Based on observation, record review, and interview, the facility failed to provide proper feeding tube (gastrostomy tube) (g-tube) care as per professional standards, related to verification of the g-tube placement not completed prior to medication administration for 1 of 1 resident reviewed for feeding tube care. (Resident 29) Finding includes: During an observation of medication pass on 3/5/25 at 12:24 p.m., RN 1 was observed preparing and administering g-tube medications to Resident 29. RN 1 prepared and crushed carbidopa-levodopa (treatment for Parkinson's disease) 25 milligram-100 milligram 2 tablets and glycopyrrolate (treatment for ulcers) 1 milligram tablet in separate medication pouches and then put them into separate medication cups after they were crushed. She washed her hands, donned a gown and gloves, and entered the resident's room. She mixed each medication with approximately 15 milliliters (ml) of water. She flushed the g-tube with 30 ml of water, milked the tubing as the water was not going down by gravity, and then pushed the plunger of the syringe to get the water to flow. She did not check for placement of the g-tube prior to administering the water flush. RN 1 then poured approximately half of the medication cup containing the carbidopa-levodopa into the g-tube. The crushed medication was not mixed in with the water. She flushed the g-tube with 30 ml of water and then administered the glycopyrrolate. She removed her gown and gloves, performed hand hygiene, and exited the room to retrieve a spoon to mix the remaining medication, leaving the medication on the resident's bedside table. She returned and administered the rest of the medication, and flushed the g-tube with water. During an interview at the time, RN 1 indicated that the policy was to check for placement once a shift, so she had checked before the morning medication pass and did not have to do check for placement again for the afternoon medication pass. During an interview on 3/7/25 at 12:15 p.m., the Director of Nursing indicated the nursing staff were to check for placement prior to every medication administration. A facility policy titled, Administering Gastric/Jejunostomy Tube Medications, and noted as current, indicated, .4. Before administering medications observe or review: e. vital signs and bowel sounds as indicated; and f. Residual volume of stomach contents .18. Perform any pre-administration assessments 23. There are multiple methods for verifying placement of the tube .a. Checking gastric residual volume (GRV) .c. pH of GRV .e. Observing changes in external length of tubing .g. For all gastric tubes, pull back gently on the syringe to aspirate stomach content .26. Administer medication by gravity flow . 3.1-44(a)(2)

Based on observation, record review and interview, the facility failed to identify or act on an irregularity in a resident's medication regimen related to a recommended lab not being completed and an accepted recommendation with no follow up for 2 of 5 residents reviewed for unnecessary medications. (Residents 16 and 8) Findings include: 1. Resident 16's record was reviewed on 3/5/25 at 8:45 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, major depression and anemia. The Quarterly Minimum Data Set assessment, dated 1/9/25, indicated the resident had severe cognitive deficits and required substantial assistance for toileting and transfers. A Pharmacy Recommendation, dated 11/19/24, indicated the resident had an order for an iron supplement for over six months and to consider checking serum iron, ferritin, TIBC and percent transferrin saturation (blood tests to determine iron iron levels) to determine if there was a continued need for supplementation. The recommendation was denied per PCP (primary care physician). There was no documentation for why the recommendation was denied. During an interview on 3/6/25 at 8:57 a.m., the Director of Nursing (DON) indicated the physician was aware of the pharmacy recommendation, but didn't want to put the resident under the stress of a blood draw for only one lab. The DON indicated the rationale had not been documented. 