**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure accommodations were made for a resident, to include the facility's bathing schedule and resident preferences for 1 of 1 resident reviewed for activities of daily living (Resident #24). Findings On 8/26/24 at 8:20 a.m. and again on 8/27/24 at 7:55 a.m. during interviews, Resident #24 stated he/she had not received a shower in seven days and prefers to be bathed in the morning two times a week. Resident #24 stated he/she has informed the Certified Nurses Aide (CNA), a Registered Nurse, and the Nurse Practitioner of his/her preferences on multiple occasions. On 8/26/24 at 12:46 p.m., observation of the Stowes Unit weekly shower schedule dated 5/2/24 indicated Resident #24 was to receive a shower Wednesday evenings. At this time during a brief interview, CNA #11 stated, the posted shower schedule was incorrect, and she follows the daily CNA schedule, which has the showers to be completed for that shift highlighted. She confirmed Resident #24 does not receive showers twice weekly. On 8/27/24 review of CNA bathing documentation stated Resident #24 received showers on 8/7/24 and 8/14/24 with the last shower documented on 8/18/24 on the evening shift. The admission [NAME] data set dated [DATE] under section F preferences for customary routine and activities states it is important for him/her to choose their bathing options. On 8/27/24 the Staffing and Transport Coordinator provided the updated Stowes Unit weekly shower schedule, which states Resident #24 receives showers on Thursday evenings once a week. On 8/28/24 at 2:15 p.m., the above information was discussed with the Administrator and Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide follow up care for 1 of 1 resident reviewed with a pacemaker. (Resident #11) Finding: Review of the admission Minimum Data Set (MDS) assessment completed on 12/6/23 noted he/she had an implanted pacemaker listed under diagnosis. A further review of the Electronic Medical Record (EMR) lacked any details about the implanted pacemaker or facility follow and/or monitoring of the pacemaker's functioning. The care plan instructed the Registered Nurse (RN) to monitor/document/report a pulse rate lower than programmed rate. The programmed rate was not located in the EMR. On 8/27/24 at 1:04 p.m. during an interview, the Licensed Practical Nurse #1 confirmed she did not know Resident #11 had a pacemaker. On 8/27/24 at 2:00 p.m. during an interview, the RN #2 stated anyone with a pacemaker would be followed by cardiology. RN #2 was unable to provide documentation on Resident #11's pacemaker programmed rate, if his/her pacemaker checks had been completed and if he/she was seen or followed by a cardiologist since admission on [DATE]. On 8/28/24 at 9:45 a.m., during an interview, the Director of Nursing confirmed the standard of care for a pacemaker was not met for Resident #11.

Based on observations and interviews, the facility failed to serve and store food in a sanitary manner during 1 of 1 observations of the refrigerator in the main dining room. Finding: On 8/26/24 at 12:20 p.m., observaton of the main dining room refrigerator lacked documentation of temperature monitoring and a very large amount of a red fluid covered the bottom of the freezer. At this time, the food service manager confirmed the observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Documentation in Resident #28's clinical record indicated that the resident was transferred to the hospital on 5/1/24 and 6/24/24 and subsequently admitted . The clinical record lacked evidence that Resident #28 and/or the resident representative were provided with written transfer/discharge notices upon either transfer. 5. Documentation in Resident #35's clinical record indicated that the resident was transferred to the hospital on 1/12/23, 10/29/23 and 4/7/24 and subsequently admitted . The clinical record lacked evidence that Resident #35 and/or the resident representative were provided with written transfer/discharge notices with all three transfers. On 8/27/24 at 9:05 a.m. during an interview, the Admissions Director confirmed the above residents and/or the resident representative were not provided with written transfer/discharge notices upon transfers. 3. Documentation in Resident #31 clinical record indicated that resident was transferred to the hospital on 8/19/24 and 8/21/24 and admitted for overnight observation and treatment. The clinical record lacked evidence that Resident #31 and/or the resident representative were provided with written transfer/discharge notices upon either transfer. Based on record review and interview, the facility failed to notify the resident, family and/or the resident's representative in writing of the transfers/discharge to an acute care hospital for 5 of 6 residents sampled for hospitalizations (Residents #7, #108, #31, #28 and #35). Findings: 1. Documentation in Resident #7's clinical record indicated that the resident was transferred to the hospital on 3/2/24 and 4/7/24 and subsequently admitted . The clinical record lacked evidence that Resident #7 and/or the resident representative were provided with written transfer/discharge notices upon either transfer. 2. Documentation in Resident #108's clinical record indicated that the resident was transferred to the hospital on 8/23/24 and returned on 8/24/24. The clinical record lacked evidence that Resident #108 and/or the resident representative were provided with written transfer/discharge notices upon transfer. On 8/26/24 at 2:34 p.m., in an interview with a surveyor, the nurse manager of the [NAME] Unit stated the nurses do not send the notices with the resident at the time of transfer. On 8/26/24 at 2:40 p.m., in an interview with a surveyor, the Admissions Director stated once a resident is admitted to the hospital, he/she or the facility's social worker, will send the notices to the resident's family. The notices are not sent for residents who are not admitted to the hospital. The Admissions Director confirmed that Resident #108 was not provided with a transfer/discharge notice.

