**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 44 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO), Resident (R)9's and R15's facility-initiated discharge to the hospital. This placed the residents at risk for impaired rights. Findings included: -R9's Electronic Health Record (EHR) revealed diagnoses of included healing fracture neck of the left femur (thigh bone,) dementia (a progressive mental disorder characterized by failing memory and confusion) osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk,) and muscle weakness. R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R9 required extensive assistance of two staff with bed mobility and transfers. The MDS further documented the resident had no falls since reentry on 01/09/25. The Activities of Daily Living Care Area Assessment (CAA), dated 01/16/25, documented the resident required one on one assistance with transfers due to recent left hip fracture repair. The CAA documented the resident was dependent on staff for all weight bearing Activities of Daily Living (ADLs) and for dressing and personal cares. The Care Plan, dated 01/29/25, documented the resident was a high fall risk due to history of a fall with a fracture, confined to her chair, required assistance with incontinence, and was not able to stand without physical help. The care plan documented staff placed a sign on the wall in her room to remind her to call for assistance and staff would constantly remind her to call for help. The care plan documented staff would assist the resident with ambulation and transfers and would keep her environment free of clutter. A Nurse's Note on 01/02/25 at 02:52 PM, documented the resident hollered for help and upon entering the room the nurse observed R9 on her left side, in a semi sitting position,-up against the end table and in between the recliner and the bathroom entry. Nurse Aide N placed a pillow behind the resident's head and removed her shoes at the resident's request. The resident complained of pain in the position she was in. The nurse and aide repositioned the resident so her back was resting against the recliner. Observation revealed her walker and wheelchair were not in reach or in use at the time of the fall. The resident stated she was trying to get a calendar that had fallen on the floor, and she fell. The resident stated she hit her head and her leg hurt. The resident stated she wanted to go to the hospital to have her leg checked out. Administrative Nurse D. documented the resident had slight shortening of the left leg with rotation observed. The resident was transferred to the hospital at 02:15 PM. On 01/09/25 at 05:07 PM, Nurse's Notes documented the resident returned from the hospital at 04:30 PM per facility van and accompanied by staff. The notes documented the resident had been hospitalized for closed left hip fracture with multiple left rib fractures. The resident had a surgery Open Reduction and Internal Fixation (ORIF) nailing of the left hip while hospitalized . R9's clinical record lacked documentation staff notified the LTCO of the resident's discharge from the facility. On 03/25/25 at 02:45 PM, Administrative Staff A stated she would send the discharges to the Ombudsman at the first of the month from the prior month discharges. Administrative Staff A reviewed the list of residents she had provided to the Ombudsman's office on 02/03/25 and verified R9. Administrative Staff A verifed R9 went to the hospital on [DATE] and she would ensure the notifed the LTCO. The facility's, undated, Transfer or Discharge, Facility -Initiated, stated the under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of the individuals in the facility would be endangered due to the clinical or behavioral status of the resident. b. The resident's health improves sufficiently to allow a more immediate transfer or discharge. c. An immediate transfer or discharge is required by the resident's urgent medical needs, or d. A resident has not resided in the facility for 30 days. A notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) Ombudsman when practicable (in a monthly list of residents that include all notice content requirements.) - R15's Electronic Medical Record (EMR) documented R15 had a diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and heart failure. R15's Modification of Quarterly Minimum Data Set (MDS), 03/12/25, documented R15 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. R15's Care Plan, revised 03/12/25, documented R15 had shortness of breath (SOB) retaining to hypoxia, and instructed staff to elevate the head of R15's bed 45 degrees as R15 would allow. The plan instructed staff to encourage R15 to clear own secretions with effective coughing, if R15 unable to do suction as needed (PRN). The Progress Note, dated 12/1/2024 at 09:32 PM, documented R15 was admitted to the hospital. The Progress note, dated 02/5/2025 at 06:59 PM, documented R15 was admitted to the hospital. Review of R15's clinical record lacked evidence the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) was notified of R15's discharge on the above dates. 03/25/25 at 03:03 PM, R15 sat in a chair in the dining room at an activity, no signs or symptoms of shortness of air. 03/27/25 at 10:00 AM, Administrative Staff A stated she was responsible for notifying the LTCO when residents were transferred to the hospital. Administrative Staff A verified the ombudsman had not been notified when the resident went to hospital on [DATE] and 02/05/25 and stated she must have printed the wrong form. The facility's Transfer or Discharge, Facility Imitated Policy, undated, documented when residents who are sent emergently to an acute care setting, these scenarios are considered facility initiated transfers. notice of transfer are provided to the resident or representative and LTCO when practicable(in a monthly list of residents that included all notice content requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 44 residents. The sample included 15 residents with one reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to initiate effective interventions to prevent the development of a left heel, facility acquired, unstageable pressure ulcer (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus,) for Resident (R) 9. Findings included: - R9 's diagnoses included healing fracture neck of the left femur (thigh bone,) dementia (a progressive mental disorder characterized by failing memory and confusion) osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk,) and muscle weakness. R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented required extensive assistance of two staff with bed mobility and transfers. The MDS further documented the resident had one unstageable pressure ulcer that was not present on admission. The Pressure Ulcer Care Area Assessment (CAA), dated 01/16/25, documented the resident was a moderate risk for pressure ulcers due to her skin is often moist, being chairfast, mobility limitations and problem with friction and shearing due to moderate to maximum assistance. The CAA documented the resident required one on one assistance with transfers due to recent left hip fracture repair. The CAA documented the resident was dependent on staff for all weight bearing Activities of Daily Living (ADLs) and for dressing and personal cares. The Braden Scale Assessment for predicting pressure ulcer risk, dated 12/26/24 documented a score of 16.0 indicating the resident was at risk. The Pressure Ulcer Care Plan, dated 01/09/25, documented the resident was at moderate risk for pressure ulcers due to skin is often moist, being chair fast, mobility limitations and problems with frictions and shearing due to moderate to maximum assistance with movement. The care plan directed the staff to complete a weekly skin assessment and report any skin concerns to the wound nurse and physician. The care plan directed the staff to provide a pressure redistribution mattress in the bed and a pressure relief cushion in her recliner. Interventions would be adjusted according to R9's needs. The Physician Order, dated 01/09/25 directed the staff to apply a pressure redistribution mattress to bed, and a pressure relieving cushion in her recliner and wheelchair. The 02/15/25 at 06:53 AM, Nurse's Notes, documented the aide reported a new skin impairment on the left heel. The nurse assessment documented the area measured 8.0 centimeter (cm) by 5.0 cm across a boney prominence of the heel. The staff were to add heel protector boots while the resident was in bed and recheck history of interventions. The staff are presently off-loading the heels at the time of impairment discovery, and staff would monitor the left heel area daily for eschar changes and notify the nurse and primary care physician if any changes were noted. The Physician Order, dated 02/16/25, documented to monitor the left heel area daily, do not apply a dressing to the area. The staff would notify the wound nurse and the primary care physician if any changes occur, or sign and symptoms of infection are present. The Weekly Pressure Injury Skin Report, dated 02/16/25, documented R9 had an area on her left heel, measuring 5.0 centimeter (cm) by 8.0 cm, no tunneling, with thick eschar (dead tissue), hard leathery black exudate (a fluid that leaks out of body vessels and tissues.) The report documented the suspected cause was from R9's recliner. The staff have added task of placing a heel protection on the left heel while in recliner. The 02/19/25 at 12:58 PM, nurse's notes, documented the resident had one wound, a patch of eschar that covered the entire heel and pressure interventions started for management include wearing protective heel and foot cushions while the resident was in the recliner. Heel protectors have been added to the care plan off-loading heels were in place at the time of the wound occurrence, and heel protectors have been added to the care plan, to be on the left heel while in the recliner as this is the suspected cause of the pressure location. R9 has been noted to draw up her left leg and place her heel in the diversion of the footrest of the chair matching roughly to the eschar location. The Weekly Pressure Injury Skin Report, dated 03/08/25, documented R9's area on left heel, measured 5.0 cm by 8.0 cm, no tunneling, unstageable, with eschar of the left heel. The Weekly Pressure Injury Report, dated 03/12/25, documented R9 had a left heel pressure ulcer, measuring 4.1 cm by 4.1 cm, no tunneling, eschar was noted to have slight peeling at the distal edges, and a ring of it came off during the week and the remainder is well adhered. The surrounding tissue is pink with some scar tissue from the healing area. The Weekly Pressure Injury Report, dated 03/22/25, documented R22 had a left heel pressure ulcer, measuring 3.5 cm by 3.7 cm, no tunneling, unstageable, with eschar, and hard leathery black exudate. The report documented more eschar flaked off during assessment and the eschar remained firmly adhered. The evaluation documented the area was improving. On 03/24/25 at 12:00 PM, observation revealed R9 sat in her wheelchair at the dining room table, awaiting staff to deliver her lunch. Continued observation revealed the resident had a pressure relieving boot on her left foot/heel and the foot has slipped between the two metal footrest pedals. On 03/25/25 at 07:45AM, observation revealed R9 sat in recliner in her room with pressure relieving boot on her left foot/heel. Continued observation revealed LN H removed the resident pressure relieving boot and sock and revealed the resident's left heel with black eschar covering the heel no drainage and the eschar had separated from the skin. LN H placed the resident's sock and pressure relieving boot on her left heel/foot. On 03/25/25 at 08:30 AM, Administrative Nurse D verified the resident developed the unstageable pressure ulcer on her left heel 02/15/25. Administrative Nurse D verified the resident did not have pressure relieving boot upon admission to the facility post left hip fracture 01/02/25. Administrative Nurse D verified the resident was at risk for skin impairment and the staff off loaded her feet when in bed but stated LN I felt the resident rested her left heel on the footrest of the recliner and this is how the area developed. The The Wound Assessment, Prevention and Treatment, policy undated, documented a resident who enters the facility without pressure ulcers would not develop them unless the individual's clinical condition demonstrates that they were unavoidable. In addition, if a resident has a wound, he/she would receive necessary treatment and services to promote healing, prevent infection, and prevent new wounds from