2. Resident 8's record was reviewed on 3/6/25 at 11:18 a.m. Diagnoses included, but were not limited to, situational depression adjustment disorder with depressed mood, cerebral infarction, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 1/17/25, indicated the resident was moderately cognitively impaired for daily decision making. She required substantial staff assistance for activities of daily living (ADL) tasks including toileting, showering, and transfers. She received antidepressants, anticoagulants, diuretics, and opioid medications during the 7-day look-back period. The current March 2025 Physician Order Summary indicated the resident received 100 milligrams sertraline (antidepressant medication) daily. A Care Plan, dated 2/7/24, indicated the resident received a psychotropic drug and was at risk for developing adverse effects from the use of the antidepressant medication. Interventions included, but were not limited to, administer medication as ordered and attempt gradual dose reduction (GDR) in two separate quarters during the first year the resident received the medication. A Pharmacist Drug Regimen Review, dated 7/22/24, indicated a recommendation for the GDR of sertraline 75 milligrams (mg) to a dose of 50 mg per day. The recommendation was denied with a rationale that there was a clinical contraindication because the resident was on hospice care. A Pharmacist Drug Regimen Review, dated 1/16/25, indicated to consider a trial dose reduction of sertraline 75 mg. The recommendation was marked as accepted. The recommendation to GDR the sertraline was not implemented. During an interview on 3/7/25 at 12:05 p.m., the Director of Nursing indicated they wanted to try the GDR. The resident had been doing well lately and getting up and going to the dining room more often. The facility staff had not met with the family yet to make sure that they were in agreement with the plan of care. A care plan meeting had been set up in February, however the family did not attend. She indicated the hospice company was not in agreement for the GDR, but was unsure why the recommendation was marked as accepted. 3.1-25(i)

Based on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to lack of non-pharmacological interventions used prior to giving anti-anxiety medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 252) Finding includes: Resident 252's record was reviewed on 3/4/25 at 3:40 p.m. Diagnoses included, but were not limited to, Parkinson's disease, bipolar disorder, and anxiety disorder. The admission Minimum Data Set (MDS) assessment, dated 3/2/25, was still in progress. A Care Plan, dated 2/25/25, indicated the resident was at risk for adverse consequences related to receiving anxiolytic medications. Interventions included, but were not limited to, attempt non-pharmacological interventions prior to administering as needed (PRN) anxiolytics and administer per orders. The current March 2025 Physician Order Summary indicated clonazepam (anxiolytic) 2 milligrams 1 tablet as needed for anxiety. The February and March 2025 Medication Administration Record (MAR) indicated the resident received the PRN clonazepam on 2/26 at 8:08 p.m., 2/27 at 6:41 p.m., 2/28 at 8:05 p.m., 3/2 at 7:10 p.m., 3/3 at 8:15 p.m., 3/4 at 7:45 p.m., and 3/5/25 at 1:42 a.m. The record lacked documentation of non-pharmacological interventions attempted prior to administering the PRN doses of clonazepam. During an interview on 3/7/25 at 11:53 a.m. the Director of Nursing indicated she had no further information to provide. 3.1-48(b)(2)

Based on observation and interview, the facility failed to ensure a medication was kept in a locked medication cart at all times for 1 of 8 residents observed during medication administration. (Resident 29) Finding includes: During an observation of medication pass on 3/5/25 at 12:24 p.m., RN 1 was observed preparing and administering g-tube medications to Resident 29. RN 1 prepared and crushed carbidopa-levodopa (treatment for Parkinson's disease) 25 milligram-100 milligram 2 tablets and glycopyrrolate (treatment for ulcers) 1 milligram tablet in separate medication pouches and then put them into separate medication cups after they were crushed. She washed her hands, donned a gown and gloves, and entered the residents room. She mixed each medication with approximately 15 milliliters (ml) of water. She flushed the g-tube with 30 mls of water, milked the tubing as the water was not going down by gravity, and then pushed the plunger of the syringe to get the water to flow. She did not check for placement of the g-tube prior to administering the water flush. RN 1 then poured approximately half of the medication cup containing the carbidopa-levodopa into the g-tube. The crushed medication was not mixed in with the water. She flushed the g-tube with 30 ml of water and then administered the glycopyrrolate. She removed her gown and gloves, performed hand hygiene, and exited the room to retrieve a spoon to mix the remaining medication, leaving the medication on the resident's bedside table. She returned and administered the rest of the medication, and flushed the g-tube with water. During an interview at the time, RN 1 indicated she should not have left the medication at the bedside. During an interview on 3/7/25 at 12:15 p.m., the Director of Nursing indicated the nurse should not have left the medication at the bedside. 3.1-25(m)

