**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents were properly screened for eligibility to receive the recommended pneumococcal vaccine, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner for four Residents (#1, #52, #49, and #278), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled Pneumococcal Vaccine Timing for Adults, dated March 2023, indicated the following: Make sure your patients are up to date with pneumococcal vaccination. Adults >= [AGE] years old, Complete Pneumococcal Vaccine Schedules: -PCV13 (pneumococcal conjugate vaccine) only at any age - give PCV20 (pneumococcal 20-valent conjugate) or PPSV23 (pneumococcal polysaccharide vaccine) >= 1 year later -PPSV23 only at any age - give PCV20 or PCV15 (pneumococcal 15-valent conjugate) >= 1 year later -PCV13 at any age and PPSV23 at >= 65 years - give PCV20 >= 5 years later Review of the facility's policy titled Pneumococcal Vaccine, revised April 2023, indicated but was not limited to the following: -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission. -Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of education shall be documented in the resident's medical record. -Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. -Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. -Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Resident #1 was admitted to the facility in March 2024 and was [AGE] years old. Review of the admission Consent for Immunization and Treatment form, dated 3/16/24, indicated Resident #1 had already received the PCV20 vaccine, but the date was unknown. The consent form did not include any other type of pneumococcal vaccine. Review of the Immunization Report did not indicate Resident #1 had received any pneumococcal vaccinations. Review of the Update Immunization document, dated 9/21/18, indicated Resident #1 was not eligible to receive the pneumococcal vaccine as the Resident had previously received it and was not due. Review of the Update Immunization document, dated 5/7/24, indicated the Resident had declined immunization at this time VIS provided though was not clear what vaccination the Resident was educated on, offered, or had declined. Review of Resident #1's Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated the following pneumococcal vaccination administered: -PCV13, 9/27/17 Review of the medical record did not indicate Resident #1 had received either the PCV20 or PPSV23 >= 1 year after the PCV13 vaccination per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended pneumococcal vaccine dose in the series, the provision of education related to the vaccine, and offering and administration (if applicable) of the vaccine in accordance with CDC guidance and facility policy. During an interview on 6/3/24 at 1:53 P.M., the Director of Nursing (DON), Infection Preventionist (IP) #1, and IP #2 said they didn't know for sure if or when Resident #1 received the PCV20 vaccine or if he/she was eligible to receive the next dose in the series and would have to look into it. During an interview on 6/4/24 at 7:52 A.M., the DON, IP #1, and IP #2 said there had been no follow up on screening and eligibility or provision of education for the Resident to receive the next recommended dose in the pneumococcal series. During an interview on 6/4/24 at 2:58 P.M., the DON, IP #1, and IP #2 said Resident #1 was eligible to receive the most up to date/recommended dose of the pneumococcal vaccine. During an interview on 6/5/24 at 10:03 A.M., IP #1 and IP #2 said the pneumococcal ineligible discussion with the Resident was held in 2018 but could not provide documentation that the Resident's pneumococcal vaccination status had been followed up on since then and the Update Immunization document, dated 5/7/24, education and refusal was for a different vaccine, not the pneumococcal vaccine. 2. Resident #52 was admitted to the facility in November 2023 and was [AGE] years old. Review of the admission Consent for Immunization and Treatment form, dated 10/10/23, indicated Resident #52 had already received the PCV13 and PPSV23 vaccines. The dates received were not indicated. The form did not contain a section related to the PCV20 vaccine for the Resident to give consent to receive the vaccine, whether the Resident had already received the vaccine and when, or to indicate refusal of the vaccine. Review of Resident #52's Massachusetts Immunization Information System (MIIS) Vaccine Administration Record and the facility's Immunization Report did not indicate previous administration of any pneumococcal vaccinations. Review of the facility's immunization tracking log indicated Resident #52 received the PCV13 pneumococcal vaccine on 7/30/20. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended pneumococcal vaccine dose, the provision of education to the Resident/representative related to the vaccine or offering and administration (if applicable) of the vaccine in accordance with CDC guidance and facility policy. During an interview on 6/3/24 at 2:51 P.M., with the DON, IP #1, and IP #2, the DON said they should have determined screening and eligibility, provided education, and offered/administered the most up to date pneumococcal vaccine for Resident #52 but did not. 3. Resident #49 was admitted to the facility in May 2024 and was [AGE] years old. Review of the admission Consent for Immunization and Treatment form, dated 5/16/24, indicated unknown for the PCV20 vaccine. The section was not completed to indicate consent to receive the vaccine, if the Resident already received the vaccine with the date received, or if the Resident had refused the vaccine. Review of the facility's immunization tracking log and Resident #49's Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated the following pneumococcal vaccinations administered: -PPSV23 - 11/15/17 The facility's Immunization Report did not indicate Resident #49 had received any pneumococcal vaccinations. Review of the medical record did not indicate Resident #49 had received the recommended PCV20 or PCV15 vaccine >= 1 year after the PPSV23 vaccine per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended pneumococcal vaccine dose, the provision of education to the Resident/representative related to the vaccine or offering of the vaccine in accordance with CDC guidance and facility policy. During an interview on 6/4/24 at 2:54 P.M., the DON, IP #1, and IP #2 said they'd need to call the primary care physician or the Resident's son to determine whether or not the Resident had received the PCV20 pneumococcal vaccine. 