Based on observation, interview and record review, the facility failed to follow physician's order to apply compression wrap for one of three residents (R25) reviewed for edema management in a sample of 14. Findings include: On 11/13/2024 at 10:16AM during observation, R25 was observed with swelling (edema) on both lower extremities. R25's right leg was observed to not have anything on it and R25's left leg was observed with a stocking on it. On 11/13/2024 at 12:15AM during observation with V11 (Licensed Practical Nurse), R25 was again observed with swelling (edema) on both lower extremities, R25's right leg was again observed to not have anything on it and R25's left leg was again observed with a stocking on it. There were no reusable compression wraps observed at bedside. On 11/13/2024 at 12:18 PM during record review with V11, R25 was noted with an order for reusable compression wraps to be applied in the morning and removed at bedtime with order date of 04/22/2021. R25's electronic treatment administration record (eTAR) also indicated that the reusable compression wraps were administered by the night shift nurse. On 11/13/2024 at 12:18 PM during record review with V2 (Director of Nursing), R25 was noted with order for reusable compression wraps to be applied in the morning and removed at bedtime with order date of 04/22/2021. R25's electronic treatment administration record (eTAR) also indicated that the reusable compression wraps were administered by the night shift nurse. On 11/13/2024 at 10:16AM during interview with R25, R25 stated that she does not put anything on her right leg because she fell and it was swollen from the fall, and R25 only has a regular stocking on her left leg. On 11/13/2024 at 12:18PM during interview with V11, V11 stated that if R25 had an order for reusable compression wraps and the eTAR indicated that it was administered, it should be on R25 right now. On 11/13/2024 at 12:38PM during interview with V2, V2 stated that if R25 had an order for reusable compression wraps and the eTAR indicated that it was administered, it should be on R25 right now. Review of R25's Order Summary Report dated 11/14/2024 with active orders as of 11/13/2024 indicated R25 was admitted in the facility on 12/23/2020 with diagnoses not limited to acute embolism and thrombosis of unspecified deep veins of left lower extremity and other specified peripheral vascular diseases, and order for reusable compression wraps to be applied in the morning and to be taken off at bedtime with order date of 04/22/2021. Review of R25's Treatment Administration Record for October and November 2024 indicated a check mark every day which means that it was administered to R25. Review of R25's Progress Notes from 06/01/2024 to 11/13/2024 did not indicate any refusal to apply the reusable compression wraps. Review of R25's care plan last reviewed 11/14/2024 indicated R25 is at risk for self-care deficit of ADLs (Activities of Daily Living) with dressing and grooming tasks related to unsteady balance, pain to left lower side of back and diagnosis of wedge compression fracture of T9-T10 vertebra with interventions including R25 is independent with dressing/undressing and grooming but needs help with putting/removing compression stockings. Review of facility's policy entitled Physician Orders revised on 08/2017 indicated the following: Purpose: To ensure that each resident receives the appropriate treatment and medication.

Based on observation, interview and record review, the facility failed to ensure all medications are labeled accurately for one of twelve residents (R5) reviewed for medication storage and labeling in a sample of 14. Findings include: On 11/12/2024 at 11:21 AM during observation with V6 Licensed Practical Nurse (LPN), the second-floor medication cart was observed with the following: 1. R5's Spironolactone 25mg (milligram) tab medication bottle with discard after date of 06/10/2024 2. 10 boxes of R5's insulin pen disposable needles with expiration dates of 3/31/2021 (1 opened box and 2 unopened boxes), 8/20/2020 (1 opened box), and 10/31/2022 (6 unopened boxes). On 11/12/2024 at 11:25 AM during observation with V5 minimum data set (MDS/Restorative Nurse), the second-floor medication cart was again observed with the following: 1. R5's Spironolactone 25mg tab medication bottle with discard after date of 06/10/2024 2. 10 boxes of R5's insulin pen disposable needles with expiration dates of 3/31/2021 (1 opened box and 2 unopened boxes), 8/20/2020 (1 opened box), and 10/31/2022 (6 unopened boxes). On 11/12/2024 at 11:20 AM during interview with V6 (LPN), V6 stated that she uses the Spironolactone from the medication bottle noted with discard after date of 06/10/2024 to give to R5. V6 also stated that she does not know why the boxes of R5's insulin pen disposable needles are in the cart. V6 added that it should have been discarded. On 11/12/2024 at 11:25 AM during interview with V5 (MDS/Restorative Nurse), V5 stated that R5 used to be a resident in the apartment area and takes care of his own medications. V5 also stated that R5 said he buys the big containers of medications and pours them out on the old, smaller bottles. V5 stated there will be no way to find out the new expiration date if it was not labeled properly. V5 also stated that they will order a new set of Spironolactone for R5 from the