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to a build up of food debris and grease on the sides of the oven, deep fryer, floor between the oven and deep fryer, and in the bottom front of a closed warming food cart. The facility also failed to have boxes of food not stored up to the ceiling in the walk in freezer. This had the potential to affect 52 of 52 residents who resided in the facility and received food from the kitchen. (Main Kitchen) Findings include: During the Initial Kitchen Sanitation Tour on 3/3/25 at 10:53 a.m., with the Director of Food Services, the following was observed: a. There was a build up of food debris and grease on the sides of the oven. b. There was a build up of food debris and grease on the sides of the deep fryer. c. There was a build up of food debris and grease on the floor between the oven and the deep fryer. d. There was a build up of food debris and grease in the bottom front of a closed warming food cart. e. There were multiple boxes of food stored up to the ceiling in the walk in freezer. During an interview on the tour, the Director of Food Services indicated the boxes should not be stored up to the ceiling in the walk in freezer and the appliances and floors should be cleaned more often and not have a build up of food and grease. An Aides Cleaning List, provided by the Executive Director on 3/10/25, indicated the kitchen staff were responsible to sweep/mop the kitchen floors daily and clean utility carts weekly. The Executive Director could not provide any facility policies for the above concerns. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained, related to not placing a dignity bag over a foley (urinary) catheter drainage bag, for 1 of 1 residents reviewed for urinary catheters. (Resident 40) Finding includes: On 2/7/24 at 10:55 a.m., Resident 40 was observed in his room in bed. His catheter drainage bag was observed uncovered and draining yellow urine by gravity. On 2/7/24 at 11:26 a.m., Resident 40's catheter drainage bag was observed uncovered and draining yellow urine by gravity. Resident 40's record was reviewed on 2/7/24 at 10:28 a.m. Diagnoses included, but were not limited to, Parkinson's disease, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side, and obstructive uropathy (obstruction causing a blockage of the flow of urine.) The admission Minimum Data Set (MDS) assessment, dated 1/18/24, indicated the resident was cognitively intact for daily decision making. He had an indwelling urinary catheter. A Physician's Order, dated 1/11/24, indicated indwelling urinary catheter size 16 french with a 5 cc balloon. A Care Plan, dated 1/21/24, indicated the resident used a foley catheter. Interventions included, but were not limited to, maintain a closed system with urinary bag below the resident's bladder and cover. During an interview on 2/7/24 at 11:26 a.m., RN 1 indicated the catheter bag should have had a dignity bag over it. During an interview on 2/8/24 at 2:52 p.m., the Director of Nursing (DON) indicated the catheter bag should have been covered with a dignity bag. 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for self-administration of medication,s and an assessment to self-administer their own medications, for 2 of 2 residents reviewed for self-administration of medication. (Residents 13 and 19) Findings include: 1. On 2/5/24 at 11:11 a.m., a bottle of Tylenol 325 milligram (mg) tablets was noted to be on Resident 13's bedside table. On 2/5/24 at 2:51 p.m., a bottle of Tylenol 325 mg tablets was noted to be on Resident 13's bedside table. The record for Resident 13 was reviewed on 2/7/24 at 12:37 p.m. Diagnoses included, but were not limited to, vascular dementia without behavioral disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 1/5/24, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 5/30/23, indicated acetaminophen tablet 325 milligrams, 2 tablets for fever/pain every 4 hours as needed. There were no orders for self-administration or a self-administration assessment completed for the medication. During an interview on 2/7/24 at 11:23 a.m., QMA 1 indicated the resident came from assisted living, and it was a constant battle to keep her medications in the drawer. During an interview on 2/7/24 at 11:37 a.m., RN 1 indicated the resident did have a bottle of Tylenol sitting on her bedside table that morning. She did not have orders to self-administer the medication. During an interview on 2/8/23 at 2:55 p.m., the Administrator indicated she was going to provide the family education on medications at the bedside, as they continuously visited and she believed they had brought the bottle of Tylenol. 