developing. On admission a comprehensive assessment that includes skin condition and other casual factors that place a resident at risk for developing pressure ulcers and/or delayed healing and the nature of the pressure to which the resident is subject to. The assessment should identify which risk factors can be removed or modified. The assessment also helps in identifying the resident with multi-system failures or an end-of-life condition or who is refusing and treatment and the basis for the refusal and the identification and evaluation of potential alternatives. All residents with a pressure ulcer and all residents identified at risk for skin breakdown would have the problem identified on the Plan of Care with appropriate preventative approaches identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 44 residents. The sample included 15 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identify and report Resident (R) 39's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use. This placed the residents at risk for inappropriate use of medication. Findings included: - The Electronic Medical Record (EMR) for R39 documented diagnoses of dementia (a progressive mental deterioration characterized by confusion and memory failure) without behavioral disturbance, vitamin D deficiency, and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The admission Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition. R39 required set-up assistance from staff for eating, oral hygiene, and partial assistance with dressing. R39 had physical and verbal behaviors toward others, wandered four to six days, and rejected care one to three days. R39 received antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) daily. The Psychotropic Drug Use Care Area Assessment (CAA), dated 12/26/24, documented R39 received risperidone (antipsychotic medication) on schedule for her anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Care Plan, dated 01/13/25, directed staff to administer medications as directed, document any side effects, and monitor her behaviors. The care plan directed staff to complete the Abnormal Involuntary Movement Scale (AIMS rating scale that was designed to measure involuntary movements know as tardive dyskinesia). The Physician's Order, dated 12/21/24, directed staff to administer risperidone, 0.25 milligrams (mg), by mouth, in the afternoon, for anxiousness (experiencing worry, unease, or nervousness), until 12/27/24. This medication was discontinued on 12/23/24. The Physician's Order, dated 12/23/24, directed staff to administer risperidone, 0.5 mg, by mouth, twice a day, for agitation. This medication was discontinued on 01/16/25. The Physician's Order, dated 01/16/25, directed staff to administer risperidone, 0.25mg, by mouth, twice a day, for psychosis (any major mental disorder characterized by a gross impairment perception). This medication was discontinued on 01/29/25. The Physician's Order, dated 01/29/25, directed staff to administer risperidone, 0.5 mg, by mouth, twice a day, for dementia without behavioral disturbance. In the review of the EMR and Consultant Pharmacist monthly review from 12/2024 to 03/2025, lacked documentation regarding the approved indication or risk versus benefit for the continued use of the risperidone medication for dementia. On 03/25/25 at 09:23 AM, R39 ambulated down to the doors to leave the Memory Care Unit, and knocked on the door over and over, stating hey lady, hey lady! On 03/25/25 at 09:40 AM, Certified Medication Aide (CMA) R stated R39 spent a lot of time at the doors going out of the Memory Care Unit, exit seeking. Staff redirect her by offering food or conversation. On 03/25/25 at 02:31 PM, Licensed Nurse (LN) G stated R39 was often more active and exit-seeking during the evening and not during the day. When R39 was anxious. staff take her to her room and show her the paintings she painted that hung in her room or show her the book she had with her paintings in it. LN G stated R39's husband visited daily and often took her out for coffee or ice cream and spent a lot of time with her. LNG stated R39's behaviors have been more under control with the risperidone medication. On 03/25/25 at 03:31 PM, Administrative Nurse D stated she was unaware of the diagnosis of dementia for risperidone and stated she did not have a risk versus benefit or any type of indication for the use of the medication. Administrative Nurse D stated, the Consultant Pharmacist had not reported any irregularities related to the medication to her. The facility's Pharmacy Services policy, undated, documented the facility ensures that pharmaceutical services, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. The facility failed to ensure that the CP identified and reported R39's antipsychotic medication had an approved indication for use. This placed the resident at risk for receiving inappropriate psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 44 residents. The sample included 15 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identify and report Resident (R) 39's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for This placed the residents at risk for inappropriate use of medication. Findings included: - The Electronic Medical Record (EMR) for R39 documented diagnoses of dementia (a progressive mental deterioration characterized by confusion and memory failure) without behavioral disturbance, vitamin D deficiency, and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The admission Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition. R39 required set-up assistance from staff for eating, oral hygiene, and partial assistance with dressing. R39 had physical and verbal behaviors toward others, wandered four to six days, and rejected care one to three days. R39 received antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) daily. The Psychotropic Drug Use Care Area Assessment (CAA), dated 12/26/24, documented R39 received risperidone (antipsychotic medication) on schedule for her anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Care Plan, dated 01/13/25, directed staff to administer medications as directed, document any side effects, and monitor her behaviors. The care plan directed staff to complete the Abnormal Involuntary Movement Scale (AIMS rating scale that was designed to measure involuntary movements know as tardive dyskinesia). The Physician's Order, dated 12/21/24, directed staff to administer risperidone, 0.25 milligrams (mg), by mouth, in the afternoon, for anxiousness (experiencing worry, unease, or nervousness), until 12/27/24. This medication was discontinued on 12/23/24. The Physician's Order, dated 12/23/24, directed staff to administer risperidone, 0.5 mg, by mouth, twice a day, for agitation. This medication was discontinued on 01/16/25. The Physician's Order, dated 01/16/25, directed staff to administer risperidone, 0.25mg, by mouth, twice a day, for psychosis (any major mental disorder characterized by a gross impairment perception). This medication was discontinued on 01/29/25. The Physician's Order, dated 01/29/25, directed staff to administer risperidone, 0.5 mg, by mouth, twice a day, for dementia without behavioral disturbance. In the review of the EMR and Consultant Pharmacist monthly review from 12/2024 to 03/2025, lacked documentation regarding the approved indication or risk versus benefit for the continued use of the risperidone medication for dementia. On 03/25/25 at 09:23 AM, R39 ambulated down to the doors to leave the Memory Care Unit and knocked on the door over and over, stating, hey lady! hey lady! On 03/25/25 at 09:40 AM, Certified Medication Aide (CMA) R stated R39 spent a lot of time at the doors going out of the Memory Care Unit, exit seeking. The staff redirect her by offering food or conversation. On 03/25/25 at 02:31 PM, Licensed Nurse (LN) G stated R39 was often more active and exit-seeking during the evening and not during the day. Wen R39 was anxious. staff take her to her room and shows her the paintings she painted that hung in her room or show her the book she had with her paintings in it. LN G stated R39's husband visited daily and often took her out for coffee or ice cream and spent a lot of time with her. LNG stated R39's behaviors have been more under control with the risperidone medication. On 03/25/25 at 03:31 PM, Administrative Nurse D stated she was unaware of the diagnosis of dementia for risperidone and stated she did not have a risk versus benefit or any type of indication for the use of the medication. Administrative Nurse D stated, the Consultant Pharmacist had not reported any irregularities related to the medication to her. The facility's Psychotropic Medication Use policy, dated 07/22, documented that residents would not receive medications that are not clinically indicated to treat a specific condition. Consideration of the use of any psychotropic medication is based on a comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms to identifying causes. The facility failed to ensure that the CP identified and reported R39's antipsychotic medication had an approved indication for use. This placed the resident at risk for receiving inappropriate psychotropic medication.

The facility had a census of 31 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 12 and R31s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when started in use and when expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 03/24/25 at 09:10 AM, observation of the facility's 100 and 200 hall treatment cart revealed the following: R12's Lantus (long-acting insulin) two flex pens were not labeled with an open or expired date. R31's Humalog (fast-acting insulin) flex pen was labeled with an open date of 02/26/25 and expired date of 03/19/25. (Date of observation 03/24/25 - 5 days past expiration) On 03/24/25 at 09:15 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened and the expiration date and should discard the expired insulin pens. Medlineplus.gov directs open, unrefrigerated Lantus and Humalog can be used within 28 days; after that time, they must be discarded. The facility's Storage of Medication policy, undated, documented the facility would assure proper storage and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperatures. The facility would provide safe and effective storage of all drugs and biologicals in a locked storage area with limited access by authorized personnel. The facility would ensure that all drugs and biologicals used would be labeled in accordance with professional standards, including expiration dates (when applicable) and with appropriate accessary and precautionary instructions (such as shake well, take with meals, do not crush, special storage instructions.) Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily tasks and should demonstrate safety in regard to the medication's integrity, such duties should include but not limited to: Remove any expired medications from active stock and discard medications according to facility policy. The facility failed to date the insulin flex pens when opened and the expiration date placing the residents at risk for ineffective medication

The facility had a census of 44 residents. Based on observation, record review and interview the facility failed to provide a safe, sanitary environment for Resident (R) 15 when staff failed to clean his carpet and recliner. Findings included: 03/24/25 at 10:00 AM, R15's room had a black stain in the carpet in front of a recliner, approximately 18 inches (in) long by eight in wide. The recliner had a red stain on the left arm , approximately six in. by three in wide. The left arm cover had a yellow stain , approximately two in by two in. The room and the recliner had a urine odor. 03/25/25 at 11:47 AM Housekeeping Supervisor (HS) V verified there was a urine odor in R15 room. HS V stated the urine smell was in the carpet and the recliner. HS v verified the stains in the carpet and on the recliner and stated she had cleaned the carpet several times and could not get the urine odor out, it was probably in the carpet pad also. 03/25/25 11:59 AM Administrative Staff A stated she was aware of the urine smell in the resident's room and recliner. The stain in front of the recliner is from when the resident was able to do crafts, he spilled paint. Administrative Staff A stated the faciity had a plan to start replacing carpeted rooms with vinyl flooring. Administrative Staff A stated she knew the recliner had an urine odor. The facility's Cleaning and Disinfection of Environmental Surfaces Policy, revised August 2019, documented environmental surfaces would be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogen standard.

