**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that two of 25 sampled residents (Resident 19 and Resident 20) were treated with dignity and respect and were able to exercise their rights in a manner that upheld their individuality and quality of life. Staff failed to ensure timely assistance with grooming, hygiene, food clean up, and linen changes. These failures resulted in residents experiencing unclean conditions, emotional discomfort, and dissatisfaction with their care. The findings include: The facility's Resident Rights policy (revised 03/22/2025) revealed that all residents have the right to be treated with dignity and respect. Section 4 stated that residents have the right to hygiene and grooming support that promotes personal dignity, including shaving and bathing, and that staff are responsible for ensuring such rights are upheld. Record review of Resident (R) 19's Resident Face Sheet revealed that R19 was admitted to the facility on [DATE] with diagnoses of leukemia, hemiplegia, dysphagia, aphasia, and anxiety. Record review of R19's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/202, revealed that R19 had a Brief Interview for Mental Status (BIM) score of 3/15, which indicated that R19's cognitive ability was severely impaired. The MDS further revealed that R19 required extensive assistance with hygiene and meals. Record review of R20's Resident Face Sheet revealed that R20 was admitted to the facility on [DATE] with diagnoses of COPD, dementia, and heart failure. Record review of R20's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/2025, revealed the R20 had a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated that R20 had a moderate cognitive impaired. It further revealed that R20 required extensive assistance with hygiene and meals. Observation of R19 on 04/14/2025 at 4:35 PM revealed that R19 had dried food stains on R19's face and food particles on his gown, chest, and bedding. Observations of R20 on 04/14/2025 at 4:14 PM revealed that he had orange food stains on his face and biscuit crumbs on his chest, gown, and bed linens. Further observation revealed that the right handrail on his bed was soiled with food stains and particles. Observation of R20 on 04/15/2025 at 3:30 PM revealed that R20 was asleep in bed with orange food stains on his face, side rail, clothing protector, and blanket. Observation of R20 on 04/16/2025 at 8:45 AM revealed that he was lying in bed with no meal tray in the room, visible gravy on his face, and a clothing protector still in use. During an interview with the unit manager on 04/14/2025 at 4:35 PM, she stated that the staff is expected to clean the residents' faces as they pick up the meal trays. She continued to state that staff must have skipped over R19 and R20 when cleaning up after meals. She further stated that residents feel better if they are clean. During an interview with R20 on 04/14/2025 at 6:55 PM, he stated that when he was clean, he felt better about himself and more presentable. R20 further stated that having the food on him made him feel dirty and if he had a mirror, then he would feel embarrassed. During the interview on 04/16/2025 at 4:06 PM, CNA 5 stated that staff cleaned the resident's face as they picked up the resident's meal tray. She further stated that leaving the residents with food stains on their faces and crumbs in their beds probably embarrasses them. During an interview on 04/16/2025 at 1:03 PM, the Administrator stated that cleaning the residents' faces after meals had been a concern in the facility in the past, and staff were educated on it. She further stated that she expected every resident to be treated with dignity and cleaned in a timely manner after each meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to review and revise the comprehensive person-centered care plan to include air boots for one (1) out of twenty (21) sampled residents, (Resident #37). Observation of Resident #37 on 10/19/2021, 10/20/2021, and 10/21/2021, revealed Resident #37 was lying in bed or sitting in his/her wheelchair and was not wearing air boots as care planned. The findings include: Review of the facility's policy entitled, Pressure Injuries/Skin Breakdown - Clinical Protocol, revised March 2014, revealed the wound would be measured and documented, the physician will write orders related to wound treatments, and the care plan would be revised to reflect changes in condition and new treatment goals and approaches. Review of the facility's policy entitled, Care Plans, Comprehensive Person Centered, no date, revealed comprehensive person-centered care plans were developed and revised for each resident and included identified problem areas, associated risk factors and reflect currently recognized standards of