pharmacy. V7 also stated that the boxes of R5's insulin pen disposable needles should have been discarded. R5's October and November 2024 Medication Administration Record indicated that Spironolactone was administered to R5 every Tuesday, Thursday, and Sunday. R5's Order Summary Report dated 11/14/2024 indicated R5 was admitted in the facility on 10/08/2024, diagnoses of not limited to End Stage Renal Disease and Chronic Systolic (Congestive) Heart Failure, and order for Spironolactone 25mg to be given by mouth in the morning every Tuesday, Thursday, and Sunday with order date of 10/08/2024. Review of facility's policy entitled Medication Storage revised on 8/2017 indicated the following: Policy: The Home shall store all drugs and biologicals in a safe, secure, and orderly manner. No expired or discontinued medications shall be stored with stock, house, routine or PRN (as needed) medications that are readily available for administration. Procedures: 1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 4. The Home shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. House stocks meds (medications) shall be checked for expiration prior to administration and not be administered if expired. Stocks meds shall be stored away from medication carts and treatment carts so as to limit possible medication errors. 5. All expired medications either prescribed or house supply shall be removed immediately upon discovery and placed in the appropriate 'holding' receptacle for pick up and destruction by the DON/Designee.

Based on observation, interview and record review, the facility failed to air dry the blender after using it to puree pork and before pureeing vegetables. This deficient practice has the potential to affect two residents (R11 and R18) receiving a pureed diet in a sample of 12 residents. Findings include: On 11/13/24 at 11:00am, during puree preparation of pork and vegetables, V4 (Dietary Manager) pureed pork, washed the blender, rinsed it out and proceeded to puree vegetables while the blender still contained about 5 units of sanitizer solution in it. V4 did not allow the blender to air dry. V4 was stopped by the surveyor until the blender had completely dried. During an interview on 11/13/24 at 11:15am, V4 stated I did not know I have to let it air dry. Facility policy titled, Cleaning and Sanitizing Food Contact Surfaces: Food contact surfaces must be cleaned and sanitized after each use, or within 4 hours of continuous use The five-step process is adapted for each of these methods: 5. Air-dry before use.

Based on observation, interview and record review, the facility failed to perform appropriate infection control practices for a resident on Enhanced Barrier Precautions for one of three residents (R21) reviewed for infection control in a total sample of 12. Findings include: On 11/13/2024 at 12:35PM during observation, V12 (Certified Nursing Assistant) was observed putting on gloves and grabbing a pack of disposable gown before going into R21's room. R21's room door was observed with a sign that reads Enhanced Barrier Precaution. On 11/13/2024 at 12:40PM during interview with V12 together with V2 (Director of Nursing), V12 stated that she put on the disposable gown inside R21's room. On 11/13/2024 at 12:40PM during interview, V2 stated that all personal protective equipment, including gown, should be donned before going inside the resident's room. On 11/13/2024 at 1:00PM during interview with V12, V12 stated that she went to R21's room to empty R21's urine bag. Review of R21's Order Summary Report dated 11/14/2024 indicated that R21 was admitted in the facility on 11/13/2021 with diagnosis of not limited to obstructive and reflux uropathy, order for enhanced barrier precautions with order date of 04/26/2024, and order for suprapubic catheter with order date of 10/15/2024. Review of R21's care plan last reviewed 10/14/2024 indicated R21 is at risk for contracting multidrug-resistant organisms' r/t (related to) having an indwelling catheter with interventions including Enhanced Barrier Precaution: Due to indwelling catheter, staff will wear gowns and gloves when doing high-contact resident care. Review of facility's policy on Enhanced Barrier Precautions revised 01/19/2024 indicated the following: Purpose: To prevent the spread of infectious diseases transmitted by contact with body substances containing the infectious agent or items contaminated with the body substances containing the infectious agent. Procedure: 1. Enhanced Barrier Precautions apply to residents who have wounds or indwelling medical devices, regardless of multidrug-resistant organism (MDRO) colonization status and infection or colonization with a MDRO. 2. Effective enhanced barrier precautions require the use of gowns and gloves during high-contact resident care activities, designed to reduce transmission of Staphylococcus aureus and MDROs. a. High-contact Resident care activities: vii. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. 4. Supplies should be kept in a cart. Include gloves and gowns, face shield of necessary, and biohazard waste bags (red), biohazard laundry bags (blue) and meltaway bags as needed. A Precaution sign on the door should indicate the type of isolation prior to entering the Resident's room with instructions as to the type of precautionary measures to be taken before entering the room.