4. Resident #278 was admitted to the facility in May 2024 and was [AGE] years old. Review of the admission Consent for Immunization and Treatment form, dated 5/26/24, indicated the Resident had already received PCV20 pneumococcal vaccine. There was no date indicated. Review of the facility's immunization tracking log and Resident #278 Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated the following pneumococcal vaccinations administered: -PCV13 - 12/1/16 -PPSV23 - 12/2/13 -Pneumococcal, unspecified, -12/2/13 Review of the facility's Immunization Report did not indicate Resident #278 had received any pneumococcal vaccinations. Review of the Resident #278's Update Immunization document indicated the Resident was educated on the COVID-19 vaccine on 3/21/24 (prior to admission), not the pneumococcal vaccine, and in the notes, field had declined all immunizations offered, VIS provided PCV, RSV, and Covid. The report indicated consent was obtained on 4/25/24 (prior to admission) as a refusal of the offered immunizations. The report did not indicate which PCV pneumococcal vaccine (PCV20 or PCV13) the Resident/representative had declined. Review of the medical record did not indicate Resident #278 had received the recommended PCV20 vaccine >= 5 years after the PCV13 and PPSV23 vaccines per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended pneumococcal vaccine dose, the provision of education to the Resident/representative related to the vaccine or offering of the vaccine in accordance with CDC guidance and facility policy. During an interview on 6/3/24 at 1:24 P.M., the DON said she would have to get back to the surveyor about Resident #278's PCV20 vaccine status. During an interview on 6/4/24 at 2:34 P.M., the DON, IP #1, and IP #2 said the admitting nurse completes the admission immunization form and reviews it with the residents. IP #1 said they had recently started to review them to see who's eligible for the vaccine. She said MIIS information gets uploaded in the documents section of the residents' electronic records and staff also obtain immunization data from discharge records, by the resident/representative, or the primary care physician. IP #1 said she hasn't checked to see if Resident #278 was eligible to receive the next recommended pneumococcal vaccination (PCV20). The DON said there weren't a lot of systems in place when they started at the facility and the immunization program needed to be looked at harder. The DON said Resident #278 was eligible to receive the PCV20 and should have been screened and eligibility determined. She said vaccine education was not on the facility's Consent for Immunization form. The DON said there was no documentation of education related to the PCV20 vaccine for Resident #278 and the admission assessments didn't have it there either. During an interview on 6/4/24 at 3:01 P.M., the DON, IP #1 and IP #2 said all residents should be offered, when indicated, pneumococcal vaccinations. They said they follow CDC guidance mostly, whatever is more stringent, and Residents #1, #52, #49, and #278 were not up to date with their pneumococcal vaccinations per CDC guidance. They said the vaccine was not administered per protocol. During an interview on 6/5/24 at 7:53 A.M., IP #2 said Resident #278's Update Immunization document had incorrect documentation regarding the date education was provided and said it was prior to the Resident's current admission. She said because of the type of insurance the Resident had, he/she had been previously discharged from the facility and was currently considered a new admission in May 2024 and should have been re-offered the recommended pneumococcal vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents were properly screened for eligibility to receive the most up to date COVID-19 vaccine, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and offered and administered (if applicable) the vaccine in accordance with CDC recommendations for three Residents (#52, #49, and #43), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Stay Up to Date with COVID-19 Vaccines, dated as revised on 4/25/24 and 5/14/24, indicated but was not limited to the following: -CDC recommends the 2023-2024 updated COVID-19 vaccines: Pfizer-BioNTech, Moderna, or Novavax, to protect against serious illness from COVID-19. -Everyone 5 years and older should get 1 dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. None of the updated 2023-2024 COVID-19 vaccines is preferred over another. -People aged 65 years and older who received 1 dose of any updated 2023-2024 COVID-19 vaccine (Pfizer-BioNTech, Moderna or Novavax) should receive 1 additional dose of an updated COVID-19 vaccine at least 4 months after the previous updated dose. -People aged 65 years and older: You are up to date when you have received 2 updated 2023-2024 COVID-19 vaccine doses. -People who are up to date have lower risk of severe illness, hospitalization, and death from COVID-19 than people who are unvaccinated or who have not completed the doses recommended for them by CDC. Review of the facility's policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents, revised January 2024, indicated but was not limited to the following: -Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident is fully vaccinated. -COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by his or her designee. -Vaccines are administered in accordance with CDC, ACIP, FDA and manufacturer guidelines. -Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. -Residents are screened for contraindications to the