Based on observation, interview and record review, the facility failed to ensure a resident had been assessed for self-administration of medications before leaving medications unattended with a resident for 1 of 1 resident randomly reviewed for self-administration of medications. (Resident 66) Finding includes: During a medication administration observation with RN 2, on 05/15/23 at 8:44 a.m., the nurse was observed to prepared nine medications for administration and set the medications on the bedside table in front of Resident 66. The resident's spouse, who was present with the resident, began to sort the pills into small groups. At 8:43 a.m., RN 2 indicated she was going to get more ice water for the resident and left the room leaving all the medications unattended with the resident and his spouse. The nurse returned to the room at 8:44 a.m. The resident had not taken the medications while the nurse was absent from the room. At 8:56 a.m., the medications had not been taken, while the nurse was present. RN 2 then exited the room leaving the medications not administered and unattended on the bedside table with the resident and his spouse. The following medications were observed to be prepared by RN 2 and left, unattended, with the resident and his spouse: 1. Dantrolene (a muscle relaxant) 25 mg (milligrams) 2. Nystatin oral (an antifungal medication) 500,000 units 3. cholecalciferol (vitamin D) 2000 units 4. gabapentin (an anticonvulsant/nerve pain medication) 100 mg 5. amoxicillin/clavulanate potassium (a penicillin antibiotic) 875 mg/125 mg 6. atorvastatin (a cholesterol medication) 40 mg 7. glipizide (anti-diabetic medication) 10 mg 8. aspirin 81 mg 9. ergocalciferol (used to treat hypoparathyroidism) 50,000 units The record for Resident 66 was reviewed on 05/16/23 at 12:15 p.m. Diagnoses included, but were not limited to, stroke, hypertension, and pneumonia. There was no assessment or orders for self-administration of medications in the record at the time of the observation. During an interview, on 05/16/23 at 8:56 a.m., RN 2 indicated Resident 66 did not have an order to self-administer medications. During an interview, on 05/18/23 at 12:11 p.m., the Administrator indicated there had not been an assessment to self-administer medications or an order prior to the nurse leaving the medications at bedside. A current policy, titled Medication Management in the ECU (extended care facility), undated and received from the Administrator on 05/16/23 at 10:36 a.m., indicated .Self-Medication is when the resident has been deemed appropriate to self-administer medications as approved by the physician per physician order 3.1-11(a)

Based on observation, interview and record review, the facility failed to assess and document skin issues for a resident on an anticoagulant (medication used to keep blood cells from forming clots in the blood stream) for 1 of 1 resident reviewed for non-pressure skin concerns. (Resident 69) Finding includes: During an observation and interview, on 05/15/23 at 11:49 a.m., Resident 69 was observed in her room wearing a short sleeve hospital gown. Her arms were visible and noted to have multiple purple and red bruising on both arms, but more heavily on her left arm. Resident 69 indicated she was taking an anticoagulant and believed it may have occurred from intravenous therapy (IV), but she had not had an IV for a while. During an observation, on 05/16/23 at 8:29 a.m., Resident 69 was observed in her room wearing a short sleeve hospital gown. Multiple red and purple bruising was easily observed on both arms. The record for Resident 69 was reviewed on 05/16/23 at 12:06 p.m. Diagnoses included, but were not limited to, coronary heart disease, pneumonia, and deep vein thrombosis (clotting in the vein). Skin assessments were completed on admission and weekly thereafter. There was no documentation to show the resident had admitted with the bruising or had acquired the bruising during her stay. There was no assessment or monitoring of the bruising. A physician's order, initiated on 05/01/23, indicated to give Apixaban (an anticoagulant) 5 milligrams (mg) twice a day. A physician's order, initiated on 05/02/23, indicated to give aspirin (helps keep platelets from sticking together and causing clots in the blood steam) 81 mg daily. A physician's order, initiated on 05/02/23, indicated to give clopidogrel (a medication used to prevent stroke) 75 mg daily. A care plan, initiated on 05/02/23, indicated the resident had a risk for bleeding related to anticoagulant therapy. The daily goal was no signs or symptoms of bleeding. One intervention was to observe for increased bruising. During an interview, on 05/16/23 at 8:35 a.m., RN 2 indicated the bruising was noted and was being monitored. During an interview, on 05/18/23 at 11:33 a.m., the Administrator indicated the bruising should have been documented to show if the bruising had been present on admission, and it was not documented. The skin issue should have been documented and followed/monitored weekly until it was healed. A current policy, titled ECU Charting Resident Assessment Guidelines, dated as last reviewed 12/2020 and received from the Administrator on 05/18/23 at 12:40 p.m., indicated .shall maintain clinical records on each resident .that are