practice for problem areas and conditions. The Interdisciplinary Team (IDT) develops and implements each resident's plan of care. The Comprehensive Care Plan (CCP) is revised as information related to the resident, treatments, and resident's conditions change. Furthermore CCPs were developed and maintained for each resident to identify the highest level of functioning. CCPs were designed to incorporate identified problem areas, risk factors associated with identified problems, and aid in preventing or reducing avoidable declines in the resident's functional status and/or functional levels. Further review revealed the IDT was responsible for the review and updating of care plans (CP) when a resident has had a significant change. Review of Resident #37's clinical record revealed the facility re-admitted the Resident on 04/04/2020, from an acute care hospital. The resident's diagnoses included but were not limited to one (1) Stage 4 pressure ulcer of the right, lateral ankle full thickness, two (2) Venous Arterial ulcers left foot partial thickness. Furthermore, review of medical record revealed Resident #37 was at risk of developing a pressure ulcer. Review of Resident #37's Annual Minimum Data Set (MDS) Assessment, dated 06/09/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderately impaired cognition. Per the assessment, the resident displayed no behaviors during assessment look back timeframe. Continued review revealed, Resident #37 had treatments to include pressure reducing device for his/her chair and bed, pressure ulcer/injury care, and application of dressing to bilateral feet. The MDS did not include the use of an air boot. Review of Resident #37's Physician Orders, dated 08/13/2021, revealed an order for air boots for bilateral feet. Review of the CP for Resident #37, re-admission date of 04/04/2020, revealed the facility had addressed the resident's pressure ulcer with ongoing interventions related to the resident's wound treatments. However, there was no evidence the facility reviewed/revised the CCP to include an air boot intervention to prevent further skin breakdown. Review of Resident #37's Wound Physicians' Wound Care follow up evaluations, dated 08/13/2021, 08/17/2021, 08/24/2021, 08/31/2021, 09/07/2021, 09/14/2021, 09/21/2021, 09/28/2021, 10/05/2021, 10/14/2021, and 10/19/2021, revealed the physician's plan reviewed and addressed recommendation for air boots. Further record reviewed the resident was seen at a via telehealth by a wound care physician. Review of the wound care evaluation revealed the wound care physician recommended air boots for Resident #37 during each visit on 08/13/2021, 08/17/2021, 08/24/2021, 08/31/2021, 09/07/2021, 09/14/2021, 09/21/2021, 09/28/2021, 10/05/2021, 10/14/2021, and 10/19/2021. Observation of Resident #37 on 10/19/2021 at 11:20 AM, revealed the resident was lying in bed on his/her back, with both heels against the mattress. Gauze dressings were intact on both the resident's feet. Further observation revealed the resident's ankles and heels were without support and there was no air boot, heel protectors, or off-loading of wound. Observation of Resident #37 on 10/19/2021 at 1:00 PM, revealed Resident #37 sitting up in a wheelchair for lunch. Gauze dressings were intact on bilateral feet. Bilateral feet and ankles were were supported by the wheelchair foot rests; however, the resident was not wearing air boots. Observation of Resident #37 on 10/19/2021 at 4:15 PM, revealed Resident #37 was lying in bed on his/her left side, with lateral aspect of both heels against the mattress. Gauze dressings were intact on bilateral feet. Bilateral feet and ankles were without support and the resident was not wearing air boots. Observation of Resident #37 on 10/20/2021 at 9:30 AM, revealed Resident #37 lying in bed. Resident was lying on his/her back, with both heels pressed against the mattress. Gauze dressing was intact on bilateral feet. Further observation revealed the resident's feet and ankles were without support and the resident was not wearing air boots. Observation of a dressing change performed by the Wound Care Nurse (WCN), on 10/21/2021 at approximately 9:30 AM, revealed a discolored purple irregular shaped, five (5) cm by approximately one (1) centimeters wound on the right lateral ankle. Additional observation revealed an approximately one (1) centimeters by one (1) centimeters arterial wound of the left foot. Surrounding skin on bilateral feet was clean, dry and intact. The WCN dressed all wounds, but did not place an air boot on the resident after providing care. Interview with WCN, prior to dressing change, on 10/21/2021 at approximately 9:30 AM, revealed she was aware an order had been written by the Wound Care Physicians for Resident #37's air boot. The