mg daily. 8/31/23: Levetiracetam Oral Tablet 1000 mg (Levetiracetam) Give 1 tablet by mouth two times a day related to Post Traumatic Seizures; Personal History of Traumatic Brain Injury. 12/13/22: CBC (Complete Blood Count), B12, CMP (Complete Metabolic Profile), TSH (Thyroid Stimulating Hormone Level), VITAMIN D LEVEL, HGBA1C (Hemoglobin A1C), Trileptal and Keppra (Levetiracetam) level every 6 months-April/October. R11's Electronic Medical Record documents, under lab and x-ray results, that no B12, TSH, Vitamin D Level, HgbA1C, Trileptal or Levetiracetam level has been done since 11/29/22. No labs were done for R11 as ordered in April 2023. R2's Care Plan, undated documents the problem: Seizure Disorder related to Traumatic Head Injury. The interventions for this care plan include Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated. On 9/19/23 at 8:35 AM V1, Administrator, stated they cannot find R11's lab results for her Keppra and Trileptal drug levels that were ordered to be done in April 2023. She stated they have reached out to their contracted lab to find out why it was missed. V1 stated R11 was being taken to the local hospital to have the labs drawn now. On 9/19/23 at 8:48 AM V2, Director of Nursing, stated R11 was on the lab's schedule on 4/6/23 to have labs drawn as ordered but it wasn't done. She stated if a resident refuses to have labs drawn, the lab techs usually put a note regarding they were unable to obtain due to the resident refusing, and then the labs are re-scheduled to try again on the next lab draw date. V2 stated she thinks the lab just missed it. The facility's policy, Laboratory Testing Incident Reporting revised in 01/2018 documents, Purpose: To outline responsibilities for reporting and review of incidents associated with laboratory testing as ordered by a resident's physician to safeguard the resident. Guidelines: The Nursing Department will ensure the timely adherence of physician's orders for laboratory testing. Definition: An inappropriate or incorrect collection or omission of a specimen; including transport time and storage (temperature) or failure of the laboratory provider to properly process and print the report in a timely manner. 1. Laboratory test errors may include: c. The laboratory service fails to collect a specimen for testing; f. Laboratory tests not performed within 24 hours of requested date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure a Registered Nurse (RN) was working at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 62 residents living in the facility. Findings include: On 09/17/2023 at 9:55 AM, V1, Administrator stated we are not having any issues with RN coverage. We have a RN working every day. On 9/17/2023 at 10:15 AM, V4, Licensed Practical Nurse (LPN) stated We did not have a RN working on Saturday because she had a wedding to go to. We were without a RN that night. Staffing schedules were reviewed from 8/25/2023 to 9/17/2023 and no RN was documented as working on Saturday, 9/16/2023. On 9/17/2023 at 9:57 AM, V1 stated We did have a RN call off on 9/16/2023 and we did not have a RN working that day. I realize the regulations require a RN to work 8 consecutive hours, seven days a week. On 9/17/2023 at 10:30 AM, V2, Director of Nursing stated, The RN called off on 9/16/2023 but normally we have a RN working every day for 8 consecutive hours. The Facility assessment dated [DATE] documents, the total of licensed beds was 65, with average census of 62. The staffing plan documents, Based on your resident population and their needs for care and support, describing your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Licensed Nurses (LN): RN, LPN providing direct care. Day shift 2, evening shift 2 and night shift 1. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 9/17/2023 documented the facility had a census of 62 residents.

Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 64 residents in the facility. Findings include: On 7/20/22 at 11:30 AM, the Nursing Working staffing schedule from January 1, 2022, through July 19, 2022 was reviewed with V2, Director of Nurses. The facility did not have consecutive 8-hour RN coverage for the following days: 1/19/22, 3/24/22, 3/28/22, 3/29/22, 4/1/22 through 4/18/22, 4/21/22, 4/25/22, 4/29/22, 4/30/22, 5/8/22, 5/27/22, 6/6/22, 6/10/22, 6/18/22, and 6/19/22. On 7/20/22 at 11:00 am V2, Director of Nurses (DON), stated she knows there were some issues with RN coverage as one RN left and came back. V2 stated she has only been employed at the facility for four months. V2 stated she has hired two RNs for evenings since she started. 7/21/22 at 9:45 AM V2 stated that they do not have a policy on staffing. V2 stated that they use the CMS guidelines. The Resident's Census and Conditions of Resident, CMS 672, dated 7/18/2022, documents that the facility has 64 residents living in the facility.