2. On 2/5/24 at 11:36 a.m., an albuterol inhaler was observed on the Resident 19's bedside table. The resident indicated she had been taking it herself as needed. On 2/5/24 at 12:09 p.m., an albuterol inhaler was observed on Resident 19's bedside table. The record for Resident 19 was reviewed on 2/7/24 at 2:01 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and chronic bronchitis. The Quarterly Minimum Data Set (MDS) assessment, dated 1/25/24, indicated the resident was cognitively intact for daily decision making. She had shortness of breath with exertion and when lying flat. She also used oxygen therapy. A Physician's Order, dated 11/20/23, indicated albuterol sulfate aerosol inhaler 90 micrograms/actuation, two puffs as needed every four hours, for shortness of breath and wheezing. May keep at bedside. The Self-Administration of Medication Assessment, dated 8/26/23 at 2:31 a.m., indicated the resident did not want to self-administer medications. The facility would set-up medications for the resident. During an interview on 2/7/24 at 11:39 a.m., RN 1 indicated the resident used to take her albuterol inhaler with her when she went on facility outings, and recently started self-administering while in the facility. During an interview on 2/8/24 at 2:51 p.m., the Director of Nursing indicated the resident had a self-administration assessment completed in 2022 which indicated she was going to self-administer the medication, however, the most recent self-administration assessment did not indicate she was going to self-administer any medications. 3.1-11(a)

Based on record review and interview, the facility failed to ensure skin odors and discolorations were assessed, monitored, and treated, for 1 of 3 residents reviewed for skin conditions (non-pressure related). (Resident 19) Finding includes: During an interview on 2/5/24 at 11:42 a.m., Resident 19 indicated she had an area of skin underneath her breasts that had a foul odor for a while and was itchy. She was unable to see if it was reddened, and indicated the facility staff were not treating the area. She was observed scratching the area and a foul odor was noted when the resident lifted her breast. The record for Resident 19 was reviewed on 2/7/24 at 2:01 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and chronic bronchitis. The Quarterly Minimum Data Set (MDS) assessment, dated 1/25/24, indicated the resident was cognitively intact for daily decision making. She had no pressure sores or skin conditions. There were no orders for a treatment or any documentation in the record related to the skin area under the breasts. The February 2024 Physician's Order Summary (POS), indicated a weekly skin assessment every Thursday. The Weekly Skin Assessment completed for February 2024, on the Treatment Administration Record, indicated the resident had no skin impairments noted on 2/1/24 or 2/8/24. During an interview on 2/8/24 at 3:50 p.m., the Director of Nursing indicated they were unaware of the skin condition, but she had the wound nurse assess the area. There was a reddened area of skin under her breasts and they were getting orders to treat the area with a powder. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to assess and monitor wounds that required treatment changes and failed to provide treatment as ordered during wound care for 1 of 5 residents reviewed for pressure ulcers. (Resident 12) Findings include: 1. On 1/24/23 at 10:09 a.m., Resident 12 was observed seated in her room in a recliner. She indicated she had sores on her bottom that were uncomfortable and the nurses were doing treatments to them. On 1/27/23 at 8:45 a.m., the resident's wound care was observed with LPN 2. There were two open areas on the right buttocks, each approximately 1.5 centimeter (cm) x 1 cm, one on the left buttock approximately 2 cm x 1 cm and the coccyx approximately 0.5 cm x 0.5 cm. The resident's record was reviewed on 1/24/23 at 3:00 p.m. The resident had been hospitalized and readmitted on [DATE]. Diagnoses included, but