WCN went to the resident's room to locate the air boot but was unable to locate. She stated it could be in the laundry. She stated when the Wound Physicians do telehealth visits, if orders are given, she transcribes them to the MAR and TAR and updates and revises the care plan as needed. However, the WCN stated she had not transcribed the order and did not know how she missed it. Interview with Certified Nurse Aide (CNA) #1, on 10/21/21 at 2:50 PM, revealed she routinely provides care for Resident #37 and the CNAs round on residents every two (2) hours and as needed. During rounding the residents are checked and changed if needed, and are repositioned. CNA #1 stated Resident #37 does not have an air boot, but staff prop bilateral feet up on pillows to off-load wound. Interview with Minimum Data Set (MDS) Coordinator, on 10/21/2021 at 2:30 PM, revealed nurses were responsible to make the updated changes to the CPP and the physician orders when new orders are written. She further stated neither the CPP nor the MAR/TAR reflected the physician's order for an air boot for Resident #37, as an intervention for wounds prior to 10/21/2021. She stated, Both the care plan and MD orders should have been updated immediately. The MDS Coordinator stated the facility should have reviewed and revised Resident #37's CP to include an intervention to ensure the resident had an air boot to prevent further skin breakdown. Interview with the Director of Nursing, (DON), on 10/21/21 3:31 PM, regarding CP revisions and updates, revealed nurses are responsible for updating the CP with any acute changes or new interventions. She revealed monitoring was performed to ensure care of residents by rounding herself, and rounding by management staff, and discussed in the IDT meeting. Monitoring of care plans, physician orders. The DON stated [NAME] were completed on a regular basis. Further interview revealed, after a wound care telemedicine visit, the wound care physicians will email the wound care follow-up evaluation to the facility. The WCN is responsible to take off orders and update and revise the CP. Continued Interview with DON, revealed it was very important to have an accurate and complete CCP. It was her expectation that nursing staff updated and revised the CP as needed. The DON reviewed Resident #37's CCP and acknowledged the care plan had not been updated to include the air boots.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility's policies, it was determined the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing for one (1) of twenty-one (21) sampled residents (Resident #37). Resident #37 had a Stage 4 pressure wound to the right medial ankle, and an arterial wound of the left foot and a physician's order for air boots; however, nursing staff failed to transcribe physician orders, document, and follow the wound care physician's orders for Resident #37's treatments related to wearing air boots, floating heels while in bed, and off-loading wounds. The findings include: Review of the facility's policy entitled, Pressure Injuries/Skin Breakdown - Clinical Protocol, revised March 2014, revealed the wound would be measured and documented, the physician will write orders related to wound treatments, and the care plan would be revised to reflect changes in condition and new treatment goals and approaches. Review of the facility's policy entitled, Care Plans, Comprehensive Person Centered, no date, revealed Comprehensive Care Plans (CCP)s were developed and revised for each resident and included identified problem areas, associated risk factors and reflect currently recognized standards of practice for problem areas and conditions. The Interdisciplinary Team (IDT) develops and implements each resident's plan of care. Care Plans are revised as information related to the resident, treatments, and resident's conditions change. Further review of the policy revealed residents have the right to Receive the services and/or items included in the plan of care. Furthermore CCPs were developed and maintained for each resident to identify the highest level of functioning. CCPs were designed to incorporate identified problem areas, risk factors associated with identified problems, and aid in preventing or reducing avoidable declines in the resident's functional status and/or functional levels. The IDT was responsible for the review and updating of care plans when a resident has had a significant change. Review of Resident #37's clinical record revealed the facility re-admitted the Resident on 04/04/2020, from an acute care hospital. The resident's diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), Unspecified Dementia without Behavioral Disturbance, Venous Insufficiency, Chronic Diastolic (Congestive) Heart