Based on observation, interview, and record review, the facility failed to properly label and store medication. This failure has the potential to affect all 64 residents living in the facility. Findings include: On 7/19/2022 at 8:14 AM the facility's medication room was inspected. The medication room contained the following medication: c1. A clear unlabeled bag of 53 dark pink pills. The clear bag had These are 50mg Benadryl not 25mg handwritten in red ink on the clear bag. On 7/19/2022 at 8:17 AM, V4, Licensed Practical Nurse (LPN), stated that she did not know what was in the bag. V4 stated that It's illegal and they (pills) are not supposed to be in there (bag). V4 stated that the medication was stock and used for everyone unless they have an allergy. On 7/19/2022 at 8:19 AM V5, LPN, stated that, The only thing we can do is fix our mistakes. 2. R19's open, unlabeled with open date, vial of Lantus 100 units. On 7/19/2022 at 8:25 AM, V2, Director of Nursing (DON), stated that Lantus is good for 28 days once open. V4 stated that this is why there is an open date. V2 stated that when a vial is opened the open date is placed on the vial. On 7/19/2022 at 8:27 AM, V5 verified that the medication was open and in use. 3. On 7/19/2022 at 11:08 AM, a medication pass was observed with V4, LPN. V4 administered R15's scheduled Clonazepam 0.125mg from a foil located inside an unlabeled clear plastic bag. On 7/19/2022 at 11:09 AM, V4 stated that the clear plastic bag did not have a label on it. V4 stated that they (nurses) usually remove the label from the box and put it on the bag. The facility's Medication Storage policy, effective date 5/2022, states 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. It also states 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. Facility should ensure that no transfers between containers are performed by non-Pharmacy personnel. The Resident's Census and Conditions of Resident, CMS 672, dated 7/18/2022, documents that the facility has 64 residents living in the facility.

Based on observation, interview and record review, the Facility failed to document and receive prior approval from the dietician before utilizing substitutions. This failure has the potential to affect all 64 residents residing in the facility. Findings include: On 7/18/2022 at 11:00 AM, V9, Dietary Aid, was observed serving Pork Loin, Stuffing, Brussel Sprouts and Applesauce with cinnamon for lunch. The Facility's Diet Spreadsheet, Spring/Summer 2022 Week 4 documents that Pork Loin, Zucchini Cornbread Dressing Bake, Brussels Sprouts, and Banana Split Cake were on the menu to be served. On 7/19/2022 at 1:30 PM, V6, Kitchen Manager stated, We didn't have Zucchini, just stuffing and our Bananas were liquified, so I sent them back. On 7/20/2022, at 2:46 PM, V1, Administrator stated, If I had known they didn't have zucchini or bananas I would have gone to the store. We just talked about following the menu. I would expect them to follow it. At this time, V1 confirmed the menu listed above was for 7/18/2022 and the menu was not followed. On 7/21/2022 at 11:45 AM, V1 stated, She (V6) should call and get permission from the dietician prior to, and she did not. She knows that now. The Facility's Menu Substitution Form documents that on 7/18/2022 stuffing was substituted for the scheduled Zucchini Corn Bread Bake. The reason for the substitution was out of stock. The Form does not include the Applesauce being substituted for the Banana Split Cake. The Facility's undated policy Making Menu Substitutions documents, A log of substitutions must be kept on file, including what food items were substituted, the date, reason and what new food item was served. The Facility's CMS 672 dated 7/18/2022, documents that there are 64 residents residing in the facility.