vaccine, medical precautions, and prior vaccination before being offered the vaccine. -When COVID-19 vaccines are administered as a series of doses, individuals who receive one in a series are scheduled for the subsequent dose. -If a resident requests vaccination, but missed earlier opportunities for any reason, the vaccine will be offered to that resident as soon as possible. Efforts to help the resident obtain vaccination are documented. -The resident's medical record includes documentation that indicates, at a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine including .the date the education took place; b. Signed consent; and c. Each dose of COVID-19 vaccine that was administered to the resident. -If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination or refusal, appropriate documentation is made in the resident's record. Review of the facility's policy titled Vaccination of Residents, revised October 2019, indicated but was not limited to the following: -New residents shall be assessed for current vaccination status upon admission. 1. Resident #52 was admitted to the facility in November 2023 and was [AGE] years old. Review of the admission Consent for Immunization and Treatment form, dated 10/10/23, indicated Resident #52 had already received the current recommended COVID-19 vaccine but the date was unknown. Review of Resident #52's Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated the following COVID-19 vaccinations as being administered: -COVID-19 Moderna 2/3/21, 3/3/21 -COVID-19 Pfizer 11/15/21 Review of the Immunization Report indicated Resident #52 received one dose of an updated 2023-2024 COVID-19 vaccination on 1/10/24 at the facility. Review of the medical record failed to indicate Resident #52 was up to date with his/her COVID-19 vaccinations per CDC guidance as he/she did not receive 1 additional dose of an updated 2023-2024 COVID-19 vaccine at least 4 months after the previous updated dose. Further review of the medical record failed to indicate documentation of follow up screening and eligibility to receive the most up to date COVID-19 vaccine, the provision of education provided to the Resident/representative related to the COVID-19 vaccine, and offering and administration (if applicable) of the vaccine in accordance with CDC recommendations and facility policy. During an interview on 6/3/24 at 2:51 P.M., with the Director of Nursing (DON), Infection Preventionist (IP) #1 and IP #2, the DON said they should have performed screening, eligibility, the provision of education, and offering/administration of the most up to date COVID-19 vaccine booster for Resident #52 but did not. 2. Resident #49 was admitted to the facility in May 2024 and was [AGE] years old. Review of the admission Consent for Immunization and Treatment form, dated 5/16/24, indicated unknown for the COVID-19 vaccine. The section of the form, if completed, would have indicated if the Resident/representative gave consent to receive the current recommended dose of the COVID-19 vaccine, had already received the vaccine, or refused to receive the vaccine. Review of Resident #49's Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated the following COVID-19 vaccinations administered: -COVID-19 Pfizer 2/24/21, 3/23/21, 12/13/21, 10/19/22 Review of the medical record did not indicate Resident #49 was up to date with his/her COVID-19 vaccinations per CDC guidance as there was no documentation that he/she had received 2 updated 2023-2024 COVID-19 vaccine doses. Further review of the medical record failed to indicate documentation of follow up screening and eligibility to receive the most up to date COVID-19 vaccine, the provision of education provided to the Resident/representative related to the COVID-19 vaccine and offering of the vaccine in accordance with CDC recommendations and facility policy. During an interview on 6/4/24 at 2:54 P.M., the DON, IP #1 and IP #2 said they didn't know the COVID-19 vaccination status of Resident #49 and would need to call the Resident's primary care physician or the Resident's son. 3. Resident #43 was admitted to the facility in July 2023 and was [AGE] years old. Review of the admission Consent for Immunization and Treatment form, dated 10/18/23, indicated the Resident/representative gave consent to receive the current recommended dose of the COVID-19 vaccine. Review of the Immunization Report indicated Resident #43 received one updated 2023-2024 COVID-19 vaccination on 12/13/23 at the facility. Review of the medical record failed to indicate Resident #43 was up to date with his/her COVID-19 vaccinations per CDC guidance as there was no documentation that he/she had received 2 updated 2023-2024 COVID-19 vaccine doses. Further review of the medical record failed to indicate documentation of follow up screening and eligibility to receive the most up to date COVID-19 vaccine, the provision of education provided to the Resident/representative related to the COVID-19 vaccine, and offering and administration of the vaccine in accordance with CDC recommendations and facility policy. During an interview on 6/4/24 at 2:34 P.M., with the DON, IP #1 and IP #2, IP #1 said the admitting nurse completes the admission immunization consent form with the resident/representative. She said they recently just started to review them though to see who's eligible to receive what immunizations. The DON said there weren't a lot of systems in place when they started at the facility and the immunization program needed to be looked at harder. During an interview on 6/4/24 at 2:56 P.M. with the DON, IP #1 and IP #2, the DON said previous CDC guidance suggested Resident #43 was due for an updated COVID-19 vaccine in April 2024 but had not received it yet. During an interview on 6/4/24 at 3:01 P.M., the DON, IP #1 and IP #2 said all residents should be offered, when indicated, COVID-19 vaccinations. They said they follow CDC guidance mostly, whatever is more stringent, and Residents #52, #49, and #43 were not up to date with their COVID-19 vaccinations. They said the vaccine was not administered per protocol.