Failure, Anemia, Cognitive Communication Deficit, Rheumatoid Arthritis, Age- Related Osteoporosis, and Osteoarthritis of Right Knee. Review of Resident #37's Annual Minimum Data Set (MDS) Assessment, dated 06/09/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderately impaired cognition. Per the assessment, the resident displayed no behaviors during assessment look back timeframe. Continued review revealed, the facility assessed Resident #37 to require substantial/maximal assistance for bed mobility, dressing, and personal hygiene; extensive assistance of two (2) staff for transfers, toileting, and bathing; set up or clean-up assistance for eating; and substantial/maximal assistance of one (1) staff for locomotion in a wheelchair. Additional review revealed Resident #37 had one (1) Stage 4 pressure ulcer of the right, lateral ankle full thickness, two (2) Venous Arterial ulcers left foot partial thickness, and was at risk of developing a pressure ulcer. Per the MDS, Resident #37 had Skin and Ulcer/Injury Treatments to include pressure reducing device for his/her chair and bed, pressure ulcer/injury care, and application of dressing to feet. Review of Resident #37's Physician Orders, dated 08/13/2021, revealed documented evidence orders were obtained related to treatment for pressure wound of the right, lateral ankle full thickness. Per the physician's orders staff were to Float heels in bed; Air boot; Reposition per facility protocol; Off-load wound Review of Resident #37's Wound Physicians' Wound Care follow up evaluations, dated 08/13/2021, 08/17/2021, 08/24/2021, 08/31/2021, 09/07/2021, 09/14/2021, 09/21/2021, 09/28/2021, 10/05/2021, 10/14/2021, and 10/19/2021, revealed the Plan of Care (PoC) reviewed and addressed recommendation to include Float heels while in bed; Air boots, Reposition per facility protocol; and Off-load wounds. Review of Resident #37's Comprehensive Care Plan's Focus regarding the potential for complications related to alterations in skin integrity/pressure, initiated on 05/13/2021, with revision on 09/20/2021, revealed the care plan addressed the pressure ulcer to the resident's right ankle; however, the care plan had not been revised to add the use of the air boot. Review of Medication Administration Record (MAR), dated 09/01/2021 to 09/30/2021, revealed an order for bilateral heel protectors at all times as resident will allow, with a start date of 09/21/2021. Additionally, nursing staff had signed off on the treatment for all shifts from 09/01/2021 through 09/30/2021 except for the 6:00 AM to 2:00 PM shift on 09/30/2021. There was no documentation of refusal of treatment by Resident #37. Further review revealed no order for air boots to be worn as resident will allow every shift related to wound to right lateral ankle and to left foot. Review of Treatment Administration Record (TAR), dated 10/01/2021 to 10/31/2021, revealed an order for bilateral heel protectors at all times as resident will allow, with a start date of 09/21/2021 and an end date of 10/21/2021. Additionally, nursing staff had signed off on the treatment for all shifts from 10/01/2021 through the 6:00 AM to 2:00 PM shift on 10/21/202. There was no documentation of refusal of treatment by Resident #37. Review of the Visual/Bedside [NAME] Report, with an as of date of 10/20/2021, revealed under the heading of Skin Care, bilateral heel protectors were to be used at all times as resident will allow. Further review of the document under the heading of Repositioning, revealed Resident #37's heels were to be elevated off the bed as resident will allow. Observation of Resident #37 on 10/19/2021 at 11:20 AM, revealed the resident was lying in bed on his/her back, with both heels against the mattress. Gauze dressings were intact on both the resident's feet. Further observation revealed the resident's ankles and heels were without support and there was no air boot, heel protectors, or off-loading of wound. Observation of Resident #37 on 10/19/2021 at 1:00 PM, revealed Resident #37 sitting up in a wheelchair for lunch. Gauze dressings were intact on bilateral feet. Bilateral feet and ankles were were supported by the wheelchair foot rests; however, the resident was not wearing air boots. Observation of Resident #37 on 10/19/2021 at 4:15 PM, revealed Resident #37 was lying in bed on his/her left side, with lateral aspect of both heels against the mattress. Gauze dressings were intact on bilateral feet. Bilateral feet and ankles were without support and the resident was not wearing air boots, heel protectors nor was there any off-loading of the wounds. Observation of Resident #37 on 10/20/2021 at 9:30 AM, revealed Resident #37 lying in bed. Resident was lying on his/her back, with both heels pressed against the mattress. Gauze dressing