The facility had a census of 44 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 44 residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food borne illness. Findings included: - On 03/24/25 at 8:20 AM, during initial kitchen tour, observation revealed the following: Two 24 inch by 24 inch, air vent located above the cooking stove area covered with brownish grease/sticky substance and gray fuzzy substance blowing directly on the food preparation and stove cooking area. Four overhead florescent light fixtures had the covers missing and located over the food preperation area. One 36 inch by 24 inch return air grill covered with brownish gray fuzzy substance that covered the metal grill. Six round light bulbs with wire cages around the bulbs, located in the exhaust hood above the stove top with brownish gray fuzzy substance affixed to the wire cages. Continued observation revealed two fire suppression spigots with brownish gray fuzzy substance that covered the hose and spigot area. On 03/24/25 at 9:00 AM, Dietary staff BB verified the dirty register grill, the dirty light bulbs and fire suppression spigots in the exhaust hood, and the overhead florescent light -the bulbs were not encapsulated with a plastic covering and lacked a cover for the light fixtures. Dietary Staff BB stated maintenance staff cleaned the grills and replaced the light bulbs and fixtures On 03/24/24 at 11:00 AM, Maintenance Staff U verified the dirty register grill, the dirty light bulbs and fire suppression spigots in the exhaust hood, and the overhead florescent light - and verified the bulbs were not encapsulated with a plastic covering and lacked a cover for the light fixtures. Maintenance Staff U stated the light fixtures had been missing the covers since he started at the facility about one year ago and stated the air grill and registers were cleaned about one month ago. The facility's Cleaning and Disinfection of Environment policy, dated October 2018, documented environmental surfaces would be cleaned and disinfected according to current Center for Disease Control (CDC) recommendations for disinfection of healthcare facilities. Housekeeping surfaces would be cleaned on a regular basis, when spills occur, and when the surfaces become visibly soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 36 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed provide written notice of transfer with the required information to Resident (R) 90 and/or to their legal representative in a practicable amount of time. The facility also failed to send notification to the office of the state Long-Term Care Ombudsman of the facility's transfers and discharges. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for these residents. Findings included: - R90's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of history of a traumatic brain injury (usually results from a violent blow or jolt to the head or body) and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R90 required extensive assistance of two staff members for activities of daily living (ADLs). The Quarterly MDS dated 04/26/23 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R90 required extensive assistance of two staff members for ADLs. R90's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/14/22 documented R90 required extensive assistance of two staff for ADLs. R90's Care Plan dated 11/16/22 documented R90 planned to remain at the facility. Review of the EMR under Progress Notes tab revealed documentation: A Nurses Note dated 06/07/2023 at 04:13 AM documented R90 had change in condition and was sent to the hospital for evaluation and treatment. A Nurses Note dated 06/07/2023 at 09:13 AM documented R90 was admitted to the hospital. R90's clinical record lacked evidence the facility provided a written notification of discharge which contained the required information to R90 and/or legal representative. On 06/15/23 at 11:00 AM the facility provided documentation the Long-Term Care Ombudsman's office was notified of transfers and discharges from 01/23/23 to 05/23/23. On 06/14/23 at 07:09 AM R90 wheeled his wheelchair down the hallway without assistance to the dining room. On 06/14/23 at 10:00 AM Administrative Staff A stated the facility did not provide the resident or their legal representative written notification. Administrative Staff A stated the facility would always call the legal representative to notify them of the transfer or discharge. On 06/15/23 at 09:30 AM Administrative Staff B stated the facility had not notified the Long-Term Care Ombudsman's office of any transfers or discharges since January 2023. The facility's Transfer or Discharge policy last revised 03/2017 documented the residents and/or representatives would be notified in writing, and in a language and format they understood. A copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. The facility failed to provide written notice of transfer with the required information to R90 and/or to their legal representative and notify the Long-Term Care Ombudsman's office of any transfers or discharges since January 2023. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for these residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure a care plan area was initiated to address Resident (R) 2's limited range of motion (ROM) due to contracture (an abnormal permanent fixation of a joint) of her joints, bilateral upper and lower extremities, and neck to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort. Findings included: - The electronic medical record for (EMR) for R2 documented diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and rheumatoid arthritis (RA-a chronic inflammatory disease that affected joints and other organ systems). The Annual Minimum Data Set (MDS) dated [DATE] for R2 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other activities of daily living (ADLs). R2 had limited functional ROM of both upper and lower extremities on both sides. R2 was not receiving restorative services. R2 was on hospice services. The Quarterly MDS dated 05/10/23 documented R2 had a BIMS of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other ADLs. R2 had limited functional ROM of both upper and lower extremities on both sides. R2 was on hospice services. R2 was not receiving restorative services. The ADL Care Area Assessment (CAA) dated 02/17/23 documented R2 was non-ambulatory (not able to walk about) and required two staff with a mechanical lift (a device used to assist with transferring a resident) for transfers due to pain and weakness. R2 would occasionally sit on the side of her bed with assistance. R2's hands were twisted with moderate contracture of the right upper extremity noted. R2 had RA. R2's bilateral lower extremities had moderate contractures as well as moderate foot drop noted. R2 was totally dependent on two staff for bed mobility. The ADLs Functional Status/Rehabilitation Potential Care Plan dated 02/17/23 for R2 directed staff that R2 was extensive to total assist of two. R2 required assistive devices of protective booties, air mattress, wheelchair, oxygen, and mechanical lift for transfers. The care plan lacked direction to staff regarding restorative services or interventions to address her contracture and/or interventions/exercises to prevent further decline of joint ROM. The Pain Care Plan dated 02/17/23 directed staff to administer pan medications as prescribed by physician. Staff would allow R2 to voice her pain and talk and ventilate about issues she may wish to discuss. Staff would attempt non-pharmacological pain relief measures, such as, removing from increased stimuli environment, calm approach, offering beverages or snacks, repositioning and massage. The Care Plan lacked a care area to address R2's contractures of hands, lower extremities, and neck; it lacked interventions to direct staff on cares for the contractures. The Orders tab in the EMR for R2 lacked any order for a restorative program or ROM exercises/devices or any type of restorative program direction for R2's contractures. On 06/15/23 at 08:30 AM R2 laid in bed wearing a hospital gown. R2 had colored pencils and a coloring page on the bed. R2 stated her neck was painful and contracted to the right. R2 stated she rested her head on her right shoulder a lot. R2 stated her hands were hideous and very painful due to her arthritis. R2 stated she wished she had a pillow or something to support her neck more; she had one at one time but does not know what happened to it. On 06/15/23 at 12:15 PM Certified Nurse Aide (CNA) M stated that R2 used to have a neck pillow, but she did not like it and would not use it most of the time. CNA M stated R2 did experience a lot of pain in her hands and neck and was not aware of any type of restorative or exercise interventions for R2. CNA M stated R2 was on hospice services and could not say what hospice might provide for R2 for her contractures. On 06/15/23 at 12:15 PM Licensed Nurse (LN) G stated he had tried to do some ROM exercises and things with R2 but would have to stop due to her severe pain she would experience. LN G was not aware of R2 being on any type of restorative program currently. LN G stated he was not positive what interventions were in place for R2's contractures without looking at her care plan. On 06/15/23 at 01:01 PM Administrative Nurse D stated R2 should have a care area and interventions in place to address her contractures and to maintain her ROM. The facility did not have a restorative program currently. Administrative Nurse D stated that therapy did not work with residents that were on hospice. Administrative Nurse D stated that some of the staff did try to do some ROM exercises with R2 but that was not charted anywhere that she was aware of. Administrative Nurse D stated the facility tried several different things to try to help with R2's contractures but due to her pain those did not work for long or R2 would refuse them. The facility did not provide a policy for care plans. The facility failed to ensure a care plan was initiated for R2 to address her limited ROM due to contractures of her joints, both upper and lower extremities and neck. The facility failed to have interventions in place to maintain R2's her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 28 had interventions in place to promote healing of a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R28 at risk for delayed healing and additional skin breakdown. Findings included: - The electronic medical record (EMR) for R28 documented diagnoses of unstageable pressure ulcer of the heel, infection of skin (occur when bacteria infect the skin and sometimes the deep tissue beneath the skin), and fracture (broken bone) of left femur (thigh bone). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R28 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R28 required extensive assistance to total dependence on two staff for her activities of daily living (ADLs). R28 was at risk for pressure ulcers. R28 had surgical wounds. R28 used a pressure reducing device for the chair and bed. R28 was on a turning/repositioning program. R28 received surgical wound care. The Quarterly MDS dated 04/05/23 documented R28 had both long and short-term memory problems. R28 displayed inattention and disorganized thinking continuously. R28 required extensive assistance of one staff for her ADLs. R28 had functional limitation in range of motion to her lower extremities. R28 utilized a wheelchair for mobility. R28 was at risk for pressure ulcers and currently had one unstageable pressure ulcer due to the coverage of wound bed by slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue). R28 used a pressure reducing device for the chair and bed. R28 had nutrition or hydration interventions to manage skin problems in place. R28 received pressure ulcer care and application of non-surgical dressing to feet. The ADL Care Area Assessment (CAA) dated 07/05/22 documented R28 was extensive to total assist with ADLs at that time. R28 needed two staff assist except with eating. R28 would feed herself at most times with set up assist after meal was served. R28 had a catheter (tube placed in the bladder to drain urine into a collection bag) in place, related to surgical wound and retention after trial removal. R28 was incontinent of her bowel. Staff anticipated her needs. The Nutritional Status Care Plan initiated 07/14/22 directed staff to provide weekly skin assessments. Nursing staff would use the Braden Scale (an assessment tool used to measure the risk for developing pressure ulcer). The Care Plan initiated 07/14/22 lacked a care area for skin and or pressure related skin concerns. The Pressure Ulcer Care Plan initiated on 10/10/22 (almost three months after the wound developed) directed staff to apply barrier cream with each incontinent episode. Staff was to complete a Braden Scale quarterly and with any readmission or significant change in status to assess any changes related to pressure risk score. Staff was to ensure a low air loss mattress was in place. Nursing was to complete weekly skin assessments and report any skin concerns to the wound nurse and physician. Staff was directed to offload hells and bony prominences while in bed R28's allowance. Staff was always to ensure R28 had protective heel boots on. Staff was to do treatment to left heel as ordered. A Braden Scale Assessment dated 06/28/22 documented R28 was at moderate risk for pressure ulcer development. The Wound Care Assessment dated 07/14/22 documented a wound to R28's left heel that measured five centimeters (cm) by 4.8 cm. The Orders tab listed an order dated 09/23/22 for wound care to left heel. Monitor daily for signs of weakening eschar adherence. The signs included drainage, peeling edges, or eschar moving when contacting it. Do not make any attempt to remove the eschar. Notify wound nurse if any changes occur. This order was discontinued 02/02/23. A Progress Note dated 06/13/23 at 06:49 PM documented R28 continues to have an unstageable pressure ulcer to the left heel. This area has been slowly positively progressing since the addition of calcium alginate (a type of wound dressing) last week. There was less moisture and exudate (drainage) was present in the wound on this visual. No pain or signs/symptoms of infection observed. Wound measured 0.9 by two (cm) currently. Significant margin improvement noted. On 06/14/23 at 07:13 AM R28 laid in bed on her right side with no heel protectors on her feet. On 06/15/23 at 08:05 AM R28 sat in her wheelchair at the dining room table, R28 had a bandage around her left heel, and her right foot was bare. On 06/15/23 at 12:15 PM Certified Nurse Aide (CNA) M stated the aides filled out a bath sheet each time a resident showered and would report skin issues to the nurse at that time. CNA M stated R28 did have a wound on her left heel. CNA M stated he thought the wound developed in the facility. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated that R28 had been in the hospital due to a fracture in June of 2022 and returned to the facility. R28 developed the wound to her left heel a few weeks after her return. LN G stated he knew that R28's heels were offloaded but could not say about any other interventions that were in place to prevent the heel wound. On 06/15/23 at 01:01 PM Administrative Nurse D stated R28's heels had been offloaded and to float the heels and skin assessments were completed weekly. Administrative Nurse D stated R28 had some other skin issues going on. Administrative Nurse D could not say if any other interventions had been in place before R28 developed the pressure wound to her left heel. The facility policy Prevention of Pressure Injuries revised April 2020 documented: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat risk assessment weekly and upon any changes in skin condition. Select appropriate support surfaces based on resident's risk factors, in accordance with current clinical practice. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. Monitor regularly for comfort and signs of pressure-related injury. For prevention measures associated with specific devices, consult current clinical practice guidelines. The facility failed to ensure staff implemented the interventions to promote pressure wound healing for R28. This deficient practice placed R28 at risk for delayed healing and additional skin break down.