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had physicians orders for Lithium (chemical element, used to treat bipolar disorder), the Facility failed to ensure nursing notified his/her Physician and Family Representative when on 5/10/23, it was determined by nursing that Resident #1's new physicians order for Lithium that had been obtained on 5/04/23, (which decreased the total weekly amount of Lithium he/she was to be administered), had not been transcribed onto his/her Medication Administration Record (MAR), and he/she continued to receive the previously ordered dosage. Although Nurse #1 identified the transcription error and reported it to the (now Former) Director of Nurses at that time, neither the Physician or Resident #1's Family Representative were notified. Findings include: Review of the Facility Policy titled, Change in a Resident's Condition, dated as last revised 2/2021, indicated that the Facility promptly notifies the resident, his/her attending physician, and the resident's representative of changes in the residents medical/mental condition and/or status. The Policy further indicated that the Nurse will notify due to the following; -Accident or incident involving the resident; -Adverse reaction to medication; -Significant Change in the resident's physical/emotional/mental condition; and -Need to alter resident's medical treatment significantly; Resident #1 was admitted to the Facility in April 2023, diagnoses included a change in mental status, urinary tract infection, dementia, and bipolar (extreme mood swings between depression and mania) disorder. Review of Resident #1's Physician's Order, dated 4/16/23, indicated to administer Lithium Extended Release (ER, medication is released over a period of time and remains longer in the body) 450 milligrams (mg) tablet, give (half tablet) for a total of 225 mg by mouth (PO) daily (for a total of 1,575 mg weekly). Review of Resident #1's Psychiatric Nurse Practitioner (NP) Progress Note, dated 5/03/23, indicated to discontinue his/her Lithium 225 mg daily and decrease his/her overall Lithium dose to Lithium 300 mg, four times a week Monday, Wednesday, Friday, and Saturday (for a total of 1,200 mg weekly), recheck Resident #1's Lithium serum (blood) level after one week and notify the NP of any issues. During an interview on 11/01/23 at 12:07 P.M., Nurse #1 said on 5/04/23, she received a verbal order from Resident #1's physician to decrease his/her Lithium dose (as recommended by his/her psychiatric NP). Review of Resident #1's Medical Record, including physician's orders and nursing progress notes, indicated that there was no documentation to support nursing obtained or transcribed a physician's order to decrease Resident #1's Lithium dose when the verbal order was given to Nurse #1 by his/her physician on 5/04/23. Review of Resident #1's Medication Administration Record (MAR), dated 5/04/23 through 5/10/23, indicated he/she received Lithium ER 225 mg daily. Nurse #1 said she realized on 5/10/23, while completing a laboratory slip for a blood draw to check Resident #1's Lithium serum level, that she never transcribed the physician's order for the change to his/her Lithium. Nurse #1 said she immediately informed the (Former) Director of Nurses (DON). Nurse #1 said she did not inform the physician, his/her family, or the psychiatric NP that the order had not been transcribed or that Resident #1 had not been receiving the correct dose of Lithium for a week. During a telephone interview on 11/06/23 at 12:18 P.M., the Physician said he was unaware until 6/06/23, when Resident #1's Family Member informed him that nursing never reduced Resident #1's Lithium dose as ordered on 5/04/23. During a telephone interview on 11/06/23 at 12:48 P.M., the Psychiatric NP said she was never made aware that her recommendations to decrease Resident #1's Lithium dose had not been completed until a week later. The NP said on 5/17/23, when she followed-up with Resident #1, she thought it was strange that knowing the dose of his/her Lithium should have been lowered back on 5/04/23, that his/her Lithium serum levels had increased. During an interview on 11/01/23 at 3:22 P.M., the (Current) Director of Nurses (DON) said she started working at the Facility 5/23/23 and Resident #1 had already been discharged . The DON said it is the expectation of the Facility that when a medication error is identified, that the resident's Physician and the Family Representative are to be notified immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure they were free from significant medication errors, when 1) Resident #1's new physicians order obtained on 5/04/23 to decrease his/her dose of Lithium (chemical element, used to treat bipolar disorder) was not transcribed by nursing until a week later, resulting in his/her serum (blood) levels of Lithium to increase, and 2) Resident #3 who was newly admitted to the Facility in July 2023, and due to an error in medication reconciliation upon admission, he/she was administered only half the physician's order dosage of Eliquis (an anticoagulant that thins the blood), during his/her stay in the facility, placing him/her at risk for reoccurrence of blood clots. Findings Include: Review of the Facility Policy, titled Telephone Orders, undated, indicated verbal/telephone orders may be accepted for each resident's attending physician and must include the following; -The order must be reduced to writing, by the person receiving the order, and record the order into the medical record; and -The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Review of the Facility Policy, titled Reconciliation of Medications on Admission, undated, indicated the purpose of the procedure is to ensure medication safety by accurately accounting the resident's medications, routes and dosages upon admission or readmission to the Facility. 