were not limited to, C.diff. (clostridium difficile, an infectious intestinal disease that causes loose stools) and sepsis. The admission Minimum Data Set assessment, dated 1/11/23, indicated the resident was admitted with 2 unstageable pressure ulcers. A Progress Note, dated 1/7/23, indicated resident had been readmitted from hospital with a pressure ulcer to left buttock measuring 4 centimeters (cm) x 2 cm, and right buttock 6 cm x 3 cm. A Progress Note, dated 1/12/23, was entered by the Wound Nurse. The right buttock measured 3 cm x 1.5 cm and the left buttock was 1.5 x 1 cm. Because the wounds were not on a bony prominence, and on the fatty portion of the buttock and the resident was having frequent loose stools, the wounds would not be classified as pressure, but as MASD (moisture-associated skin damage). A Progress Note, dated 1/15/23, indicated wounds to fatty portion of buttocks remained. Treatment in place with frequent dressing changes due to frequent loose stools. There was a new open area to the resident's coccyx. There were no measurements or assessment of the new area to the coccyx. There were no additional measurements of the right or left buttocks in progress notes. A Physician's Order, dated 1/7/23, indicated to apply Medihoney and foam dressing to right and left buttocks every three days. A Physician's Order, dated 1/14/23, indicated to cleanse right and left buttock with would cleanser or normal saline, apply skin prep around the wound, apply calcium alginate to wound bed and cover with foam dressing every three days and as needed. A Physician's Order, dated 1/15/23, for coccyx was to cleanse with wound wash or normal saline, apply skin prep around wound and apply foam dressing every three days A Physician's Order, dated 1/25/23, indicated to to cleanse coccyx, right and left buttock with wound wash or normal saline, apply skin prep around wounds, apply collagen to wound beds and cover with foam dressing every three days and as needed. There was no indication in the progress notes as to why the treatments had been changed, or if the wounds had improved or worsened. Interview with Nurse Consultant 1 on 1/26/23 at 12:57 p.m., indicated if a wound wasn't pressure it did not require it to be monitored in wound rounds or measured weekly. It would be monitored by nursing staff and the Wound Nurse would assess it weekly. Consistent nursing staffing was planned to monitor improvement or worsening. The wounds were being considered moisture associated skin damage (MASD). Interview with LPN 2 on 1/27/23 at 9:15 a.m., indicated she was unsure if there had been two open areas on the resident's right buttock before, one of the areas might be new, it had been about a week since she had last observed the wounds. She indicated the resident no longer had C.diff or loose stools. 2. On 1/27/23 at 8:45 a.m., Resident 12's wound care was observed with LPN 2. There were two open areas on the right buttocks, each approximately 1.5 cm x 1 cm, one on the left buttock approximately 2 cm x 1 cm and the coccyx approximately 0.5 cm x 0.5 cm. The LPN cleansed the area with wound wash and patted gently with gauze. She then applied a piece of collagen to the open area on the left buttock. She then covered the entire area with a large foam dressing. A Physician's Order, dated 1/25/23, indicated to to cleanse coccyx, right and left buttock with wound wash or normal saline, apply skin prep around wounds, apply collagen to all wound beds and cover with foam dressing every three days and as needed. Interview with the LPN, on 1/27/23 at 9:15 a.m., indicated she was not aware she had done the treatment incorrectly and she would re-do it. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a Physician Order was in place for a resident receiving oxygen for 1 of 1 residents reviewed for respiratory care. (Resident 12) Finding includes: On 1/24/23 at 10:09 a.m., Resident 12 was observed seated in her room. She had a nasal cannula in place and oxygen was flowing at 2 liters per minute (lpm) via oxygen concentrator. The resident's record was reviewed on 1/24/23 at 3:00 p.m. Diagnoses included, but were not limited to, acute respiratory failure and sepsis. There was no Physician's Order for oxygen. A Respiratory Care Plan, dated 1/17/23, indicated the resident had the potential for shortness of breath when laying flat due to respiratory failure. Interview with LPN 1 on 1/25/23 at 9:45 a.m., indicated she was unable to locate a Physician's Order for oxygen and would contact the physician to clarify. 3.1-37(a)(6)