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the failed to ensure a restorative program was provided to Resident (R) 2, who had limited range of motion (ROM) due to contracture (an abnormal permanent fixation of a joint) of her joints, to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort. Findings included: - The electronic medical record for (EMR) for R2 documented diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and rheumatoid arthritis (RA-a chronic inflammatory disease that affected joints and other organ systems). The Annual Minimum Data Set (MDS) dated [DATE] for R2 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other activities of daily living (ADLs). R2 had limited functional ROM of both upper and lower extremities on both sides. R2 was not receiving restorative services. R2 was on hospice services. The Quarterly MDS dated 05/10/23 documented R2 had a BIMS of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other ADLs. R2 had limited functional ROM of both upper and lower extremities on both sides. R2 was on hospice services. R2 was not receiving restorative services. The ADL Care Area Assessment (CAA) dated 02/17/23 documented R2 was non-ambulatory (not able to walk about) and required two staff with a mechanical lift (a device used to assist with transferring a resident) for transfers due to pain and weakness. R2 would occasionally sit on the side of her bed with assistance. R2's hands were twisted with moderate contracture of the right upper extremity noted. R2 had RA. R2's bilateral lower extremities had moderate contractures as well as moderate foot drop noted. R2 was totally dependent on two staff for bed mobility. The ADLs Functional Status/Rehabilitation Potential Care Plan dated 02/17/23 for R2 directed staff that R2 was extensive to total assist of two. R2 required assistive devices of protective booties, air mattress, wheelchair, oxygen, and mechanical lift for transfers. The care plan lacked direction to staff regarding restorative services or interventions to address her contracture and/or interventions/exercises to prevent further decline of joint ROM. The Orders tab in the EMR for R2 lacked any order for a restorative program or ROM exercises or any type of restorative program direction. On 06/15/23 at 08:30 AM R2 laid in bed wearing a hospital gown. R2 had colored pencils and a coloring page on the bed. R2 stated her neck was painful and contracted to the right. R2 stated she rested her head on her right shoulder a lot. R2 stated her hands were hideous and very painful due to her arthritis. R2 stated she wished she had a pillow or something to support her neck more; she had one at one time but does not know what happened to it. On 06/15/23 at 12:15 PM Certified Nurse Aide (CNA) M stated that R2 used to have a neck pillow but she did not like it and would not use it most of the time. CNA M stated R2 did experience a lot of pain in her hands and neck and was not aware of any type of restorative or exercise interventions for R2. CNA M stated R2 was on hospice services and could not say what they might provide for R2. On 06/15/23 at 12:15 PM Licensed Nurse (LN) G stated he had tried to do some ROM exercises and things with R2 but would have to stop due to her severe pain she would experience. LN G was not aware of R2 being on any type of restorative program currently. On 06/15/23 at 01:01 PM Administrative Nurse D stated the facility did not have a restorative program currently. Administrative Nurse D stated that therapy did not work with residents that were on hospice. Administrative Nurse D stated that some of the staff did try to do some ROM exercises with R2 but that was not charted anywhere that she was aware of. Administrative Nurse D stated the facility tried several different things to try to help with R2's contractures but due to her pain those did not work for long or R2 would refuse them. The ADLs, Supporting facility policy revised March 2018 documented: Appropriate care and services would be provided for residents who were unable to carry out ADLs independently. A resident's ability to perform ADLs would be measured using clinical tools, including the MDS. Functional decline or improvement would be evaluated in reference to the assessment reference date (ARD). Interventions to improve or minimize a resident's functional abilities would be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions would be monitored, evaluated and revised as appropriate. The facility failed to ensure a restorative program was provided to R2, who had limited ROM due to contractures of her joints, in order to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 36 residents. The sample included 12 residents with four reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for Residents (R)17 and provide sanitary Foley catheter (tube inserted into the bladder to drain urine into a collection bag )care for R10. This deficient practice placed the residents at risk for complications related to infection and incontinence. Findings Included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of amputation of right foot great toe, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), gout (inflammation of the joints), and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling). A review of R17's Significant Change Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS indicated he required limited assistance from one staff for bed mobility, transfers, dressing, personal hygiene, toileting, and bathing. The MDS indicated he was occasionally incontinent of urine and always continent of bowel. The MDS indicated he had no toileting program in place. A review of R17's Activities of Daily Living (ADLS) Care Area Assessment (CAA) completed 02/20/23 indicated he required supervised to limited assistance with his ADLs due to his recent toe amputations. The CAA indicated he could call for assistance when needed. R17's Urinary Incontinence CAA completed 02/20/23 indicated a plan will be created to address his urinary incontinence. The CAA indicated he was occasionally incontinent of urine and will use a portable urinal to void. The CAA indicated he used a bedside commode (portable toilet) for bowel movements. A review of R17's Care Plan initiated 03/07/23 indicated he required supervision to limited assistance from one staff for his ADLs. The plan indicated he had occasional urinary incontinence. The plan indicated he required assistance dressing and using incontinence products after incontinent episodes. The care plan lacked individualized interventions to prevent, maintain and promote R17's highest level of functioning related to incontinence. A review of R17's EMR revealed a Bladder Observation form completed on 02/08/23. The form indicated he was incontinent of bladder. The form indicated he had occasional nocturia (nighttime urinary incontinence) and bed wetting. The form indicated he was at risk for stress incontinence. A review of R17's EMR revealed a Bladder Observation form completed on 02/23/23. The form indicated he was incontinent of bladder. The form indicated he had impaired mobility, diabetes, and urge incontinence. A review of R17's EMR revealed a Bladder Observation form completed on 05/15/23. The form indicated he was incontinent of bladder. The form indicated he had impaired mobility, diabetes, and urge incontinence. On 06/13/23 at 07:08AM R17's room smelled heavily of urine. Three portable urinals sat on the floor next to his bed. One of the urinals was one-third full of urine. The portable commode was positioned across the room next to his roommate's bed. R17 reported that since his toe amputation his ability to go to the bathroom has decreased. He stated he used to be able to take himself but now required more staff assistance. He stated his incontinence episodes have increased. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated R17 often had urinals next to his bed in case he needed to urinate at nighttime. He stated R17 was not on a toileting program but was incontinent of bowel and bladder. He stated R17 was independent but recently required more assistance due to his toe amputation. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected check on each resident every two hours to offer restroom breaks. She stated staff should ensure each resident's call light is in place and check on them frequently. She stated R17 can use his portable urinal, but staff should offer assistance for the commode due to him being a fall risk due to his toe. A review of the facility's Urinary Incontinence policy revised 09/2010 indicated each resident will be continually assessed and provided interventions to maintain and promote each resident's care and prevent a decline. The policy noted each resident's medication, diagnosis, and environmental factors will be assessed to provide personalized care plans to address to care needs. The facility failed to implement individualized toileting plans or attempt a toileting program related to bowel and bladder incontinence for R17. This deficient practice placed R17 at risk for complications related to incontinence. - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of urinary tract infection (UTI-an infection in any part of the urinary system), unspecified bladder disorder, retention of urine (lack of ability to urinate and empty the bladder), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R10 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R10 had an indwelling catheter (tube inserted into the bladder to drain urine) during the look back period. The Quarterly MDS dated 05/17/23 documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented that R10 was dependent on two staff members assistance for ADLs. The MDS documented R10 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) during the look back period. R10's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 02/13/23 documented R10 was dependent on staff for ADLs. R10's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 02/13/23 documented R10 had an indwelling catheter related to her diagnosis of urinary retention. R10's Care Plan dated 02/13/23 documented R10 would be provided catheter care every shift. Review of the EMR under Orders tab revealed physician orders: Obtain urine output every shift dated 10/30/20. Indwelling catheter care every shift dated 1/07/20. May Irrigate foley catheter daily with 30 milliliters (ml) of sterile saline for catheter occlusion, if not effective, may change catheter as needed dated 01/04/23. Foley catheter size 18 French, or 20 French (nurse may choose size), change monthly and as needed. Change every third day of the month (special instructions: indicate the Size of catheter used) dated 06/02/23. Review of R10's EMR revealed from 01/01/23 to 05/30.23 R10 had received antibiotic treatment for UTIs: Cephalexin capsule (antibiotic used to treat bacterial infections) 500 milligrams (mg) one capsule by mouth twice a day for seven days for UTI dated 01/13/23. Cipro tablet (antibiotic used to treat bacterial infections) 500 mg one tablet by mouth twice a day for seven days for UTI dated 03/19/23. Cephalexin capsule 500 mg give one capsule twice a day for seven days for UTI dated 05/07/23. On 06/14/23 at 09:06 AM Certified Nurse Aide (CNA) N and CNA P transferred R10 with a Hoyer lift from a recliner into the bed. R10's urine collection bag, covered by a dignity bag, was attached to the arm of Hoyer lift next to R10's head. CNA N and CNA P removed the resident from the Hoyer lift, and then CNA N and CNA P removed R10's slacks, sock and checked R10's incontinence product while the window blinds were open out to the front of facility and the parking area in front of the building. On 06/14/23 at 11:42 AM CNA N and CNA P explained to R10 they were going to perform catheter care. CNA N donned gloves, CNA P had gloves on. CNA N removed the tape from the incontinent brief and pulled the brief downward between R10's legs. CNA N removed a disposable wipe from the package; she wiped in downward motion around R10's labia, CNA N disposed of the soiled wipe and repeated this for three more wipes. CNA P helped R10 to turn onto her left side. CNA N wiped R10's coccyx and rectal area. CNA N removed soiled brief from under R10's bottom. Without changing soiled gloves, CNA N placed a clean brief under R10, and CNA P helped apply incontinent brief onto R10. CNA N and CNA P both doffed gloves but did not perform hand hygiene. The CNAs then and assisted R10 with pulling up slacks and putting her sock back onto her foot. On 06/15/23 at 12:19 PM Certified Nurse Aide (CNA) M stated staff should always hand sanitize between doffing and donning a new pair of gloves after providing peri-care or catheter care before clean items are touched or applied. CNA M stated a resident's catheter bag should always be placed below the bladder. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated hand hygiene should always be preformed before donning gloves and between each glove change. LN G stated a resident's catheter bag should never be placed above a resident's bladder at any time. On 06/15/23 at 01:02 PM Administrative Nurse D stated the facility had begun to work on hand hygiene and catheter care competencies in April 2023 with nursing staff. Administrative Nurse D stated her expectation was for the staff to complete hand hygiene between glove changes, between dirty and clean and any time their hands where visibly soiled. Administrative Nurse D stated she would except the staff to keep any resident's catheter bag below their bladder to prevent urinary tract infections. The facility's Catheter Care, Urinary policy last revised 09/2014 documented the purpose of this procedure is to prevent catheter-associated urinary tract infections. The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The facility failed to ensure the standard of care was provided during catheter care and failed to maintain the catheter drainage bag below the bladder for R10, who had a history of frequent UTIs. This deficient practice placed R10 at risk of catheter related complications and further UTIs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 36 residents. The sample included 12 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility additionally failed to date and store Resident (R)35's supplemental oxygen equipment (masks and tubing) in a sanitary manner. This deficient practice placed R35 at risk for complications related to respiratory care and infections. Findings Included: - The Medical Diagnosis section within R35's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), chronic obstructive pulmonary disorder (COPD), shortness of breath, ,and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). A review of R35's Significant Change Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated he required limited assistance from one staff for all his Activities of Daily Living (ADLs). The MDS indicated he received hospice and respiratory services. A review of R35's ADLs Care Area Assessment (CAA) completed 05/02/23 indicated he required one-to-one assistance for transfers, bed mobility, dressing, toileting, bathing, and personal hygiene. R35's Fall CAA completed 05/02/23 indicated he recently admitted to hospice services and was a high fall risk. The CAA indicated he had high fall risk related to dressing, toileting, and transfers to his wheelchair. A review of R35's Care Plan initiated 05/02/23 indicated he received hospice services due to his diagnoses. The plan indicated hospice provided oxygen therapy and supplies. The plan indicated staff would provide oxygen per the medical provider's order. A review of R35's EMR under Physician's Order revealed an order dated 02/28/23 for staff to administer three liters of oxygen continuously. A review of R35's EMR revealed no documentation tracking his oxygen equipment changes or maintenance. On 06/13/23 at 08:01AM R35's nebulizer face mask and tubing were on his bed, unbagged. His tubing was not labeled/dated indicating what day the tubing was placed. R35's humidifier bottle on his supplemental oxygen machine was not labeled/dated to show when it was filled. On 06/14/23 at 01:34PM R35's unbagged nebulizer face mask and tubing sat on his bedside dresser. His nebulizer tubing was dated with a tape label. R35's nasal cannula and oxygen tubing sat over his bedside table. His oxygen tubing and humidifier had no date/label. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated indicated tubing should be changed weekly. He stated oxygen equipment should be stored in a provided storage bag when not in use. He stated the equipment should be dated to should when the equipment was changed. He stated the oxygen equipment should never touch contaminated equipment. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected check to oxygen equipment each time they entered a resident's room to ensure sanitary storage. She stated the tubing and equipment should be changed out weekly and dated upon placement. A review of the facility's Oxygen Therapy policy revised 10/2010 indicated the facility will follow safe oxygen administration practices that included sanitary administration and equipment storage, tracking of treatments, and continual assessment of the residents and equipment. The facility failed to ensure R35's supplemental oxygen therapy equipment was dated and stored in a sanitary manner when not in use. This deficient practice placed R35 at risk for complications related to respiratory care and infections.