1) Review of Resident #1's Medication Incident Report, dated 5/26/23, indicated that on 5/10/23, Nurse #1 realized she had not transcribed an order that she verbally received from his/her Physician on 5/04/23 to decrease Resident #1's Lithium dosage. Review of an Article in Drugs.com, Lithium Prescribing Information Data, dated as last updated May 27, 2023, indicated Lithium Carbonate is a mood stabilizing agent indicated for the treatment of manic episodes and as maintenance treatment for bipolar disorder. The Article indicated that the normal blood serum lithium concentrations should be maintained at 0.8 to 1.0 milliequivalents (mEq/L), that Lithium toxicity is closely related to serum lithium concentrations and can occur at doses close to therapeutic concentrations. The Article indicated Geriatric patients often respond to reduced dosages and may exhibit signs of toxicity at serum concentrations ordinarily tolerated by other patients. The Article further indicated toxic concentrations for Lithium toxicity are greater than or equal to 1.5 mEq/L and some early signs of lithium toxicity may include diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination. Resident #1 was admitted to the Facility in April 2023, diagnoses included a change in mental status, urinary tract infection, dementia, and bipolar disorder (mental health condition that involves extreme mood shifts). Review of Resident #1's Physician's Order, dated 4/16/23, indicated to administer Lithium Extended Release (ER) tablet 450 milligrams (MG), give (1/2 tablet) for a total 225 mg by mouth (PO) daily (for a total of 1,575 mg a week). Review of Resident #1's Psychiatric Nurse Practitioner (NP) Progress Note, dated 5/03/23, indicated to discontinue his/her Lithium ER 225 mg daily and decrease his/her overall dose to Lithium ER 300 mg four times a week (for a total of 1,200 mg a week), to be administered on Monday,Wednesday, Friday, Saturday and recheck Resident #1's Lithium serum level after one week. The Psychiatric NP Progress Note also indicated that Resident #1's latest Lithium serum level, drawn on 4/25/23 was 1.04 mEq/L and nursing was to notify his/her Pinnacle Nurse Practitioner (NP) with any issues. During an interview on 11/01/23 at 12:07 P.M., Nurse #1 said on 5/04/23, she received a verbal order from Resident #1's physician to decrease his/her Lithium dose (as recommended by his/her psychiatric NP), however, said she realized on 5/10/23, while completing a laboratory slip for a blood draw to check Resident #1's Lithium serum level, that she never transcribed the order. Nurse #1 said she immediately informed the (Former) Director of Nurses (DON). Nurse #1 said she did not inform the physician, the family, or the psychiatric NP that the order had not been transcribed or that Resident #1 had been receiving the correct dose of Lithium for a week. Review of Resident #1's Medication Administration Record (MAR), dated 5/04/23 through 5/10/23, indicated he/she continued to received Lithium ER 225 mg daily. Review of Resident #1's Medical Record, including physician's orders and nursing progress notes, indicated that there was no documentation to support that on 5/04/23, Nurse #1 transcribed the verbal physician's order she obtained to decrease Resident #1's Lithium dose until 5/10/23. Review of Resident #1's Laboratory Results, dated 5/11/23, indicated his/her lithium serum level increased to 1.44 mEq/L. Review of Resident #1's Physician's Order, dated 5/12/23, indicated to administer Lithium ER 300 mg every Monday, Wednesday, Friday, and Sunday (not Saturday). Review of Resident #1's Physician's Order, dated 5/13/23, indicated to administer Lithium ER 225 mg every Monday, Wednesday, Friday, and Saturday (for a weekly total of 900 mg). Review of Resident #1's Physician's Orders, dated 5/16/23, indicated to hold his/her Lithium secondary to a high Lithium serum level which had reached 1.58 mEq/L. Review of Resident #1's Psychiatric NP Progress Note, dated 5/17/23, indicated to continue to hold Lithium and if levels do not improve or worsen consider transfer (to Hospital) for an acute evaluation. During a telephone interview on 11/06/23 at 12:48 P.M., the Psychiatric NP said she was never made aware that her recommendations on 5/03/23 to decrease Resident #1's Lithium dose had not been completed until a week later. The NP said on 5/17/23, when she followed-up with Resident #1, she thought it was strange that knowing that the Lithium dose should have been lowered back on 5/04/23, that his/her Lithium serum levels had actually increased. During an interview on 11/01/23 at 2:42 P.M., the Administrator said Resident #1's Family Member came to him (exact date unknown) and voiced concerns about Resident #1 not being his/herself and said that the Family Member was concerned about his/her lithium serum levels. The Administrator said that Resident #1's Family Member thought his/her lithium serum level was too high for him/her and said they (family members) were assured that the psychiatric NP had recommended lowering the dose. During a telephone interview on 11/06/23 at 1:21 P.M., the Speech Language Pathologist (SLP) said Resident #1's ability to eat declined the week prior to his/her discharge to the Hospital. The SLP said Resident #1 was unable to self feed and he/she exhibited increased confusion as evidence by his/her orientation and short term memory were off. Review of Resident #1's Interact Form dated, 5/19/23, indicated that on 5/12/23, he/she began experiencing a significant change in status, including increased lethargy, requiring more assistance with eating, an increased lithium serum level and on 5/15/23 Resident #1's Health Care Proxy was activated due to increased confusion and on 5/19/23, he/she was sent to the Hospital Emergency Department for evaluation and was admitted . Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated discharge diagnoses included acute toxic metabolic encephalopathy, lithium toxicity, and dehydration. During a telephone interview on 11/06/23 at 12:18 P.M., the Physician said, in regards to Resident #1's Lithium, he was unaware that there was a significant medication error until 6/06/23 when Resident #1's Family Member informed him that the nursing had not reduced Resident #1's Lithium dose as ordered on 5/04/23. The Physician said he activated Resident #1's Health Care Proxy on 5/15/23 related to cognitive changes. During an interview on 11/01/23 at 3:22 P.M., the (Current) Director of Nurses (DON) said she started working at the Facility on 5/23/23 and that Resident #1 had already been discharged to the Hospital. The DON said it is the expectation of the Facility that when a medication error is identified, a medication incident form is filled out, that the DON is to be notified immediately once discovered and the Physician and the Family Representative were to be notified immediately. During an interview on 11/01/23 at 1:12 P.M., the Director of Clinical, Quality, and Compliance, said she was unaware of the transcription/medication error until after the fact and said she did not begin an investigation until 5/26/23. The Director said to the best of her knowledge no one had investigated the error and said she was uncertain if the physician or Resident #1's Family Member had been notified by someone at the Facility about the error. The Director said that the Facility's expectation is that once a medication error is identified, it is to be reported to the DON and investigated immediately. The Director said it is expected that notification to the physician and the Family Representative be made in a timely manner. 2) Resident #3 was admitted to the Facility in July 2023, diagnoses included status post left thalamic (portion of the brain) hemorrhage (bleed), right upper lung pulmonary (lung) embolism (blood clot), and aspiration (inhaled food) pneumonia. Review of Resident #3's Hospital Discharge summary, dated [DATE], indicated to administer Eliquis (medication used to thin the blood) 5 milligrams (mg) by mouth (PO) two times a day (for a total of 10 mg daily). However, review of Resident #3's Physician's Orders, dated 7/21/23, indicated to administer Eliquis 5 mg daily. Review of Resident #3's Medication Administration Record (MAR) indicated he/she received Eliquis 5 mg once daily for his/her entire stay at the Facility (total of 18 days). Review of Resident #3's Physician's and Nurse Practitioner Progress Notes, dated 7/24/23 through 8/07/23, indicated he/she was taking Eliquis 5 mg, two times a day. Review of Resident #3's Medication Error Reporting Form, dated 8/08/23, indicated that upon review of his/her discharge medications, nursing staff recognized an error had been made upon admission within the medication reconciliation process. During an interview on 11/01/23 at 12:07 P.M., Nurse #1 said she could not remember filling out the medication reconciliation form for Resident #3 upon his/her admission. Nurse #1 said when she transcribed Resident #1 medication orders, she completely missed the physicians directions (to be administered two times a day) for the Eliquis. Nurse #1 said she did not identify the medication reconciliation error regarding the administration of Eliquis until his/her day of discharge, (8/08/23). During an interview on 11/01/23 at 3:22 P.M., the Director of Nurses said that she was unaware of the medication reconciliation error until Nurse #1 notified her upon Resident #3's discharge. The DON said it is the expectation of the Facility for nurses to complete the Medication Reconciliation Form electronically in the Point Click Care System (Electronic Medical Record) system. The DON said it is the expectation of the Facility that all nurses follow the proper procedures for medication reconciliation upon admission and readmission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3) the Facility failed to ensure they maintained complete and accurate medical/clinical records, including but not limited to their Medication Administration Records (MAR), the transcription of Physician's Orders and Medication Reconciliation, when 1) for Resident #1, who although nursing obtained a verbal order to change the dose and administration schedules of his/her Lithium (chemical element, used to treat bipolar disorder) the order was not transcribed by nursing until a week later, resulting in the incorrect dosage of Lithium being administered during that time period, and 2) for Resident #3 who was newly admitted to the Facility in July 2023, due to an error in medication reconciliation upon admission, he/she was administered half the physician's ordered dose of Eliquis (medication used to thin the blood) during his/her stay in the facility. Findings Include; Review of the Facility Policy tilted Charting and Documentation, dated as last revised 9/2023, indicated all services provided to the resident, progress towards the care plan goal, or any changes in the resident's condition shall be documented in the resident's medical record. The medical record should facilitate communication between interdisciplinary team regarding the resident's condition and response to care. 1) Resident #1 was admitted to the Facility in April 2023, diagnoses included a change in mental status, urinary tract infection, dementia, and bipolar disorder (mental health condition that involves extreme mood shifts). Review of Resident #1's Physician's Order, dated 4/16/23, indicated to administer Lithium Extended Release (ER) tablet 450 milligrams (mg), give (1/2 tablet) 225 mg by mouth (PO) daily (for a total of 1,575 mg a week). During an interview on 11/01/23 at 12:07 P.M., Nurse #1 said she received a verbal order on 5/04/23 from Resident #1's Physician to decrease his/her Lithium dose. Nurse #1 said Resident #1 new order for Lithium was for 300 mg of Lithium to be administered on Monday, Wednesday, Friday and Saturday (for a weekly total of 1,200 mg). Nurse #1 said on 5/10/23 when she was completing a laboratory slip for a blood draw to check Resident #1's Lithium level, that was when she realized she had not transcribed the new order. Review of Resident #1's Medication Administration Record (MAR), dated 5/04/23 through 5/10/23, indicated he/she received Lithium ER 225 mg daily. Review of Resident #1's Medical Record, including physician's orders and nursing progress notes, indicated that there was no documentation to support Nurse #1 transcribed a Physician's Order to decrease Resident #1's Lithium dose on 5/04/23 until the error was discovered on 5/10/23. 