was intact on bilateral feet. Further observation revealed the resident's feet and ankles were without support and the resident was not wearing air boots, heel protectors nor was there any off-loading of the wounds. Observation of a dressing change performed by the Wound Care Nurse (WCN), on 10/21/2021 at approximately 9:30 AM, revealed a discolored purple irregular shaped, five (5) cm by approximately one (1) centimeters wound on the right lateral ankle. Additional observation revealed an approximately one (1) centimeters by one (1) centimeters arterial wound of the left foot. Surrounding skin on bilateral feet was clean, dry and intact. Observation of Resident #37 on 10/21/2021 at 4:30 PM, revealed Resident #37 lying in bed. Resident was lying on his/her back. There was an intact gauze island dressing over the pressure wound of the right lateral ankle, and the right foot was in an air boot. The left foot was not in an air boot, did not have a heel protector, and was not off-loaded. Interview with Certified Nurse Aide (CNA) #1, on 10/21/21 at 2:50 PM, revealed CNAs round on residents every two (2) hours and as needed. During rounding the residents are checked and changed if needed, and are repositioned. CNA #1 stated Resident #37 does not have an air boot, but staff prop bilateral feet up on pillows to off-load wound. She stated Resident #37 can resist care. The CNA stated staff notify the nurse if the resident resists care. Interview with CNA #2, on 10/21/21 at 2:55 PM, revealed she provided care for Resident #37 routinely. The CNA stated she does her round on her assigned residents every two (2) hours and as needed. During rounding CNA #2 stated residents are checked, changed, and repositioned if needed. CNA #2 was not aware if Resident #37 used an air boot. Interview with Licensed Practical Nurse (LPN) #1, on 10/19/2021 at 1:20 PM, revealed nursing staff round on resident every two (2) hours and as needed. Nurses observe residents during medication passes. LPN #1 stated weekly skin assessments are completed on all residents. Per the LPN, if there is a change in condition, the Resident's Care Plan will be revised, and the family and physician should be notified. If new orders are obtained, they are transcribed to the MAR and TAR. She stated the WCN does wound care treatments. Interview with Licensed Practical Nurse (LPN) #3, on 10/21/2021 at 3:00 PM, revealed physician orders are managed depending on how it is entered. If the physician is in the facility, he/she usually does a direct entry into the resident's medical record (EMR). Nurses enter any faxed physician orders into the resident's EMR. Nurses are responsible for entering treatment orders and updating Care Plan (CP). Interview with WCN, prior to dressing change, on 10/21/2021 at approximately 9:30 AM, revealed she was aware an order had been written by the Wound Physicians for Resident #37's air boot. The WCN went to the resident's room to locate the air boot but was unable to locate. She stated it could be in the laundry. She stated when the Wound Physicians do the telehealth visits, if orders are given, she transcribes them to the MAR and TAR and updates and revises the care plan as needed. Per the WCN, she could not explain how the orders for the air boots was missed. Interview with Minimum Data Set (MDS) Coordinator, on 10/21/2021 at 2:30 PM, revealed nurses were responsible to make the updated changes to the Comprehensive Care Plan (CPP) and the physician orders when new orders are written. She further stated neither the CPP nor the MAR/TAR reflected the physician's order for an air boot for Resident #37, as an intervention for wounds prior to 10/21/2021. She stated, Both the Care Plan and MD orders should have been updated immediately. Interview with the Director of Nursing, (DON), on 10/21/21 3:31 PM, revealed the Wound Care Physicians currently do telemedicine visits with residents needing wound care treatments. The resident was treated by a wound doctor weekly through telehealth and also seen and treated according to physician orders by the wound nurse. Further interview revealed, after the visit, the physicians will email the wound care follow-up evaluation to the facility. The WCN is responsible to take off orders and added them to the MAR/TAR. If special supplies have to be ordered, the MAR/TAR is not updated until the supplies come in. SSA Surveyor requested a copy of the air boot invoice, but the document was never given to SSA Surveyor. Interview with the Administrator, on 10/21/21 4:35 PM, regarding Resident #37's air boot, revealed she had checked stock, and the facility had three (3) air boots in storage. She stated, per physician orders, the staff had placed one (1) air boot on Resident #37 on 10/21/2021 at approximately 4:30 PM. Continued interview revealed her expectations was for to staff to provide care per the residents' needs and clinical conditions. Per interview, the Administrator stated it was her expectation all staff followed all applicable facility policies as doing so ensured the wellbeing of residents.