The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure nurse aid staff possessed the competency and skills necessary to care for residents' catheters (a tube placed into the bladder to drain urine into a collection bag). This deficient practice placed the affected residents at risk for catheter related urinary tract infection (UTI-an infection of the organs of the urinary tract) or other urinary system complications. Findings included: - On 06/14/23 at 09:06 AM Certified Nurse Aide (CNA) N and CNA P transferred R10 with a Hoyer lift (a mechanical lift used to aid in the safe transfer of a resident from one surface to another) from a recliner into the bed. R10's urine collection bag, covered by a dignity bag, was attached to the arm of Hoyer lift next to R10's head. On 06/14/23 at 11:42 AM CNA N and CNA P explained to R10 they were going to perform catheter care. CNA N donned gloves, CNA P had gloves on. CNA N removed the tape from the incontinent brief and pulled the brief downward between R10's legs. CNA N removed a disposable wipe from the package; she wiped in downward motion around R10's labia, CNA N disposed of the soiled wipe and repeated this for three more wipes. CNA P helped R10 to turn onto her left side. CNA N wiped R10's buttocks and rectal area. CNA N removed the soiled brief from under R10's bottom. Without changing the soiled gloves, CNA N placed a clean brief under R10, and CNA P helped apply incontinent brief onto R10. CNA N and CNA P both doffed gloves but did not perform hand hygiene. The CNAs then and assisted R10 with pulling up slacks and putting her sock back onto her foot. Review of facility training materials revealed the facility held a Skills Competency Check for staff members on 03/13/23, 03/14/23, and 03/15/23. The nurse aide staff were checked off for competency skills that included glove use; hand hygiene/alcohol based-rub use; infection control and precautions; personal protective equipment (PPE); Hoyer lift, and sit to stand lift. The facility was unable to provide evidence of training and competency assessment for catheter care. On 06/15/23 at 12:15 PM CNA M stated that the catheter bag should always be below the level of the bladder. CNA M stated privacy should be provided when giving a resident care and the curtain pulled and blinds should be shut in the room. CNA M stated the aides did a competency check about three months ago and went over hand washing, and catheter care. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated staff had competency checks were done a few months ago that included hand hygiene. LN G stated that catheter care checkoff was done annually. LN G stated when a resident was being transferred using a lift, the catheter bag should always be kept below the level of the bladder, so the urine did not flow back into the bladder. LN G stated the blinds and curtains should be closed when care was provided to a resident. LN G stated hand hygiene should be done any time you take off dirty gloves and put on clean gloves. On 06/15/23 at 01:01 PM Administrative Nurse D stated the facility held competency checkoffs back in March for all staff and new hires were checked off at the time of hire. Administrative Nurse D stated the competency check included hand hygiene, gloves, catheter care, PPE use. Administrative Nurse D stated the catheter bag should never be hung or transported above the level of the bladder as the urine could backflow into the bladder. Administrative Nurse D would expect staff to perform hand hygiene anytime they took gloves off and put clean gloves on. The facility lacked a policy regarding staff skills competency. The facility failed to ensure nurse aid staff possessed the competency and skills necessary to care for residents' catheters. This deficient practice placed the affected residents at risk for possible catheter related urinary tract infection

The facility identified a census of 36 residents. The sample included 12 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of staff monitoring Resident (R) 36 for side effects and behaviors associated with the use/administration of the antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication mirtazapine. These deficient practices placed R38 at risk of unnecessary mediation administration and potential adverse side effects. Findings included: - The electronic medical record (EMR) for R36 documented diagnoses of major depressive disorder (major mood disorder), and Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) for R36 documented she had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R36 required supervision with her activities of daily living (ADLs). R36 required the use of an anti-depressant. The Psychotropic Care Area Assessment (CAA) documented R36 received the antidepressant mirtazapine. The Psychotropic Drug Use Care Plan dated 04/26/23 for R36 directed nursing staff would assess for increased signs and symptoms of depression as evidenced by withdrawal, sad affect, and crying. The nursing staff would monitor for evidence of worsening behavior. If noted, staff would notify the responsible party and physician and document findings. Nursing staff would monitor for side effects of mirtazapine. The Orders tab for R36 documented an order dated 04/18/23 for mirtazapine 7.5 milligrams (mg) daily at bedtime for Alzheimer's disease. This order was discontinued on 05/02/23. The Orders tab for R36 documented an order dated 05/02/23 for mirtazapine 15 milligrams (mg) daily at bedtime for major depressive disorder. R36's clinical record including the Medication Administration Record/Treatment Administration Record (MAR/TAR) and Tasks for April 2023, May 2023 and June 2023 lacked evidence that R36 was monitored for target behaviors and side effects associated with the administration of mirtazapine. The April 2023 Pharmacist Monthly Medication Regimen Review (MRR) for R36 recommended the diagnosis of major depressive disorder for R36's mirtazapine. The May 2023 MRR lacked any recommendations for R36. On 06/13/23 at 08:03 AM R36 wandered about the memory unit, and stated she was waiting for her husband to come visit her. On 06/15/23 at 09:00 AM R36 walked about her room talking to herself. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated that a resident should be monitored for side effects and behaviors when on an antidepressant. LN G stated R36 was on an antidepressant medication and there should be monitoring of that medication on the TAR but could not say positively that R36 was being monitored for side effects or behaviors. LN G stated he had entered nursing recommendations and/or physician responses to the CP's MRR when received. On 06/15/23 at 01:01 PM Administrative Nurse D stated that the Pharmacist would email her recommendations to the facility and management nursing would review the recommendations and then would forward them to the physician(s). Administrative Nurse D stated when the physician signed responses was received, they would be given to the charge nurse or nurse on duty for them to make the changes and notify family as needed. R36 should be monitored for side effects and behaviors. On 06/19/23 at 01:34 PM Consultant GG was unavailable to answer questions. The facility did not provide a policy regarding MRR/Pharmacy Review. The facility failed to ensure the CP identified and reported the lack of staff monitoring and documenting R36 for side effects and increased behaviors associated with the administration of the antidepressant mirtazapine. This deficient practice placed R36 at risk for unnecessary medication administration and adverse side effects.

The facility identified a census of 36 residents. The sample included 12 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview the facility failed to ensure that staff monitored Resident (R) 36 for side effects and behaviors associated with the use/administration of the antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication mirtazapine. This deficient practice placed these resident at risk of unnecessary mediation administration and adverse side effects. Findings included: - The electronic medical record (EMR) for R36 documented diagnoses of major depressive disorder (major mood disorder), and Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) for R36 documented she had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R36 required supervision with her activities of daily living (ADLs). R36 required the use of an anti-depressant. The Psychotropic Care Area Assessment (CAA) documented R36 received the antidepressant mirtazapine. The Psychotropic Drug Use Care Plan dated 04/26/23 for R36 directed nursing staff would assess for increased signs and symptoms of depression as evidenced by withdrawal, sad affect, and crying. The nursing staff would for evidence of worsening behavior. If noted, staff would notify the responsible party and physician and document findings. Nursing staff would monitor for side effects of mirtazapine. The Orders tab for R36 documented an order dated 05/02/23 for mirtazapine 15 milligrams (mg) daily at bedtime for major depressive disorder. R36's clinical record including the Medication Administration Record/Treatment Administration Record (MAR/TAR) and Tasks for May 2023 and June 2023 lacked evidence that R36 was monitored for increased behaviors and side effects associated with the administration of mirtazapine. On 06/13/23 at 08:03 AM R36 wandered about the memory unit, and stated she was waiting for her husband to come visit her. On 06/15/23 at 09:00 AM R36 walked about her room talking to herself. On 06/15/23 at 09:05 AM Certified Medication Aide (CMA) R stated that a person on an antidepressant should be monitored for side effects and increased behaviors. CMA R stated that side effect and behavior monitoring was documented on the MAR/TAR. CMA R stated that R36 should be being monitored since she was taking mirtazapine. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated that a resident should be monitored for side effects and behaviors when on an antidepressant. LN G stated R36 was on an antidepressant medication and there should be monitoring of that medication on the TAR but could not say positively that R36 was being monitored for side effects or behaviors. On 06/15/23 at 01:01 PM Administrative Nurse D stated that when R36 was admitted the admitting nurse putting in the medication orders should input the monitoring for side effects and behaviors for the specific medication; the EMR system should flag the user. Administrative Nurse D stated that R36 should be monitored for side effects and behaviors. The night shift LN was responsible for reviewing orders that were entered each day. The Administering Medications facility policy revised April 2019 documented: as required or indicated for a medication, the individual administering the medications records in the resident' medical record - any complaints for symptoms for which the drug was administered; any results achieved and when those results were observed. The facility failed to ensure nursing staff monitored R36 for side effects and target behaviors associated with the administration of the antidepressant mirtazapine. This deficient practice placed R36 at risk for unnecessary medication administration and adverse side effects.