complete, accurately documented .nursing documentation .with ongoing assessment information necessary to .provide appropriate care and services for each resident .Documentation of observations should be specific .Descriptive terms might include .Bruises .Color .Petechiae-ecchymosis (red or purple spots caused by bleeding into the skin) 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with professional standards in 1 of 1 medication cart randomly observed during medication administration. Finding includes: During the medication administration observation with RN 2, on 05/15/23 at 8:44 a.m., the nurse was observed to prepared nine medications for administration and set the medications on the bedside table in front of Resident 66. At 8:43 a.m., RN 2 indicated she was going to get more ice water for the resident and left the room. The medication cart, parked in the room, was noted to have the top right drawer open. The cart was not closed and locked, and it was left unattended while RN 2 was out of the room. The nurse returned to the room at 8:44 a.m. During an interview, on 05/16/23 at 8:56 a.m., RN 2 indicated she should not have left the cart open, unlocked, and unattended. During an interview, on 05/16/23 at 9:06 a.m., the Administrator indicated the medication cart would automatically lock, but not when the drawer was left open. A current policy, titled Medication Security, last revised in 06/2022 and received from the Administrator on 05/16/23 at 10:36 a.m., indicated .Medications .are to be stored in a locked area (a drawer, room or cart) or stored so that unauthorized individuals (such as patients, visitors and staff) do not have access to them .Medications are not to be left in the patient's room unattended 3.1-25(m)

Based on observation, interview and record review, the facility failed to ensure freezer items were not left open to air, had open dates and were labeled, failed to ensure refrigerator items were not left open to air and were dated when opened, failed to ensure measuring cups or scoops were not left stored in flour, failed to ensure dry goods in the pantry were not left open to air and dated when opened, and failed to put received by dates on bulk can goods to ensure the first in, first out rule was adhered to when using the items. This deficient practice had the potential to affect 8 of 8 residents residing in the ECU (extended care facility). Findings include: During a walk-through of the kitchen, on 05/16/23 beginning at 9:46 a.m., with [NAME] 3 in attendance, the following observations were made: 1. In the freezer, a container of chicken tenders was found opened but not labeled and without an open date. A ten (10) pound box of cod was found open to freezer air and without an open date. An 11.2-pound box of Philly beef was found open to freezer air and without an open date. A box with four (4) frozen eclairs was found open to freezer air and without an open date. During an interview, on 05/16/23 at 10:04 a.m., [NAME] 3 indicated all items needed to be closed and labeled with the date opened in all refrigerators and freezers. 2. A 50-pound box of rice was found open to air in the pantry and missing an open date. In the pantry, on the rack for bulk item canned goods, there were 11 cans of diced tomatoes, six (6) cans of crushed tomatoes, four (4) cans of olives, five (5) cans of apple butter, two (2) cans of diced peaches, two (2) cans of mandarin oranges, three (3) cans of diced pears, three (3) cans of tomato sauce, six (6) cans of tomato paste, two (2) cans of refried beans, one (1) can of pineapple, three (3) cans of chocolate pudding, five (5) cans of tomato puree, 10 cans of kidney beans, one (1) can of sweet potatoes, six (6) cans of black beans, one (1) can of beets, four (4) cans of pumpkin, four (4) cans of green beans, and two (2) cans of sliced peaches. None of the cans had a received by date. During an interview, on 05/16/23 at 10:09 a.m., [NAME] 3 indicated the canned goods are used by the first in-first out rule (FIFO), and there should have been dates on the cans to show when they came into the facility. 3. In the reach-in (cooler) number 4, a 1/2 pint of chocolate milk and a 1/2 pint of white milk were found open without an open date. During an interview, on 05/16/23 at 10:18 a.m., [NAME] 3 indicated there should have been an open date on the containers. 4. In the bulk flour storage bin, two (2) measuring cups were found in the flour. During an interview, on 05/16/23 at 10:19 a.m., [NAME] 3 indicated the measuring cups should not have been left stored in the flour. 