4. Resident #28's clinical record revealed the resident was transferred to an acute care hospital on 5/1/24 and 6/24/24 and subsequently admitted . The clinical record lacked evidence that Resident #28 and/or the resident representative were provided with a written bed hold notices upon either transfer 5. Resident #35's clinical record reveals the resident was transferred to an acute care hospital on 1/12/23, 10/29/23 and 4/7/24 and subsequently admitted . The clinical record lacked evidence that Resident #35 and/or resident representative were provided with a written bed hold notices upon all three transfers. On 8/27/24 at 9:05 a.m. during an interview, the Admissions Director confirmed the above residents and/or resident representative were provided with a written bed hold notices upon transfers. 3. Resident 31's clinical record revealed the resident was transferred to an acute care hospital on 8/1924 and 8/21/24 and admitted . The clinical record lacked evidence that Resident #31 and/or the resident representative were provided with a written bed hold notices upon either transfer. Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member and/or legal representative for 5 of 6 sampled residents who had been transferred to the hospital ((Residents #7, #108, #31, #28 and #35). Findings: 1. Resident #7's clinical record revealed the resident was transferred to an acute care hospital on 3/2/24 and 4/7/24 and subsequently admitted . The clinical record lacked evidence that Resident #7 and/or the resident representative were provided with a written bed hold notices upon either transfer. 2. Resident #108's clinical record revealed that the resident was transferred to the hospital on 8/23/24 and returned on 8/24/24. The clinical record lacked evidence that Resident #108 and/or the resident representative were provided with a written bed hold notice upon transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all facility staff maintain training in cardiopulmonary resuscitation (CPR) for Healthcare Providers, resulting in staff who are responsible for providing CPR without an active CPR certificate for 8 of 27 days reviewed. This has the potential to effect all of the residents. Findings: On [DATE] an anonymous staff member expressed concerns about facility staff not recieving education or maintaining their CPR Certification. On [DATE] at 2:24 p.m., during an interview, the Director of Nursing (DON) stated she herself was not CPR certified, it's not a facility requirement for staff and she does not know what staff are current with their CPR certification. On [DATE] at 3:20 p.m., the Administrator confirmed there are 7 of 56 residents who are Full Code and could potentially require CPR however, all residents are at risk for choking. A review of the facility staffing with CPR certification for the month of August had the following shifts where there were no staff available with current CPR certification: [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] evening and night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification The following facility Policy's and Procedures: > Emergency response policy, last revised [DATE] states, It is the policy of Horizons Living and Rehab Center to provide emergency care with a quick response, during a life or death situation regardless of code status. Examples of emergency may include (but are not limited to) severe bleeding and choking. > Finding a resident with no pulse or respiration, last revision on [DATE], instructing staff to If a resident is a full code, Call 911 and Immediately begin CPR. > Obstructed airway/choking episode/Heimlich Maneuver last revision on [DATE], instructing staff to establish that the victim is actually choking . immediately begin Heimlich maneuver. On [DATE] at 2:00 p.m., the facility provided documentation of current CPR certifications for 4 of 14 Registered Nurses, 2 of 12 Licensed Practical Nurses and 7 of 51 Certified Nurses Aids. The above was confirmed with both the Administrator and the Director of Nursing who stated going forward there would be a CPR certified staff on every shift while other staff are obtaining their certification.