2) Resident #3 was admitted to the Facility in July 2023, diagnoses included status post left thalamic (portion of the brain) hemorrhage (bleed), right upper lung pulmonary(lung) embolism (blood clot), and aspiration (inhaled food) pneumonia. Review of Resident #3's Hospital Discharge summary, dated [DATE], indicated to administer Eliquis (medication used to thin the blood) 5 milligrams (mg) by mouth (PO) two times a day (for a total of 10 mg a day). Review of Resident #3's Facility Physician's Orders, dated 7/21/23 (as transcribed by nursing), indicated to administer Eliquis 5 mg po daily. However, review of Resident #3's Physician's and Nurse Practitioner Progress Notes, dated from 7/24/23 through 8/07/23, indicated he/she was being administered Eliquis 5 mg twice a day. Review of Resident #3's Medication Administration Record (MAR), dated 7/22/23 through 8/08/23, indicated he/she received Eliquis 5 mg once daily for his/her entire stay at Facility (18 days). During an interview on 11/01/23 at 12:07 P.M., Nurse #1 said she could not remember filling out the medication reconciliation form for Resident #3 upon his/her admission. Nurse #1 said when she transcribed Resident #1 medication orders, she completely missed the physicians directions (to be administered two times a day) for the Eliquis. Nurse #1 said she did not identify the medication reconciliation error regarding the administration of Eliquis until his/her day of discharge, (8/08/23). During an interview on 11/01/23 at 3:22 P.M., the Director of Nurses (DON) said that she was unaware of the medication reconciliation error until Nurse #1 notified her on Resident #3's day of discharge. The DON said that it is the expectation of the Facility to complete the medication reconciliation form found in the Point Click Care System (electronic medical record system). The DON said it is the expectation of the Facility that all nursing staff follow the proper procedure for medication reconciliation upon admission and readmission and that a second licensed nurse will verify orders with the Nurse prior to reviewing medications with the Physician.

Based on observations, record reviews, and interviews, the facility failed to notify the physician of changes in the health condition of one Resident (#69), out of a total sample of 22 residents. Findings include: Review of the facility's policy, Change in Resident's Condition or Status, last revised February 2021, included but was not limited to: -Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status Resident #69 was admitted to the facility in April 2021 with diagnoses including chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/7/23, indicated Resident #69 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15, required extensive assistance from staff for toileting and did not have a urinary catheter. On 2/14/23 at 8:28 A.M., the surveyor observed Resident #69 sitting upright in bed eating breakfast. The Resident's urinal was on the overbed table which contained a small amount of dark pink/red tinged urine. Nurse #4 entered Resident #69's room and placed bilateral hearing aids into the Resident's ears. The nurse did not notice the urinal containing dark pink/red tinged urine on the Resident's overbed table. The surveyor pointed to the urinal and asked the nurse if the color of the urine was normal for Resident #69. Nurse #4 said the urine was very dark pink and was not normal for the Resident. She took the urinal to the bathroom, poured the urine into the toilet, and flushed. She said she would let the Physician know the Resident's urine was dark pink. On 2/14/23 at 1:32 P.M., the surveyor observed Resident #69 seated in a wheelchair at the bedside sleeping. A urinal was on an overbed table which contained a small amount of dark pink/red tinged urine. During an interview on 2/14/23 at 2:03 P.M., Nurse #4 said that she had not yet notified Resident #69's Physician that his/her urine was dark pink/red tinged this morning. She said the Physician is supposed to be coming into the facility tonight and will be notified when he comes in. During an interview on 2/14/23 at 2:05 P.M., Unit Manager #2 said Nurse #4 did not notify her that she saw Resident #69's urine was tinged dark pink/red this morning. She said Nurse #4 should have notified her, notified the Physician and further assessed the Resident within one hour of finding the Resident's urine dark pink/red this morning. Unit Manager #2 said it was not acceptable to wait for the Physician to come into the facility to notify him of a change in condition.

Based on interview, record review, and policy review, the facility failed for one Resident (#30), out of a total sample of 22 residents, to develop and implement a comprehensive behavior care plan with measurable goals and individualized interventions to address behaviors exhibited towards a roommate. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated but was not limited to the following: - comprehensive care plans include measurable objectives and timetables to meet a resident's psychosocial needs - the comprehensive care plan should reflect currently recognized standards of practice for problem areas Resident #30 was admitted to the facility in August 2022 for a short-term rehabilitation stay following a fall at home. During an interview on 2/9/23 at 7:55 A.M., Resident #30 said he/she had issues with their roommate and said their roommate is noisy intentionally to get attention. Review of the progress notes for Resident #30 indicated in November of 2022 the Resident was informed he/she was not safe to return home independently and the family decided the Resident would remain at the facility long term. A follow up note by Social Work in December of 2022 indicated the Resident was not exhibiting any behaviors but was sad he/she couldn't return home and admitted to feeling anxious at