The facility identified a census of 36 residents. The sample included 12 residents with five residents reviewed for reviewed for vaccination status. Based on record reviews, and interviews, the facility failed to obtain influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination consent, declination, or administration information for Resident (R) 35. This deficient placed R35 at increased risk for influenza and related complications. Findings included: - Review of the R35's EMR under the Immunization tab lacked documentation of influenza vaccination. The facility was unable to provide a signed consent or declination On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated residents were offered immunizations at the time of their admission. LN G stated the resident would sign a consent or declination at that time. LN G stated the local pharmacy came to the facility to administer the vaccine. On 06/15/23 at 11:35 AM Administrative Staff B stated the Infection Preventionist (IP) tracked the immunizations at the time a resident was admitted to the facility. Administrative Staff B stated the IP checked online for the immunization status under the Kansas Department of Health and Environment web site. Administrative Staff B stated the IP then gave that information to the MDS coordinator to enter the immunization information into the residents EMR. Administrative Staff B stated she was not sure if R35 had been offered the immunizations. The facility's Influenza Vaccine policy last revised 10/2019 documented all residents who have no medical contraindications to the vaccine would be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Between October 1st and March 31st each year, the influenza vaccine would be offered to residents, unless the vaccine is medically contraindicated, or the resident had already been immunized. The facility failed to obtain influenza vaccination consents, declinations, or administration information for R35. This placed R35 at increased risk for influenza and related complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 36 residents. The sample included 12 residents with five residents sampled for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations. Based on record review and interviews, the facility failed to obtain signed consents or declinations for COVID-19 vaccinations for Resident (R) 35. This deficient practice placed the resident at increased risk for COVID-19. Findings included: - R35 admitted to the facility on [DATE]. His medical record lacked evidence a COVID-19 vaccination was previously received or offered upon admission. The record lacked evidence of a signed consent or declination for COVID-19 vaccination for R35. On 06/15/23 at 11:35 AM Administrative Staff B stated the Infection Preventionist (IP) tracked the immunizations at the time a resident was admitted to the facility. Administrative Staff B stated the IP checked online for the immunization status under the Kansas Department of Health and Environment web site. Administrative Staff B stated the IP then gave that information to the MDS coordinator to enter the immunization information into the residents EMR. Administrative Staff B stated she was not sure if R35 had been offered the immunizations. The facility was unable to provide a policy related to resident immunization. The facility failed to offer and obtain signed consents or declinations for COVID-19 vaccinations for R35. This deficient practice increased R35's risk for COVID-19 and related complications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R18's Electronic Medical Record (EMR) documented diagnoses of repeated falls, dementia (progressive mental disorder characterized by failing memory, confusion), and age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which suggested R18 was cognitively intact. The MDS documented R18 required extensive assistance of one staff member for many of her activities of daily living (ADL). The ADLs Functional Status/Rehabilitation Potential Care Area Assessment (CAA), dated 12/28/22, documented R18 was limited to extensive assist on one staff member for ADLs. The MDS documented that R18 was unsteady and required stand by assist for safety. The Falls CAA dated 12/28/22, documented R18 was a high risk for falls due to history of falls, secondary diagnosis, and that she required an ambulatory aide and staff assistance. The Care Plan dated 01/16/23, documented R18 was a high risk for falls due to history of falls, secondary diagnosis, weakness and need for ambulatory aide. An approach dated 01/16/23 documented R18 slipped to the floor in the shower room with staff present and directed staff to make sure the floor was dry or use a towel/bathmat to stand on and offer shoes or slippers. An undated Complaint Investigation Witness Statement documented that Certified Nurse's Aide (CNA) O was transferring R18 from the shower chair to her walker. R18 slipped and fell on her bottom. CNA O documented that the floor was still a little wet during the transfer. A Fall Scene Investigation Report dated 04/22/22 documented the root cause of the fall appeared to be the floor not being dried while R18 transferred from a seated to standing position. The report further documented an intervention to prevent future falls that staff were to dry the floor or have a mat or towel down away from water on the floor. A Progress Note dated 04/26/22, documented R18 slid in the shower on 04/22/22 while staff were present. It documented that staff were to make sure that the floor is not slick in the future by using a towel or floor mat for R18 to stand on and to offer the option of wearing slipper or shows prior to standing in the shower. An observation on 06/14/23 at 12:12 PM revealed R18 sat in her recliner in her room and watched TV. Staff assisted and setup her meal try. On 06/15/23 12:17 PM Certified Nurse Aide (CNA) M stated before attempting to transfer residents in the shower room, staff should wipe up any water on the floor. On 06/15/23 at 12:34 Licensed Nurse (LN) G stated before transferring a resident in the shower room, staff should do as much as they can to dry the resident as much as possible and get them dressed in the shower chair. LN G then stated staff should use a gait belt and clean up any water that is noted to be on the floor prior to transferring the resident. On 06/15/23 at 01:02 PM Administrative Nurse D stated staff were expected to dry the floor prior to transferring residents in the shower room. The facility's Falls policy revised on March 2018, documented that frail and elderly individuals are often at greater risk for serious adverse consequences of falls. The facility failed to prevent an avoidable accident when staff failed to ensure the shower room floor was dried/cleared of water before attempting to transfer R18 causing her to slip and fall. This deficient practice placed R18 at risk for injury. The facility had a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the nine cognitively impaired, independently mobile residents. The facility additionally failed to identify and implement resident centered fall intervention for Resident (R)20's repeated falls and failed to ensure implemented interventions identified during some investigations were added to the R20's plan of care. The facility further failed to prevent an avoidable accident when staff failed to ensure the floor was dry prior to a transfer, resulting in a fall for R18. This placed the affected residents at risk for preventable accidents and related injuries. Findings Included: - On 06/13/23 at 07:03AM an inspection of the facility's 100 and 200 hallway shower rooms revealed unsecured disinfectant cleaning products accessible inside both unlocked rooms. An inspection of the 100 hallway revealed an unlocked soiled linen room with disinfectant cleaner and furniture polish in an accessible cabinet. An inspection of the Assisted Living hallway, accessible to all facility residents, revealed a laundry room with two disinfectant cleaning bottles in an unsecured cabinet. All products identified contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 06/15/23 at 12:17PM Certified Nurse's Aide (CNA) M stated residents should not have access to cleaning chemicals. He stated staff should lock up cleaners and spray to prevent accidental poisoning. On 06/15/23 at 01:02PM Administrative Nurse D stated the cleaning chemicals should be stored in a locked cabinets or supervised when in use. A review of the facility's Hazardous Area, Device, and Equipment policy revised 07/2017 indicated the facility will protect its residents from potentially hazardous equipment, areas, and toxic chemicals. The facility failed to secure chemicals in a safe, locked area, and out of reach of the nine cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents. - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), retention of urine, type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), weakness, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). A review of R20's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS indicated he required limited assistance from one staff for transfers, personal hygiene, dressing, toileting, and bathing. The MDS indicated he was frequently incontinent of urine and occasionally incontinent of bowel with no toileting program. A review of R20's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 11/22/22 indicated he required limited to extensive assistance from staff for transfers, dressing, toileting, and personal hygiene. The CAA indicated he had an unsteady gait and required assistance from staff for safety and reduction of failing. The CAA indicated he was a high fall risk and overestimated his limits. R20's Urinary Incontinence CAA completed 11/22/22 indicated he was occasionally incontinent of urine and bowel. The CAA indicated he required staff him for ADLs. The CAA indicated he required a one-to-one staff assist for transfer, dressing, and toileting. R20's Fall CAA completed 11/22/22 indicated he was a fall risk related to his medical diagnoses, bowel/bladder incontinence, needs for assistance with ADLs, and unsteady gait/balance. The CAA instructed staff to assist him with transfers and ADLs. A review of R20's Care Plan initiated 11/22/22 indicated he required limited to extensive assistance with transfers, dressing, and bathing. The plan noted he required limited assistance from one staff for bed mobility and toileting (11/22/22). The plan indicated nursing staff will provide incontinence cares after each toileting and as needed (11/22/22). The plan indicated staff will check R20 every two hours for incontinence and complete skin assessment. The plan indicated he was a high fall risk. The plan indicated staff will provide one to one assistance for all ambulation and transfers (11/22/22). The plan noted R20 was intermittently confused and required constant reminders to call staff for assistance (11/22/22). A review of R20's EMR revealed a Fall Investigation dated 11/11/22. The report indicated he was found on the floor of his bathroom after attempting to use the restroom. The report indicated he was provided a portable urinal and staff completed hourly checks for the night to reinforce waiting for staff assistance. A review of R20's EMR revealed a Fall Investigation dated 03/08/23. The report indicated he was found on the floor next to his bed. The report indicated he did not activate his call light before attempting to transfer himself. The intervention indicated staff would reinforce the needed use for his call light. The report indicated he had a personal safety alarm (pad alarm). A review of R20's EMR revealed a Fall Investigation dated 04/01/23. The report revealed R20 was found by staff laying on his restroom floor. The reported noted R20 reported he lost his balance and slid down the bathroom door. The reported noted he was incontinent of bladder. The report's intervention was for R20 not to leave his bathroom unattended by staff. The report indicated staff would help toileting before and after meals. A review of R20's Progress Notes indicated he had a fall on 05/24/23 at 10:22pm. The note indicated he suffered a bruise in his coccyx. The note indicated he was found on the bathroom floor by staff after attempting to self-toilet himself. The note indicated he was reminded to use his call light for staff assistance. The note indicated R20 reported he was in a hurry to use the restroom and fell due to weakness. The facility did not provide a fall investigation for this incident. On 06/13/22 at 09:02AM R20 sat on his bed. A urinal sat on the floor next to his bed. R20 reported he had multiple falls. He stated his falls had been related to going to his bathroom. He stated he would lose his balance or fall due to being weak. He reported he sometimes forget to call for staff before going to the restroom. R20's restroom had non-skid floor strip and a grab bar installed by the toilet. On 06/15/23 at 12:05PM Certified Nurse's Aide (CNA) M stated R20 often forgets to call for help and will take himself to the bathroom without assistance. He stated staff offered frequent reminders, but R20's memory was too bad to remember. He stated staff will check on R20 frequently and offer help. He stated R20 often turned off his alarm and staff would not know when he took himself to the restroom. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated R20 did not have issues during the day but often got up in the middle of the night to use the restroom. He stated most of R20's falls occurred during the night. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected provide toileting for R20 per his care planned interventions. She stated R20 had poor memory recall and needed multiple reminders to use his call light. She stated R20 fell because his muscles were weak, and he attempted to self-transfer to the restroom. She stated it depended on what kind of day R20 was having and how alert he was. A review of the facility's Accident/Falls policy revised 03/2018 indicated the facility will identify risk related to falls/accidents to allow interventions to be implemented. The policy noted a plan of care will address the individualized focus, goal, and interventions directed towards reducing the resident's risk of injury and potential reoccurrences of falls. The facility failed to identify and implement resident centered fall interventions for R20's repeated falls and failed to ensure implemented interventions identified during some investigations were added to the resident's plan of care. This placed him at risk for preventable accidents and injuries.

The facility reported a census of 36 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 06/13/23 at 07:02AM a medication treatment cart outside Resident (R)10's room contained a Novolog Flexpen (injectable short-acting hormone which regulates blood sugar) left unsecured on top of the cart from 07:02AM to 07:10AM. The insulin belonged to R10. At 07:10AM Licensed Nurse (LN) G returned to the cart and secured the pen. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated medication should be secured when not being immediately administered or supervised. He stated staff should locked up medication in the cart when stepping away from the cart. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected to lock up medication when not in use or keep constant supervision on medication being prepared for the residents. A review of the facility's Medication Storage policy revised indicated that all medications will be stored in a manner that is sanitary, temperature/moisture controlled, and secured. The policy indicated medication supply will be monitored and reordered before expiration or low supply. The facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors.