Based on review of annual evaluations and interviews, the facility failed to complete a annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 5 of 5 CNA's reviewed with employment greater than 1 year (CNA #12, CNA #13, CNA #14, CNA #15, CNA #16). Findings: On 8/28/24, a surveyor reviewed the following employee files: 1. CNA #12 was hired on 8/19/2020. The employee file lacked evidence of an annual review being completed since date of hire. 2. CNA #13 was hired on 8/4/2021. The employee file lacked evidence of an annual review being completed since date of hire. 3. CNA #14 was hired on 8/10/2022. The employee file lacked evidence of an annual review being completed since date of hire. 4. CNA #15 was hired on 9/16/2021. The employee file lacked evidence of an annual review being completed since date of hire. 5. CNA #16 was hired on 7/29/2020. The employee file lacked evidence of an annual review being completed since date of hire. On 8/28/24 at 12:30 p.m., during an interview, the Director of Nursing confirmed that the annual performance review for 5 of 5 employees had not been completed since their date of hire.

Based on the cumulative effect of deficiencies cited during the recertification survey from 8/26/24 through 8/28/24, the facility was not administered in a manner that enabled residents to attain or maintain their highest practicable well-being as evidenced by Federal findings listed under 483.10- Resident rights (F558, F585); 483.15- Resident Notification (F623, F625); 483.24- Quality of Life (F678); 483.25- Quality of Care (F684); 483.35- Nursing Services (F726, F730, T206); 483.60- Food Safety (F812) and 483.95- Training Requirements (F940, F947). These failures to assure a process was in place to monitor staff development and resident care resulted in the facility failing to assist residents to maintain their highest functional and practicable well-being and has the potential to affect all 56 residents. In addition, the Administration failed to follow the Facility Assessment ensuring staff education/training and competencies were completed and failed to ensure policies and procedures were reviewed and updated annually. Findings: 1. Based on interviews and record review, the facility failed to ensure that accommodations were made for a resident, to include the facilities bathing schedule and resident preferences for 1 of 1 resident reviewed for activities of daily living (Resident #24). (F558) 2. Based on interviews and record review the facility failed to develop and implement a grievance policy which includes the resident's rights to a grievance, how to file and/or access grievance forms including anonymously and the response or resolution to grievances. (F565) 3. Based on record review and interview, the facility failed to notify the resident, family and/or the resident's representative in writing of the transfers/discharge to an acute care hospital for 5 of 6 residents sampled for hospitalizations (Residents #7, #108, #31, #28 and #35). (F623) 4. Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member and/or legal representative for 5 of 6 sampled residents who had been transferred to the hospital ((Residents #7, #108, #31, #28 and #35). (F625) 5. Based on interviews and record reviews the facility failed to ensure all facility staff maintain training in cardiopulmonary resuscitation (CPR) for Healthcare Providers, resulting in staff who are responsible for providing CPR without an active CPR certificate for 8 of 27 days reviewed. (F678) 6. Based on interviews and record reviews, the facility failed to provide follow up care for 1 of 1 resident reviewed with a pacemaker (Resident #11). (F684) 7. Based on observations, interviews and record reviews, the facility failed to ensure that staff maintained the appropriate competency and skill required to provide Cardio-Pulmonary Resuscitation (CPR) for 11 of 12 newly hired nursing staff reviewed. This has the potential to effect 7 residents in the facility that maintained a Full Code status. (F726) 8. Based on review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 5 of 5 CNA's reviewed with employment greater than 1 year (CNA #12, CNA #13, CNA #14, CNA #15, CNA #16). (F730) 9. Based on record reviews and interviews, the facility failed to ensure nursing policy & procedure were in place, to develop and implement continuing education for nursing staff, evaluate nurse competencies and develop and maintain a job description for