5. In the cook reach-in cooler, an open gallon of milk, with the seal broken, was found without an open date. There was also a 5-pound bag of shredded cheese found open to air and without an open date. 6. In the cafe cooler, a 5-pound bag of shredded cheese, with the seal broken, was found without an open date and a small rectangular metal container of yellow cheese slices was found open to air and without an open date. A current policy, titled Sanitation-Standards For Food Storage, dated as last reviewed 08/2022 and received from the Administrator on 05/16/23 at 12:59 p.m., indicated, .Refrigerator Storage .Food is stored to protect it from contamination .all packages, containers are covered .All ready to eat refrigerated foods are labeled with the date or day by which food should be consumed, sold or discarded .All foods taken out of original packaging shall be placed inside a sealed zip-lock bag or container that has a tight fitting lid, and labeled to include the open date and date to discard with employee initials on the label .Freezer Storage .all food is stored to protect if from contamination .all packages, containers are covered and or sealed to prevent foods from becoming freezer burnt .Dry Storage .follows the FIFO principal .all cans & packages of foods taken out the original cases are dated with the month and year they are placed on the shelf .Working containers holding dry food or ingredients that are removed from their original packages are identified with common name of the food & discard dates 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician and monitor blood pressure readings timely for a resident with an elevated blood pressure and a history of a cerebral vascular accident for 1 of 1 resident reviewed for a change in condition. (Resident 59) Finding includes: The record for Resident 59 was reviewed on 04/29/22 at 8:56 a.m. Diagnoses included, but were not limited to, cerebral vascular accident (stroke), hypertension and chest pain. An admitting nurses note, dated 04/22/22 at 5:25 p.m., indicated the resident was admitted from the hospital after a left knee replacement. On 04/22/22 at 6:00 p.m., the resident's blood pressure was documented as 192/70. A nurse's note, dated 04/22/22 at 8:15 p.m., indicated the resident had an elevated blood pressure and the attending physician was called. The nurse left a message regarding the elevated blood pressure and requested the MD to return the call. The resident's blood pressure documented at that time was 202/76. On 04/22/22 at 9:00 p.m., the resident's blood pressure was documented as 202/76. It also indicated the resident was given pain medication and the MD was notified. A nurses note, dated 04/22/22 at 11:38 p.m., indicated the resident complained of pain in his chest and left arm. His blood pressure at that time was 146/96 with a heart rate of 156, he stated he was not feeling well. The nurse called the physician at that time and received an order to send the resident to the emergency room for evaluation and treatment. There was not any documentation the resident's blood pressure was reassessed from 6:00 p.m. to 8:15 p.m., or the physician returned the call after the nurse left a message at 8:15 p.m. The physician was not made aware until 9:00 p.m., when another nurse administered pain medication to the resident and she notified him. There was also not any documentation the resident's blood pressure was reassessed, after administrating the pain medication, from 9:00 p.m. to 11:38 p.m. The hospital Discharge summary, dated [DATE], indicated the resident recently had a total knee arthroplasty and was transferred to the care facility where he developed chest pain. His heart rate was noted to be in the 160s and he was sent to the ER. There he was found to have an elevated troponin level (a blood level used to indicated damage to the heart muscle, the greater the level of troponin in the blood the greater the damage to the heart muscle) and tachycardia (elevated heart rate). During an interview, on 4/22/22 at 3:20 p.m., the Director of Nursing (DON) indicated she could not provide documentation the physician was made aware of the resident's elevated blood pressure at 6:00 p.m., or returned the phone call from the message the nurse left at 8:15 p.m. She also indicated the nurse should have made the physician aware of the elevated blood pressure at 6:00 p.m., and reassessed the resident's blood pressure after he was given pain medication. A current facility policy, titled Notification of changes in resident condition in ECU [Extended Care Unit], dated 11/2021 and provided by the Director of Nursing on 04/29/22 at 2:30 p.m., indicated .Residents must be assessed accurately for changes in condition .The Extended Care Personnel must immediately notify .the resident's physician .when there is a change in condition. 3.1-37(a)

Based on interview and record review, the facility failed to maintain medical records which were complete and accurate as indicated by missing documentation of a physician's order to release a body to the funeral home of choice for 1 of 1 resident reviewed for death. (Resident 9) Finding includes: The record for Resident 9 was reviewed on 04/29/22 at 2:23 p.m. Diagnoses included, but were not limited to, acute cerebrovascular accident (stroke) and aspiration pneumonia (food or liquids are breathed into the lungs). A nurses note, dated 03/01/22 at 5:32 a.m., indicated Resident 9 had passed away. There was not a physician's order to release the body to the funeral home found in the resident's medical record. During an interview, on 04/29/22 at 3:11 p.m., the Director of Nursing indicated she could not provide a physician's order to release the body from the facility to a funeral home and there should have been one. During an interview, on 04/29/2022 at 3:37 p.m., the Director of Nursing indicated there was not a policy and procedure in place to guide staff regarding the release of an expired resident's body. 3.1-50(a)(1) 3.1-50(a)(2)