Based on observation, interview, and review of facility's policy, it was determined the facility failed to ensure drugs and biologicals stored in the facility were not expired, labeled, and stored in accordance with currently excepted professional principles; and failed to store medications according to appropriate environmental controls to preserve their integrity for one (1) out of three (3) medication storage rooms, and one (1) out of five (5) medication carts. Observation of D hall medication cart revealed Resident #2's discontinued Hydrocodone 5/325 mg tablets were found stored in the medication cart's narcotic lock box. Per physician orders, the medication had been discontinued on 10/13/2021. Observation of D hall medication refrigerator revealed a carton of beer was being stored along with medications. The medication refrigerator was full with very little room for proper air flow compromising the integrity of the Vaccines and Medications. Additionally, one (1) multidose vial of Moderna COVID-19 Vaccine was observed in the door of the refrigerator and was expired on 10/17/2021. Four (4) packages of Flu Vaccines were stored in the refrigerator door, which closed up against carton of beer. The findings include: Review of the facility's policy titled, Storing of Medication Requiring Refrigeration, dated 03/01/2020, revealed the purpose of the policy is to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of the medications by exposure to improper temperature and environmental controls. Furthermore, the facility must ensure all drugs are stored according to manufacturer's recommendations to preserve their integrity. Additional review of the facility's policy revealed refrigerators will be used solely for the purpose of storing medications and biologicals that require refrigeration and not used for food. In addition, staff should remove any expired medication from active stock and discard medication according to facility policy. Review of facility policy Medication Storage in the Facility, dated April 2018, revealed the purpose of the policy is to ensure medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. Further, the facility should ensure outdated and discontinued medications are stored separate from active stock, and discard medication according to facility policy. Review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, updated 09/29/2021, revealed best practices for storage of Vaccines is to: 1) Monitor and comply with Vaccine expiration dates, including the COVID-19 Vaccine. 2) Don't over-pack the refrigeration unit. Place the Vaccine packages in such a way that air can circulate around the compartment and promote air circulation; 3) Position Vaccines and diluents two to three inches from the unit's walls, ceiling, floor, and door; 4) Do not store on door shelf, top shelf, or on the floor of the refrigerator as the temperature in these areas may differ significantly from the temperature in the body of the unit; and 5) Do not store Vaccines in a refrigerator with food or beverages. Review of Resident #2's clinical record revealed the facility re-admitted the Resident on 01/21/2020. Resident #2's diagnosis included but were not limited to Alzheimer's Disease, Chronic Obstructive Pulmonary Disease (COPD), Primary Generalized (Osteo) Arthritis, Low Back Pain, Unspecified Fracture of T11-T12, Wedge Compression Fracture of Second, Fourth, and Fifth Lumbar Vertebra, Unspecified Dementia with Behavioral Differences, Hypertensive Heart Disease Without Heart Failure, and Muscle Weakness. Per physician orders, Resident #2's Hydrocodone 5/325 mg tablets was discontinued on 10/13/2021 and a new order for Hydrocodone 7.5/325 mg was received. Observations, on 10/20/2021 at 12:30 PM of the D hall medication cart, revealed Resident #2's discontinued Hydrocodone 5/325 mg tablets were found stored in the medication cart's narcotic lock box. Observations, on 10/20/2021 at 12:50 PM, of the D and E hall medication refrigerator revealed the refrigerator was over-packed and full with very little room for proper air flow. Further observation revealed a carton of beer was being stored with medications. Additionally, one (1) vial of Moderna COVID-19 Vaccine was observed in the door of the refrigerator and was expired on 10/17/2021. Four (4) packages of Flu Vaccine were stored in refrigerator door, which closed up against the carton of beer. Interview with Licensed Practical Nurse (LPN) #5, on 10/20/2021 at 12:38 