each level of nursing personnel. (T206) 10. Based on observations and interviews, the facility failed to serve and store food in a sanitary manner during 1 of 1 observations of the refrigerator in the main dining room. (F812) 11. Based on interview and employee personnel record reviews, the facility failed to implement and maintain effective training programs for nursing staff in the areas of cardiopulmonary resuscitation (CPR), nursing competencies, dementia care, resident rights and the required 12 hours of annual in-service education training for Certified Nurses Aid (CNA) for 11 of 12 newly hired nursing staff reviewed and 4 of 5 randomly selected CNAs employed greater than 1 year. (F940) 12. Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training and the mandatory yearly trainings for dementia care and resident rights for 4 of 5 randomly selected CNAs employed greater than 1 year (CNA #13, CNA #14, CNA #15, CNA #16). (F947) 13. Review of the Facility Assessment, revised on 8/17/24 states The facility assessment collects information about the facilities resident population to identify the number of resident; facility capacity; the care required; staff competencies . the facilities resources are identified and evaluated to ensure that care can be provided to meet residents needs during the day-to-day operations. Under section, Staff education, Training and Competencies states, every position has a job description that identifies the required education and credentials for the specific job. All credentials in education are verified before hiring . competencies are based on current standards of practice and may include knowledge and a test, knowledge and a return demonstration and observed ability, knowledge and observed behavior in an annual performance evaluation. Competencies are based on the care and services needed by the resident population. Under section, Policies and Procedures for the Provision of Care states, Policy and procedures are reviewed and updated at least annually and as needed with the introduction of new resident care needs, new technology or equipment or a change in the physical plant or environmental hazards. Creation of new policies/revision of existing policies will be done in consultation with the regulatory view in resident needs. On 8/28/24 at 11:42 a.m., during an interview, the Administrator and the Director of Nursing confirmed the facility had never developed or implemented a skills fair or competencies for the nursing staff neither upon hire or annually. In addition, the Director of Nursing confirmed the lack of job descriptions and was unable to provide job descriptions for the following staff: Registered Nurses, Licensed Practical Nurses, Certified Nurses Aid and Certified Medication Technician. Review of the following policies, contained the following: > Emergency Response, was last revised 9/4/2013. > Obstructed airway/choking episode/Heimlich Maneuver was last revised on 9/3/2013. In addition, the policy does not reflect the need for Basic Life Support / Cardiopulmonary Resuscitation (CPR) training for staff. > Finding a resident with no pulse or respiration, was last revised on 7/16/2013 and instructs staff to confirm the resident code status by visualizing a Green dot on the resident's chart binder indicating the resident is a FULL CODE and No dot indicates resident is a DNR (Do Not Resuscitate). The policy does not reflect the need for CPR training and/or maintaining a CPR certificate. On 8/26/24 upon entrance to the facility, the Administrator stated there were no longer any hard charts for the residents, all the resident's records are now in an Electronic Medical Record form (online). On 8/26/24 at 2:22 p.m., during an interview, the Administrator confirmed the facility did not have a grievance policy or procedure in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and employee personnel record reviews, the facility failed to implement and maintain effective training programs for nursing staff in the areas of cardiopulmonary resuscitation (CPR), nursing competencies, dementia care, resident rights and the required 12 hours of annual in-service education training for Certified Nurses Aid (CNA) for 11 of 12 newly hired nursing staff reviewed and 4 of 5 randomly selected CNAs employed greater than 1 year. Findings: Review of the Facility Assessment, revised on [DATE] under section, Staff education, Training and Competencies states, every position has a job description that identifies the required education and credentials for the specific job. All credentials in education are verified before hiring. All employees are trained in the following topics upon hire and annually: Resident rights and Dementia and dealing with difficult behaviors and competencies are based on current standards of practice and may include knowledge and a test, knowledge and a return demonstration and observed ability, knowledge and observed behavior in an annual performance evaluation. Competencies are based on the care and services needed by the resident population. 