The facility identified a census of 35 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to clean supply storage, respiratory equipment, shared care equipment, hand hygiene during medication administration, and providing cares. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 06/13/23 at 07:10AM an inspection of the 100-hallway shower room revealed three opened packages of incontinence briefs stored on a shelf above the toilet. The content of packages (incontinence briefs) was pulled out of the plastic wrapper and stored directly on the shelf. On 06/13/23 at 08:01 AM Laundry Staff V stated she obtained water temperature daily but only recorded the temperature weekly. The facility was unable to provide evidence staff routinely assessed laundry water temperature. On 06/13/23 at 08:01AM Resident (R)35's nebulizer face mask and tubing were on his bed, unbagged. His tubing was not labeled/dated indicating what day the tubing was placed. R35's humidifier bottle on his supplemental oxygen machine was not labeled/dated to show when it was filled. On 06/14/23 at 07:08 AM Certified Medication Aide (CMA) S prepared medication for R 33, entered R33's room, administered the medication to R33 from the plastic medication cup. CMA S filled R33's water pitcher. CMA S exited the room, pushed the medication cart to R4's room. Without performing any hand hygiene, CMA S prepared medication from the medication cards into a plastic cup. CMA S entered R4's room and handed the medication cup to R4. CMA S exited the room, pushed the medication cart to R10's room. Without performing any hand hygiene still, CMA S prepared medication from medication cards into a plastic medication cup, entered R10's room, and administered medication to R10 with a spoon. CMA S exited R10's room without performing hand hygiene. On 06/14/23 at 09:14 AM Certified Nurse Aide (CNA) N completed a Hoyer lift (total body mechanical lift used to transfer residents) transfer for R10. CNA N then rolled the Hoyer lift into the beauty shop to store without disinfecting the lift after use. On 06/14/23 at 11:42 AM CNA N and CNA P explained to R10 they were going to perform catheter care. CNA N donned gloves, CNA P had gloves on. CNA N removed the tape from the incontinent brief and pulled the brief downward between R10's legs. CNA N removed a disposable wipe from the package; she wiped in downward motion around R10's labia, CNA N disposed of the soiled wipe and repeated this for three more wipes. CNA P helped R10 to turn onto her left side. CNA N wiped R10's coccyx and rectal area. CNA N removed soiled brief from under R10's bottom. Without changing soiled gloves, CNA N placed a clean brief under R10, and CNA P helped apply incontinent brief onto R10. CNA N and CNA P both doffed gloves but did not perform hand hygiene. The CNAs then and assisted R10 with pulling up slacks and putting her sock back onto her foot. On 06/14/23 at 01:34PM R35's nebulizer face mask and tubing sat unbagged on his bedside dresser. His nebulizer tubing was dated with a tape label. R35's nasal cannula and oxygen tubing sat over his bedside table. His oxygen tubing and humidifier had no date/label. On 06/14/23 at 09:14 AM CNA N stated the Hoyer lift should be disinfected between each use. CNA N stated the staff usually used wet wipes and wiped it down, because they did not have any disinfect wipes. On 06/15/23 at 12:17PM CNA M stated hand hygiene should be completed in before and after cares were provided. He stated medical equipment shared by more than one resident should be thoroughly disinfected before using on other residents. He stated urinary catheter collection bags should be held and placed below the resident's bladder. He stated clean hygiene products and linen should be stored separately from soiled or dirty items. CNA M stated oxygen therapy equipment should have been stored in clean plastic bag to prevent contamination. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated hand hygiene should be completed before prepping medications, performing blood glucose (blood sugar) checks, providing cares, and transferring residents. He stated hand hygiene should be completed directly after doffing gloves. He stated oxygen tubing and masks should be stored in a plastic bag and never meet contaminated surfaces. He stated shared equipment was always disinfected in between uses. LN G stated hand hygiene should be preformed between each resident when administering medication. On 06/15/23 at 01:02PM Administrative Nurse D stated the facility currently was holding in-services related to infection control practices. She stated shared equipment should be wiped down with alcohol-based wipes in between uses Administrative Nurse D stated she would expect hand hygiene to be completed between each resident during medication administration. A review of the facility's Oxygen Therapy policy revised 10/2010 indicated the facility will follow safe oxygen administration practices that included sanitary administration and equipment storage, tracking of treatments, and continual assessment of the residents and equipment. A review of the facility's Cleaning and Disinfection of Resident-Care Equipment policy revised 07/2014 indicated all care equipment will be disinfected before and after use. The policy indicate hand hygiene will be completed in between cares provided and using equipment. A review of the facility's Handwashing /Hand Hygiene revised 08/2015 indicated hand hygiene will be completed to prevent the spread of infection. The policy no01/2014 ted hand hygiene should be completed before, during, and after providing cares. The policy noted hand hygiene should be completed directly after removing personal protective equipment (PPE). A review of the facility's Laundry Policy revised 01/2014 indicated laundry temperature must be monitored for sanitary cycling. The policy indicated the facility must ensure high temperatures washes remained at least 160 degrees Fahrenheit. The facility failed to ensure proper infection control standards were followed related to clean supply storage, respiratory equipment, shared care equipment, and delivery of cares. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility identified a census of 36 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings included: - On 06/13/23 at 07:15 AM in the kitchen's small refrigerator an observation revealed a bag of mozzarella cheese open with no date. On 06/13/23 at 07:16 AM in the kitchen's small refrigerator an observation revealed bacon, cut into small pieces, in a resealable bag that had no label or date. On 06/13/23 at 07:17 AM in the kitchen's small refrigerator an observation revealed three, unlabeled bottles of salad dressing that were open with no date. On 06/13/23 at 07:26 AM on a small storage shelf in the main kitchen area, an observation revealed a bag of raisin bran cereal that was opened with no date. On 06/13/23 at 07:34 AM in the kitchen's large refrigerator an observation revealed one resealable bag of various lunch meat. The bag did not have a label and was undated. On 06/13/23 at 07:35 AM in the kitchen's large refrigerator an observation revealed one, resealable bag of small sub sandwiches. The bag did not have a label and was undated. On 06/13/23 at 07:36 AM in the kitchen's large refrigerator an observation revealed one, resealable bag of cheese cubes. The bag did not have a label and was undated. On 06/13/23 at 07:40 AM in the kitchen's freezer an observation revealed a resealable bag of chicken strips. The bag did not have a label and was undated. On 06/13/23 at 07:44 AM in the kitchen's dry storage area an observation revealed one, opened bag of breadcrumbs. The bag did not have a label and was undated. On 06/13/23 at 07:47 AM in the kitchen's dry storage area an observation revealed one box of cocoa powder on the top shelf. The box contents were open to air and undated. On 06/13/23 at 07:50 AM in the kitchen's dry storage area an observation revealed three bags of noodles. Two bags remained in the manufactures packaging and were opened with no date. One bag was resealable with no label and was undated. On 06/15/23 at 11:28 AM Dietary BB stated opened food items should be sealed, labeled, and dated. She further stated that some food items would be placed back into their original boxes if they were in an unlabeled bag. She stated that food items should not have been left open to air and should have been sealed. The Facility's Food Receiving and Storage policy revised on October 2017, documented all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). The facility failed to maintain sanitary dietary standards related to storage of food. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record (EMR) for R13 documented diagnoses of heart failure and chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS) dated [DATE] for R13 documented a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. R13 required extensive assist with one staff for all activities of daily living (ADL's). The ADL's Care Area Assessment dated 8/19/2021 documented staff assisted R13 with cares and encouraged resident to maintain current level of ADL. The Orders tab in the EMR under the Order Report documented an order dated 08/09/2021 for carvedilol (Coreg-a medication used to treat high blood pressure and heart failure) 3.125 milligram (MG) tablet to be given by mouth twice a day for heart failure. The physician-ordered parameters indicated that the medication should be held if the systolic pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) below 110 or a pulse below 60 beats per minute (bpm). The Orders tab in the EMR under Order Report documented an order dated 8/10/2021 for vitals signs (blood pressure, temperature, pulse, respiration rate, and oxygen saturation) to be taken every Monday (weekly). R13's Medication Administration Record (MAR) and clinical record for September, October and November 2021 indicated no parameters were documented and lacked evidence blood pressure and pulse were assessed before administering the medication. The Progress Notes under Resident Reports indicate no entries from staff or physician regarding R13's medications withheld or vital sign documentation for September, October, and November. The Medication Administration Review completed by the consulting pharmacist (CP) for R13 for the month of September and October 2021 showed no noted irregularities for the prescribed carvedilol or the lack of blood pressure and pulse readings for the medication during those months. On 11/03/21 at 07:37 AM R13 slept in her wheelchair. The resident briefly awoke and called for help. On 11/04/2021 at 12:05 PM Licensed Nurse (LN) G stated that whoever passed medications was responsible for checking and documenting parameters. She stated that if the certified nurses aid (CNA) checked vitals, they were responsible for notifying the nurse of parameters. The medication would be held, and the physician notified. LN G was unable to locate the documented parameters at the time of interview and acknowledged that they had not been documented for this specific medication. LN G stated that the administrative nurses completed chart audits monthly and the consulting pharmacy was responsible for conducting monthly medication reviews. On 11/04/2021 at 12:39 PM Administrative Nurse D stated that she audited the charts each month. She stated that the parameters were documented in the MAR. If a medication was held the physician must be notified. The CP was also responsible for reviewing the resident's orders and communicating irregularities. The facility policy Medication Regimen Review implemented on 10/02/2021. Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication.The MRR policy indicates that if the consulting pharmacist identifies immediate action required regarding a finding, he/she will communicate with the physician and note in report, as well as, the licensed nurse caring for the resident. The facility failed to ensure that the CP identified and reported irregularities for R13, when a SBP and/or pulse was not obtained and documented before administration of Coreg, which had the potential for unnecessary medications and unwarranted side effects. The facility identified a census of 44 residents. The sample included 15 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified a blood pressure medication order for Resident (R)35 lacked a pulse parameter ordered by the physician or documentation of the pulse , and blood pressure and pulse reading for R13 was not documented. This deficient practice had the potential risk for unnecessary medication and unwarranted side effects for those two sampled residents. Findings included: - The electronic medical record (EMR) for R35 documented diagnoses of atrial fibrillation (a rapid, irregular heartbeat), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) documented R35 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. He required extensive assistance to total dependence of two staff members for his activities of daily living (ADLs), had an impairment on one side of the upper and lower extremity, and required a wheelchair for mobility. He received a diuretic (a medication to promote the formation and excretion of urine) medication six of seven days during the look back period. The ADL Care Area Assessment (CAA) dated 10/06/21 documented R35 was an extensive to total assist of one to two staff. He was left sided paralysis (the loss of muscle function, sensation, or both). The admission Care Plan dated 10/11/21 did not address cardiac medications. In the Orders tab report documented an order dated 09/29/21 for metoprolol tartrate (a medication used to control heart rhythm, treat chest pain, and reduce blood pressure) 25 milligrams (mg) tablet to administer 50 mg via gastric tube twice daily for CHF. This order was discontinued on 10/14/21. In the Orders tab report documented an order dated 10/14/21 for metoprolol tartrate 25 mg tablet to administer 50mg by mouth twice daily for CHF. The facility had standing physician orders and parameters for vital signs documented that the physician would be notified if the pulse was below 60 beats per minutes (BPM) or more than 120 BPM. Blood pressure medications would be held if the pulse was less than 60 BPM. R35's medication order for metoprolol tartrate lacked pulse parameters and an area on the September Medication Administration Record (MAR) to record/document a pulse reading. The pulse reading was not documented three out of three opportunities when medication was administered on the MAR or anywhere in the clinical record. The October MAR for metoprolol tartrate for R35 lacked a pulse parameter and documentation of the pulse reading on 62 of 62 opportunities. The November MAR for metoprolol tartrate for R35 lacked a pulse parameter and documentation of a pulse reading on seven of seven opportunities. The October Medication Regimen Review (MRR) dated 10/12/21 done by the CP documented no noted