2. On 11/14/2024 at 12:00PM during record review with V2 (Director of Nursing), R16 was noted with Consultant Pharmacist Recommendation to Physician printed on 10/06/2024 with no response from the physician or prescriber. On 11/14/2024 at 12:00PM during interview with V2, V2 stated that she talked to the nurse practitioner (NP) regarding R16's consultant pharmacist's recommendation on Pantoprazole. V2 stated that the physician should respond and sign on all consultant pharmacist's recommendation. On 11/15/2024 at 12:25PM during interview with V14 (Pharmacist), V14 stated that the acceptable time for a response on the pharmacist recommendation is 30 days. Review of R16's Consultant Pharmacist Recommendation to Physician printed 10/06/2024 indicated recommendation to physician to consider trial dose reduction of Pantoprazole from 40mg (milligrams) to 20mg. Review of R16's Progress Notes from October to November 2024 did not indicate any communication or response from the physician regarding the consultant pharmacist's recommendation for 10/06/2024. Review of R16's Physician Medical Exam dated 10/24/2024 and signed by NP on 10/26/2024 did not indicate any rationale for continuous use of Pantoprazole. Review of R16's Order Summary Report dated 11/14/2024 indicated admission date of 11/30/2017, diagnoses of not limited to major depressive disorder and gastro-esophageal reflux disease without esophagitis, and order for Pantoprazole 40mg with order date of 03/11/2024. Review of facility's policy entitled Medication Regimen Review dated 3/2017 indicated the following: Procedure: 3. Irregularities identified will be documented on a separate, written report and sent to attending physician, medical director, and director of nursing, listing the resident name, relevant drug, and irregularity the pharmacist has identified. If in the professional judgment of the pharmacy consultant that an irregularity requires urgent action, the pharmacy consultant will immediately report the irregularity to the Director of Nursing and/or Unit Charge Nurse and the attending physician by phone. 5. The attending physician will document in the resident record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician must document rationale as to why the change is not indicated in the resident record. Based on interview and record review, the facility failed to follow up with the physician for a response related to pharmacy recommendations for four residents (R5, R8, R16, and R21) reviewed for unnecessary medications in a sample of 12 residents. Findings include: During record review on 11/14/24 at 11:30am, R5's Consultant Pharmacist Recommendation to Physician dated 11/6/24, reads Please consider changing the dosing time of this resident's Donepezil 5mg from every morning to at bedtime as the medication may cause GI upset and dizziness/fainting which may put residents at risk of fall. During record review on 11/14/24 at 11:30am, R8's Consultant Pharmacist Recommendation to Physician dated 10/6/24 reads; . this resident has been taking Zoloft 50mg every day since 8/2023 without a gradual dose reduction (GDR). Could we attempt a dose reduction at this time to Zoloft 25mg every day to verify this resident is on the lowest possible dose? If not, please indicate response below. During record review on 11/14/24 at 11:30am, R21's Consultant Pharmacist Recommendation to Physician dated 10/7/24 reads; Please consider changing the dosing time of this resident's Donepezil 10mg from every morning to at bedtime as the medication may cause GI upset and dizziness/fainting which may put residents at risk of fall. During an interview on 11/14/24 at 12:00pm, V2 (Director of Nursing) stated that she has not been able to reach the Psychiatric Physician for him to come and carry out the recommendations due to their conflicts in schedule. V2 stated that when she is available, the Psychiatric Physician is not available to come into the facility. Facility policy titled; Medication Regimen Review revised 3/2017 reads. Purpose: To provide a comprehensive accurate and standardized review of each residence medication regimen to ensure safety through the identification, communication, and resolution of irregularities in the medication prescribed to the home and physician there by promoting positive outcomes and minimizing adverse consequences associated with medications in caring for our residents. Facility policy titled; Psychoactive Drugs revised 08/2017 reads. Purpose: 1. To ensure that each resident receives appropriate medication and medication monitoring. 2. To protect the rights of residents from receiving unnecessary drugs. Procedure. 4.Each resident's drug regimen is free of unnecessary drugs and drugs are only administered to treat a specific documented condition. A. The director of nursing is responsible for assuring that each resident is reviewed in accordance with the law by the attending physician to ensure that unnecessary drugs are discontinued.