1. On [DATE] at 2:24 p.m., during an interview, the Director of Nursing (DON) stated she herself was not CPR certified and the facility does not require a CPR certification for staff. On [DATE] at 2:00 p.m., the facility was only able to provide documentation of current CPR certifications for 4 of 14 Registered Nurses, 2 of 12 Licensed Practical Nurses and 7 of 51 Certified Nurses Aids. 2. On [DATE] at 11:42 a.m., during an interview, the Administrator and the Director of Nursing stated the facility had never developed or implemented a skills fair or competencies for the nursing staff neither upon hire nor annually. 3. On [DATE], review of CNA #13, CNA #14, CNA #15 and CNA #16 employee education files lacked dementia and/or resident rights education as well as 12 required hours for continuing education yearly. On [DATE] at approx. 2:15 p.m., the above was discussed with the Administrator and Director of Nursing

Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training and the mandatory yearly trainings for dementia care and resident rights for 4 of 5 randomly selected CNAs employed greater than 1 year (CNA #13, CNA #14, CNA #15, CNA #16). Findings On 8/28/24, a surveyor reviewed the following employee education files: 1. CNA #13 was hired 8/4/21. Review of CNA #13 Employee In-service/attendance Records lacked evidence of dementia and resident rights training. In addition, she has 7.5 of the 12 hours required for continuing education for the year of 2023. 2. CNA #14 was hired 8/10/22. Review of CNA #14 Employee In-service/attendance Records lacked evidence of dementia training. In addition, she has 9 of the 12 hours required for continuing education of the year 2023. 3. CNA #15 was hired 9/16/21. Review of CNA #15 Employee In-service/attendance Records lacked evidence of dementia training and resident rights training. In addition, she has 11 of the 12 hours required for continuing education of the year 2023. 4. CNA #16 was hired 7/29/20. Review of CNA #16 Employee In-service/attendance Records lacked evidence of resident rights training. In addition, she has 5.5 of the 12 hours required for continuing education of the year 2023. On 8/28/24 at 12:30 p.m., in a interview, the Director of Nursing confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to adequately ensure maintenance services necessary to maintain resident's wheelchairs in good repair and sanitary condition and failed to maintain a clean homelike environment on 2 of 3 units ([NAME] and [NAME]). Findings: From 5/9/22 - 5/10/22 a surveyor observed the following: 1. [NAME] unit; room [ROOM NUMBER], 102A and 121 wheelchair armrests were ripped/torn and missing material, creating uncleanable surfaces. 2. [NAME] Unit: room [ROOM NUMBER] wheelchair armrests were ripped/torn and missing material, creating uncleanable surface. 3 stained ceiling tiles in between the nurse's station and the kitchenette, 1 stained ceiling tile above the cabinets in kitchenette and 2 stained ceiling tiles in the TV room across from the kitchenette. The hall fan wire cover, between room [ROOM NUMBER] and 107, was ripped from the wall, peeling off paint with several pieces of scotch tape holding it in place. On 5/10/22 at 4:32 p.m., a surveyor confirmed the above findings during the environment tour, with the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a care plan included a care area for diabetes management for 1 of 36 sampled residents with care plans developed electronically (#25), Finding: Resident #25 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus and is on medications related to diabetes management. The medical record lacked evidence that a comprehensive care plan had been developed in the areas of diabetes mellitus management. On 5/11/22 at 12:45 p.m., during an interview with the Director of Nursing, a surveyor confirmed this finding.