irregularities for the metoprolol tartrate for R35. On 110/04/21 at 07:15 AM R35 rested in bed, head of bed elevated, the staff nurse was in the room at this time administering his ordered medications, medications taken and swallowed without difficulty. In an interview with Licensed Nurse on 110/04/21 at 12:05 PM, she stated that for parameters the facility has standing physician orders that state if the pulse is below 50 BPM or above 120 BPM to call the physician. She further stated that some physicians have their own set of parameters for blood pressure medications and those would be documented under the orders or as a general order under the special instructions. The staff member that is passing/administering medications is responsible for following the parameters and to notify the nurse if it was a medication aide passing medications, the nurse would notify the physician, and the medication would be held if out of parameter and that would be documented on the MAR. The CP remotely reviews resident's charts monthly and emails the recommendations to the Director of Nursing (DON), then each halls nurse takes care of entering the recommendations into the computer. In an interview with Administrative Nurse E on 11/04/21 at 08:10 AM, she stated that they do get blood pressure and pulse reading for certain medications. Each physician has their set parameters and how often they should be taken. She stated that R35 was a new resident and it looked like the pulse reading and parameter was not input at the time the medication was entered into the MAR at admission. In an interview with Administrative Nurse D on 11/04/21 at 12:39 PM, she stated that parameters are documented on the MAR when they are obtained for a medication. The order should have the parameter for the pulse rate in it, if they physician has a specific parameter that is different from the facility's standing physician orders. If the medication was held that would be documented on the MAR. The nurse should be reporting any out of parameter vitals to the physician and document a progress note in the resident's chart. The CP reviews the charts monthly and will make recommendations then the recommendations are emailed to her and she gives the recommendations to the nurse in each hall. In an interview with CP GG on 11/08/21 at 0953 AM, she stated that she typically reviewed resident charts monthly and looked at any new and existing orders as well as vital signs, blood sugars, and progress notes for residents. She does not have access to residents MAR, so she was not able to view if a pulse or blood pressure was obtained before a medication was administered. She does review all physician orders that would have any parameters for medications on them. Some residents have been there long term and only require a weekly blood pressure and pulse reading. The facility policy Medication Regimen Review dated 10/02/19 documented: The CP will perform a drug regiment review on each resident living in the community monthly in long term care. The drug regimen review will identify: medications prescribed for residents without adequate indication for use documented in the resident's clinical record; indication for an ordered medication identified, but medication was not administered; medication ordered and/or administered was not the proper medication for the condition; medications that were ineffective to treat the identified condition; medications ordered and administered in excessively high dose or duration; residents whose clinical record and/or clinical condition indicates and adverse drug reaction to an ordered medication; and medications used without adequate monitoring. The facility failed to ensure that the CP identified and reported irregularities in the MAR for R35, when a pulse was not obtained and documented before administration of his metoprolol tartrate, which had the potential for unnecessary medications and unwarranted side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record (EMR) for R13 documented diagnoses of heart failure and chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS) dated [DATE] for R13 documented a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. R13 required extensive assist with one staff for all activities of daily living (ADL's). The ADL's Care Area Assessment dated 8/19/2021 documented staff assisted R13 with cares and encouraged resident to maintain current level of ADL. The Orders tab in the EMR under the Order Report documented an order dated 08/09/2021 for carvedilol (Coreg-a medication used to treat high blood pressure and heart failure) 3.125 milligram (MG) tablet to be given by mouth twice a day for heart failure. The physician-ordered parameters indicated that the medication should be held if the systolic pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) below 110 or a pulse below 60 beats per minute (bpm). R13's Medication Administration Record (MAR) and clinical record for September, October and November 2021 indicated no parameters were documented and lacked evidence blood pressure and pulse were assessed before administering the medication. The Orders tab in the EMR under Order Report documented an order dated 8/10/2021 for vitals signs (blood pressure, temperature, pulse, respiration rate, and oxygen saturation) to be taken every Monday (weekly). The Progress Notes under Resident Reports indicate no entries from staff or physician regarding R13's medications withheld or vital sign documentation for September, October, and November. On 11/03/21 at 07:37 AM R13 slept in her wheelchair. The resident briefly awoke and called for help. On 11/04/2021 at 12:05 PM Licensed Nurse (LN) G stated that whoever passed medications was responsible for checking and documenting parameters. She stated that if the certified nurse's aid (CNA) checked vitals they were responsible for notifying the nurse of parameters. The medication would be held, and the physician notified. LN G was unable to locate the documented parameters at the time of interview and acknowledged that they had not been documented for this specific medication. LN G stated that the administrative nursed completed chart audits monthly. On 11/04/2021 at 12:39 PM Administrative Nurse D stated that she audits the charts each month. She stated that the parameters were documented in the MAR. If a medication was held the physician must be notified. The facility did not provide a policy. The facility failed to ensure staff obtained and documented a blood pressure and pulse as ordered prior to administration of R13's carvedilol. This had the potential of unnecessary medication administration and unwarranted side effects for R13. The facility identified a census of 44 residents. The sample included 15 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure that a pulse was obtained and documented for Resident (R)35's metoprolol tartrate (a medication used to control heart rhythm, treat chest pain, and reduce blood pressure) prior to administration; and blood pressure and a pulse reading for R13 was not documented prior to administration of carvedilol (a medication used to high blood pressure and heart failure). This deficient practice had the potential risk for unnecessary medications and unwarranted side effects for those two sampled residents. Findings included: - The electronic medical record (EMR) for R35 documented diagnoses of atrial fibrillation (a rapid, irregular heartbeat), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) documented R35 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. He required extensive assistance to total dependence of two staff members for his activities of daily living (ADLs), had an impairment on one side of the upper and lower extremity, and required a wheelchair for mobility. He received a diuretic (a medication to promote the formation and excretion of urine) medication six of seven days during the look back period. The ADL Care Area Assessment (CAA) dated 10/06/21 documented R35 was an extensive to total assist of one to two staff. He was left sided paralysis (the loss of muscle function, sensation, or both). The admission Care Plan dated 10/11/21 did not address cardiac medications. In the Orders tab report documented an order dated 09/29/21 for metoprolol tartrate 25 milligrams (mg) tablet to administer 50 mg via gastric tube twice daily for CHF. This order was discontinued on 10/14/21. In the Orders tab report documented an order dated 10/14/21 for metoprolol tartrate 25 mg tablet to administer 50mg by mouth twice daily for CHF. The facility had standing physician orders and parameters for vital signs documented that the physician would be notified if the pulse was below 60 beats per minutes (BPM) or more than 120 BPM. Blood pressure medications would be held if the pulse was less than 60 BPM. R35's medication order for metoprolol tartrate lacked pulse parameters and an area on the September Medication Administration Record (MAR) to record/document a pulse reading. The pulse reading was not documented three out of three opportunities when medication was administered on the MAR or anywhere in the clinical record. The October MAR for metoprolol tartrate for R35 lacked a pulse parameter and documentation of the pulse reading on 62 of 62 opportunities. The November MAR for metoprolol tartrate for R35 lacked a pulse parameter and documentation of a pulse reading on seven of seven opportunities. On 110/04/21 at 07:15 AM R35 rested in bed, head of bed elevated, the staff nurse was in the room at this time administering his ordered medications, medications taken and swallowed without difficulty. In an interview with Licensed Nurse on 11/04/21 at 12:05 PM, she stated that for parameters the facility has standing physician orders that state if the pulse is below 50 BPM or above 120 BPM to call the physician. She further stated that some physicians have their own set of parameters for blood pressure medications and those would be documented under the orders or as a general order under the special instructions. The staff member that is passing/administering medications is responsible for following the parameters and to notify the nurse if it was a medication aide passing medications, the nurse would notify the physician, and the medication would be held if out of parameter and that would be documented on the MAR. In an interview with Administrative Nurse E on 11/04/21 at 08:10 AM, she stated that they do get blood pressure and pulse reading for certain medications. Each physician has their set parameters and how often they should be taken. She stated that R35 was a new resident and it looked like the pulse reading and parameter was not input at the time the medication was entered into the MAR at admission. In an interview with Administrative Nurse D on 11/04/21 at 12:39 PM, she stated that parameters are documented on the MAR when they are obtained for a medication. The order should have the parameter for the pulse rate in it, if they physician has a specific parameter that is different from the facility's standing physician orders. If the medication was held that would be documented on the MAR. The nurse should be reporting any out of parameter vitals to the physician and document a progress note in the resident's chart. The facility failed lacked a policy for Medication Administration. The facility failed to ensure that staff administering medications obtained and documented a pulse for R35 before administration of his metoprolol tartrate, which had the potential for unnecessary medications and unwarranted side effects.

The facility identified a census of 44 residents. The facility had two medication storage rooms. Based on observation, record review and interview, the facility failed to ensure medications were stored properly in one of the two medication storage rooms. This placed residents at risk for decreased medication effectiveness and unnecessary side effects. Findings Included: - On 11/02/2021 at 07:40 AM observation revealed the medication storage refrigerator which contained controlled substances (drugs which have a high abuse risk) was not locked. The following medications were present: R1's morphine sulfate (controlled narcotic pain medication) 20 milligrams (mg)/milliliter (ml) bottle, lorazepam (medication used to treat agitation, anxiety and air hunger) 2mg/ml bottle R15's morphine sulfate 20mg/ml bottle, lorazepam 2mg/ml bottle R9's morphine sulfate 20mg/ml bottle, lorazepam 2mg/ml bottle R38's morphine sulfate 20mg/ml bottle, lorazepam 2mg/ml bottle On 11/02/2021 at 07:45 AM, the medication refrigerator temperature log lacked 11 of 30 entries for September 2021 and 12 of 31 entries for October 2021. On 11/02/2021 at 07:50 AM, three bottles of expired medications were stored with the active medications. The expired medication bottles identified were as follows: R33's hydroxyzine (treats anxiety, itchiness, and allergies) 25mg -Discard after 06/08/2021 R42's metoprolol (treats high blood pressure, chest pain, and heart failure) ) 25mg -Discard after 09/18/2021 Synthroid (treats low thyroid hormone) 50 micrograms (mcg) -Discard after 09/03/2021 The facility's Storage of Medication policy dated 09/20/2019 stated that Schedule II controlled medications are maintained within a separately locked permanently affixed compartment. A locked drawer or section of the medication cabinet will be designated for storage of controlled substances. The key to the drawer or section will be different from the key that opens to the locked drawer. The medication cabinet will remain locked except when in use. No policy was provided by the facility for refrigerator temperature inspection. The facility's Destruction of Drugs and Biological policy dated 10/02/2019 indicated that discontinued, outdated, and deteriorated drugs and biologicals will be destroyed as provided by state and federal law. On 11/02/2021 at 07:50 AM, Licensed Nurse (LN) G stated that the refrigerator temperatures are taken daily by the on-duty nurse. LN G stated that the medication refrigerator was usually locked when not in use and a nurse may have counted controlled medications and forgot to lock it. LN G stated that the expired medication was brought in by the resident's wife and was not being used by the resident. LN G moved the medication away from the active medication storage area to the return to pharmacy rack. On 11/04/2021 at 12:40 PM, Administrative Nurse D stated that controlled medications should be locked up under double lock when not in use. She stated that medication room audits occur regularly, and nurse should not be leaving the refrigerator unlocked. She stated that expired medication should be destroyed if the families do not take them home with them. The facility failed to properly secure schedule II control medications, dispose of expired medications, and track refrigerator temperatures for medications. This could potentially cause adverse consequences or ineffective treatment to the affected residents.