Based on observation, interview and record review, the Facility failed to maintain a sanitary environment in the food storage, prep, and serving area. This failure has the potential to affect all 64 residents residing in the building. Findings include: On 7/18/2022, at 8:45 AM, the white air conditioning unit in the dry food storage area had a black substance covering the vent. V6, Kitchen Manager, stated, I don't know what that is. I will have the maintenance man clean it. On 7/18/2022 at 10:35 AM V9, Dietary Aid, was preparing the mechanical soft meat. This surveyor saw a blackish/brown bug, approximately one inch in length, with long antennas scurry across the floor in the kitchen near the steam table. V9, nonchalantly stated, Yeah, that's a roach. I see them off and on. Usually, they are dead because they spray for them. On 7/18/2022, at 10:45 AM, V6, stated, We are supposed to call the pest control company if we see them. On 7/19/2022 at 8:30 AM, V1, Administrator stated, The black stuff was a foam seal that was in there to keep the air conditioner from rattling. It had gotten wet and disintegrated. On 7/19/2022 at 10:00 AM, V10, Maintenance, stated, I know they had an issue yesterday in the kitchen. They saw a roach in the kitchen. At this time, there were 3 dead bugs on the floor in the social service office. V10 picked them all up, without a glove and verified that one was a roach. On 7/20/2022 at 3:45 PM, V11, Dietary Aid, stated, We don't have a specific cleaning schedule, we just all pitch in. I never noticed all that dust up there. Yes, that's where the clean dishes come out of the washer. The Facility's Kitchen Sanitation Manual dated 2/2022 documents, Cleaning Schedule Policy: There will be a written comprehensive cleaning schedule posted and monitored to maintain the cleanliness and sanitation of food service equipment. It continues to document, A cleaning schedule will be posted, and employees will initial and date tasks when completed. The Facility's CMS 672 dated 7/18/2022, documents that there are 64 residents residing in the facility.

Based on observation, and record review, the facility failed to provide 80 square feet of floor space per resident bed for 33 two-bed resident rooms for 60 of 62 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31,R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R45, R46, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61, R62 and R63 ) reviewed for room sizes in the sample of 63. Findings include: 1. The facility has 33 two-bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide 76 square feet per bed. All these rooms are certified for Medicaid beds. 2. R1, R8, R12, R14, R15, R17, R18, R20, R23, R26, R27, R30, R32, R34, R36, R37, R39, R40, R41, R42, R44, R45, R46, R47, R49, R52, R55, R58, R59, R61, and R63 reside in rooms XX-XYZ on the A-hall. 3. R2, R3, R4, R5, R6, R7, R9, R10, R11, R13, R16, R19, R21, R22, R24, R25, R28, R29, R31, R33, R35, R38, R43, R48, R50, R51, R53, R54, R56, R57, R60, and R62, reside in rooms YY-YZX on B hall. On 7/19/22 at 9:00 AM V1, Administrator, stated that he is aware of square footage of the rooms and stated that he always gets a tag for this. On 7/21/2022 at 11:15 AM facility room size policy was requested. The policy was not provided by the facility.

Based on observation, interview and record review the facility failed to provide effective pest control program so that the facility is free of pests. 1. On 7/18/22 at 10:30 AM R38 stated that she has had to kill multiple bugs in her room. R38 stated that she has squashed spiders and roaches in her room. 2. On 7/19/2022 from 1:30 PM to 2:00 PM multiple large blackish brown bugs approximately 1 inch in length with antennas was observed crawling on the floor. On 7/19/22 at 2:00 PM V2, Director of Nursing (DON) identified the bug as a roach. 3. On 7/21/2022 at 11:50 AM observed a large black bug running across the floor in the social service office. On 7/21/22 at 3:00 PM V10, Maintenance, stated that they do have an exterminator company that comes out monthly. V10 stated that the company was out last month but they only spray the entry points. When asked to clarify? V10 stated that the company only sprays the entrances to the building and other areas when identified. 4. On 7/18/2022 at 10:35 AM V9, Dietary Aid, was preparing food in the prep area. This surveyor saw a blackish/brown bug, approximately one inch in length, with long antennas scurry across the floor in the kitchen near the steam table. At this time, V9, nonchalantly stated, Yeah, that's a roach. I see them off and on. Usually, they are dead because they spray for them. On 7/18/2022, at 10:45 AM, V6, Dietary Manager, stated, We are supposed to call the pest control company if we see them. On 7/21/2022 at 10:45 AM, V10, Maintenance, stated, I have not done anything about the bugs because the pest control company is coming Tuesday. The Facility's Pest Control Policy dated 9/2018 documents, Purpose: To prevent or control insects and rodents from spreading disease. It continues to document, 10. The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents. The Facility's CMS 672 dated 7/18/2022, documents that there are 64 residents residing in the facility.