Based on record review and interview, the facility failed to establish a system of records for disposition for all controlled drugs to enable accurate reconciliation for the use of Fentanyl (controlled substance, schedule II) transdermal patch for 2 of 3 residents reviewed for Fentanyl transdermal patch use (#37 and #51). Findings: On 12/10/21 at 4:19 p.m., Division of Licensing received the following facility report of drug diversion: On 12/10/21 at 9:30 a.m., Licensed Practical Nurse (LPN #1) became acutely ill while working and was sent to the hospital. LPN #2 was unable to find Resident #37's Fentanyl patch on his/her person that had noted to be in place at the onset of LPN #1's shift and discovered the narcotic count for the Resident #37 Fentanyl patches was missing one patch. On 12/15/21 the facilities follow up indicated both of the patches were found at the hospital with LPN #1. The actions taken by the facility stated, they had revised our Fentanyl patch polices to include a policy of two nurse's signing off when removing and old patch and accounting for the destruction of the used patch. Guardian Pharmacy: Control Substance Disposal policy and procedure, effective 5/1/18 states in Section B. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed staff, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substance wasted for any reason. Controlled Substance Storage policy and procedure, effective 5/1/18 states in Section E: At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two appropriately licensed/certified personnel and is documented. Facilities Monitoring the Placement of Fentanyl Patches on Residents, after application and Removal of the Used Patches policy and procedure, revised on 12/16/21 after the drug diversion incident, to include the following: Removal and disposing of used fentanyl patch. 1. When removing a fentanyl patch, two licensed nurses, must dispose of the used patched together into a sharp container. 2. Both licensed nurses shall sign off and acknowledge the destruction of the used patch on the form titled Disposal of Open and Used Fentanyl Patches On 5/9/22 Resident #37's medical record lacked evidence of fentanyl patch destructions with 2 nurses prior to 12/19/21. Further review noted on 4/21/22 the record lacked documentation of destruction of the fentanyl patch by 2 nurses. On 5/9/22 Resident #51's medical record lacked evidence of the fentanyl patch destruction with 2 nurses on 4/29/22 and there was no evidence of fentanyl patch placement review for the month of March and April of 2022. On 5/11/22 at 12:29 p.m., in an interview with the Director of Nursing (DON) she confirmed the above findings and stated she could not find March and April 2022 fentanyl patch placement review. On 5/9/22 at 1:35 p.m., in an interview with LPN #3 she stated, prior to December, she was allowed to remove a fentanyl patch from the resident and destroy it without a second nurse witness. Since then, she is required to have another nurse witness destruction of the used fentanyl patch. She then stated they had always counted the cart with 2 nurses and checked to verify the patch placement when changing shifts. On 5/9/22 at 1:45 p.m., in an interview with LPN #4, she stated, prior to December, she doesn't believe fentanyl patches were destroyed with 2 nurses. On 5/9/22 at 1:49 p.m., in an interview with the DON, she stated she has been working in a nurse capacity since 2010 and has never had to have 2 nurses sign off to destroy fentanyl patches stating, nurses were always able to destroy by themself and It wasn't until the incident (12/10/21) when we updated the policy to have 2 nurses verify destruction of fentanyl patches. She then stated, on 12/10/21 LPN #1 was responsible for the medication cart containing narcotics but did not sign to verify placement of the patch on Resident #37 or the count for the patches. On 5/11/21 at 1:32 p.m., during an interview with the LPN #2, she stated she was called into work on 12/10/21 because LPN #1 was sent to the hospital. When she arrived approx. 9:30-10:00 a.m., she took over the medication cart from the Nurse Manager and did not count the controlled substances at that time. When it was time to administer Resident #37's new fentanyl patch, the count was wrong. On 5/11/22 at 2:13 p.m., during an interview with the Director of nursing, the above concerns were discussed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility failed to date biological's after opened and according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms, 3 out of 3 medication carts and 1 of 3 treatment carts. In addition, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked in 1 of 2 medication rooms observed. Findings: Guardian Pharmacy policy and procedure for Controlled Substance Storage, effective 5/1/18 states in Section B: Schedule [II-V] medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation and Section C: Controlled substances that require refrigeration are stored within a locked box within the refrigerator. For NF/SNF facilities, this box must be attached to the inside of the refrigerator. 