PM, revealed she was assigned to the D hall medication cart. LPN #5 assisted the Surveyor with observation of the D hall medication cart and medication storage room. Further interview revealed Resident #2's was given a new prescription for Hydrocodone, and the Hydrocodone 5/325 mg tablets, found stored in the medication cart's narcotic lock box had been discontinued. Continued interview with LPN #5, revealed it was facility policy to store expired or discontinued controlled medications in the medication cart lock box and the Director of Nurses (DON) is to be notified. LPN #5 stated the DON was to be alerted that the controlled medication needs to be disposed of, at which time the DON removes it and destroys it according to facility policy. Per physician orders, Resident #2's medication had been discontinued on 10/13/2021. LPN #5 further stated the nursing staff is responsible for ensuring medications are labeled according to facility process, which is to record the date opened on the medication package when the medication has been opened. Furthermore, LPN #5 stated if an item is found to be expired, labeled, and or stored improperly, the nursing staff is responsible to discard the medication according to policy. LPN #4 further stated the importance was to ensure the safety of all residents. Interview with LPN #2, on 10/20/2021 at 1:35 PM, revealed it is the responsibility of the nursing staff to ensure medications are stored according to facility policy and procedure; Any expired medications are discarded according to facility policy to ensure the safety of all residents. Interview with LPN #3, on 10/20/2021 at 3:00 PM, revealed it is the responsibility of the nursing staff to ensure the medication cart is clean, medications are in the proper place. Any expired scheduled medications are discarded according to facility policy, which is to notify the DON. The DON removes it and destroys it. She stated all Vaccines are stored in the D and E hall refrigerator. Interview with LPN #4, on 10/20/2021 at 3:10 PM, revealed it is facility policy to notify the DON of any discontinued controlled medication. If the DON is not available, nursing staff is to store the expired or discontinued controlled medication in the medication cart's lock box. LPN #4 stated nursing staff is to notify the DON if a controlled medication needs to be taken out of the medication cart lock box. LPN #4 stated it was the responsibility of the nursing staff to ensure medications are labeled according to facility policy and process; and expired medications are discarded according to facility policy. LPN #4 assisted SSA Surveyor with observation of D and E hall medication storage room refrigerator. Observation on 10/20/2021 at 3:10 PM revealed the Vaccines were still stored in the door shelf, and the expired COVID-19 Vaccine had not been taken out. Interview with DON, on 10/20/2021 at 3:15 PM, revealed the DON stated the beer in the D and E Hall refrigerator was ordered for a resident, and needed to be locked up according to facility policy. According to the DON, she was unaware it was a CDC guideline that Vaccines could not be stored on the shelf of the door. The DON removed the expired Moderna COVID-19 Vaccine from the refrigerator and moved the Flu Vaccine to the middle shelf. Interview with the DON, on 10/21/2021 at 10:10 AM, revealed it is her expectation all nursing staff follows facility policy and procedures related to medication storage and labeling. The DON stated, if an item is found to be expired, labeled, and or stored improperly, it is her expectation nursing staff return or discard the medication according to facility policy. Additionally, if a controlled medication is expired or discontinued, it is facility protocol for the nurse to notify the DON. The DON will lock the medication up in her office. The DON stated when she has accumulated a few cards of controlled drugs, she and the Assistant Director of Nurses (ADON) will destroy the control medications. According to the DON, it is her expectation nursing staff alert her regarding any expired or discontinued scheduled narcotic on the day it is expired or discontinued to assure all controlled drugs are accounted for and stored properly. The DON further stated the importance was to ensure the safety of all residents. Per the DON, she was not notified of Resident #2's expired medications on 10/13/2021 and was not aware until 10/21/2021 when discussed in interview. Interview with the Administrator, on 10/21/2021 at 3:50 PM, revealed it was her expectation for medication to be stored and labeled appropriately by guidelines and facility policy and nursing staff follow current policies and protocols. The Administrator further stated the importance was to ensure the safety of all residents.