1. On 5/10/22 at 7:20 a.m., observation of the facilities main medication room, [NAME] unit medication cart and treatment cart with a Licensed Practical Nurse (LPN) the following was observed: * In the main medication room: one opened bottle of Melatonin 1 milligram (mg) tablets with an expiration date of 3/22 and two opened multi use vials of Tuberculin Purified Protein Derivative (TB) with manufactures directions to discard opened product after 30 days, further observation revealed that the TB vials did not have an opened date nor a discard date. * [NAME] Medication cart: one bottle of Melatonin 1 mg tablets with an expiration date of 3/22 and an opened bottle of Acidophilus, Probiotic, with manufactures instruction to Refrigerate after opening. * [NAME] Treatment cart: an opened Basaslar Kiwi insulin Pen, with a manufacturer specification indicating after first use to discard unused medication after 28 days, further observation revealed the insulin pen did not have an opened date nor a discard date. At this time the LPN confirmed the above observations. 2. On 5/10/22 at 7:39 a.m., observation of the [NAME] unit medication cart with a Registered Nurse (RN) the following was observed: * One opened bottle of Melatonin 1 mg tablets with an expiration date of 3/22 * One opened bottle of Acidophilus, Probiotic, with manufactures instruction to Refrigerate after opening. At this time the RN confirmed the above observations. 3. On 5/10/22 at 7:52 a.m., observation of [NAME] unit medication cart and the medication room with an LPN the following was observed: * In the [NAME] medication cart: One opened bottle of stool softener, Docusate 100 mg tablets with expiration date of 4/22, an opened bottle of Melatonin 1 mg tablets with an expiration date of 3/22 and an opened bottle of Cetirizine 10 mg with expiration date of 4/22. * In the [NAME] medication room refrigerator, containing OTC medications, on the door of the refrigerator, was an opened bottle of liquid Lorazepam (controlled substance, schedule IV) for Resident #53. The Lorazepam was not stored in a permanently affixed and double locked compartment separate from other medications. On 5/10/22 at 11:31 a.m., observation of the main medication room refrigerator with the Director of Nursing (DON), contained a locked toolbox, not affixed to the fridge. The Director of Nursing stated the only liquid Ativan that is double locked is in the emergency kit (the toolbox) for which the key is obtained through the Pyxis. Otherwise, resident's liquid Ativan is in the fridge on the units, under one lock. At this time, the surveyor discussed the above findings with the DON who confirmed the liquid Lorazepam in the toolbox was not affixed to the fridge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure the confidentiality of protected health information for 3 of 62 residents 2 of 4 days of survey (Residents #2, #25 and #37). Findings: 1. On 10/22/19 at 7:40 a.m., a surveyor observed the [NAME] Medication Cart computer, located in the hallway, with a full open display monitor unlocked, leaving Resident #37's electronic Medication Administration Record (eMAR) displayed, visible and easily accessible to residents, visitors or other unauthorized persons. There were two residents near the area. Approximately five (5) minutes later, a Licensed Practical Nurse (LPN) returned to the [NAME] Medication cart computer and secured the screen from view. The LPN stated he/she had brought a resident to the main dining room off the unit. On 10/22/19 at 7:45 a.m. in an interview with the LPN, the surveyor confirmed that the screen with the eMAR was open and confirmed the concern for exposing clinical information on the medication cart computer. 2. On 10/23/19 at 8:30 a.m., a surveyor observed medication administration on the [NAME] Unit with a LPN. The LPN prepared medications for Resident #2 at the medication cart in the unit corridor, then proceeded to Resident #2's room down the corridor to administer the medications, leaving the eMAR open, exposing Resident #2's identifying and clinical information in areas where unauthorized personnel pass through. On 10/23/19 at 9:00 a.m., the surveyor observed medication administration on the [NAME] Unit with the same LPN. The LPN prepared medications for Resident #25 at the medication cart in the unit corridor and left the medication cart to retrieve liquid lorazepam from the medication refrigerator, leaving the eMAR open exposing Resident #25's identifying and clinical information. On 10/23/19 at 9:10 a.m., in an interview with the LPN, the surveyor informed the LPN that he/she had left Resident #2 and #25's eMARs open, exposing confidential clinical information for both residents. During the interview the LPN acknowledged the privacy concern and the surveyor confirmed the privacy finding. On 10/24/19 at 9:14 a.m., in an interview with the Director of Nursing, the surveyor informed him/her of the privacy concern and confirmed the finding.