times. In December of 2022 Resident #30 agreed to a room change and on the following morning the Resident voiced a complaint regarding the noise of his/her new roommate's oxygen concentrator and that this Resident could not sleep all night. No documentation regarding a follow up to this concern was documented in the medical record. Further review of Resident #30's Nursing Progress notes titled Behavior indicated the following: - 2/6/23 at 2:53 P.M., Resident is accusatory to his/her roommate, the roommate was visibly upset and told me so - 2/6/23 at 10:55 P.M., Resident is upset over roommates coughing stating the roommate is attempting to make him/her sick, this Resident was raising their voice and pointing their finger and asking the nurse to do something and the roommate said they are confronted every morning - 2/7/23 at 4:23 P.M., Resident continues to complain about roommate coughing and is difficult to redirect Review of the current Care Plans for Resident #30 failed to identify any care plans or interventions to assist with Resident #30's roommate concerns or to redirect the behavior of Resident #30. During an interview on 2/14/23 at 8:18 A.M., Resident #30 said their roommate annoyed them and that they yell at their roommate sometimes in a very nice way to be quiet. During an interview on 2/14/23 at 8:38 A.M., Unit Manager (UM) #1 said Resident #30 had confrontational behaviors with their roommate and makes comments about the roommate having their TV too loud or coughing. She said she believed Resident #30 was being followed by psych services for this behavior and had a care plan to address the behavior. Upon review of the medical record, UM #1 said there was no evidence that psych services were aware of Resident #30's behavior and no care plan to address how to deescalate Resident #30. She said a care plan for this should have been in place and was not. During an interview on 2/14/23 at 8:51 A.M., Social Worker #1 said she was aware that Resident #30 had issues with noise in the room from the roommate including the roommate coughing, dueling loud televisions, and the roommate's oxygen concentrator. She said she met with Resident #30's roommate who was content to ignore the behaviors and remain in the room. The Social Worker said she had discussions and interactions with Resident #30 regarding these behaviors and had offered a room change, but Resident #30 declined the room change. She said she didn't think a care plan was necessary for a new behavior and hoped it would resolve itself and said she did not document any of her discussions with Resident #30 in the medical record. She said she should have followed up and documented what she had done. During an interview on 2/14/23 at 9:04 A.M., Nurse #2 said she had documented some of the behaviors she has witnessed by Resident #30. She said Resident #30 is accusatory and confrontational with his/her roommate. She said she believes Resident #30 is exhibiting the behaviors because he/she is having a hard time adjusting to long term care. She said she would expect there is a care plan in place for the behavior and believed psych services was involved. On review of the medical record, she said there was no evidence that psych services was involved with the Resident. She said she would have expected there would be a care plan in place to manage and address this behavior and there was not. During an interview on 2/14/23 at 10:04 A.M., the Director of Nurses was made aware of the concerns regarding Resident #30. She said that her expectation is that a care plan should have been in place for the behaviors. She said her expectations were not met.

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#43), in a total sample of 22 residents. Specifically, the facility failed to ensure nail care was performed for Resident #43. Findings include: Resident #43 was admitted to the facility in October 2021. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/26/22, indicated the Resident needed extensive assist of one staff person for personal hygiene. Review of the Care Plans indicated Resident #43 was at risk for skin impairments with an intervention to keep the fingernails short. During an interview on 2/9/23 at 8:23 A.M., the surveyor observed Resident #43 to have long fingernails varying in length, the right thumb was jagged and the Resident said he/she was infuriated with my nails, it's the most annoying thing. The Resident said he/she had asked staff if they had nail clippers, but no one had cut their nails. During an interview on 2/10/23 at 2:50 P.M., the surveyor observed Resident #43 to have long, uneven nails and the Resident said he/she looked like a freak and wanted someone to cut their nails. The surveyor informed Nurse #5 of Resident #43's request for their nails to be cut. During an interview on 2/14/23 at 7:33 A.M., Resident #43 said no one had cut their nails this weekend. The surveyor observed the Resident's nails to be long and jagged. During an interview on 2/14/23 at 7:40 A.M., Nurse #5 said she was not sure why the nails were not cut over the weekend, at the request of the Resident.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#294), out of a total sample of 22 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to ensure the Resident's air mattress was set per physician's orders and ensure pressure related interventions were consistently implemented to promote wound healing. Findings include: Resident #294 was admitted to the facility with diagnoses including unspecified severe protein-calorie malnutrition, stage 2 (partial-thickness skin loss with exposed dermis) pressure ulcer of the left buttock, and pressure-induced deep tissue damage of contiguous site of back, buttock, and hip. Review of the Minimum Data Set (MDS) assessment, dated 1/30/23, indicated that Resident #294 had one or more unhealed pressure ulcers/injury upon admission and was at risk of developing pressure ulcers/injuries. Review of the care plans for Resident #294 indicated a wound of the coccyx, right buttock, left buttock, and deep tissue injury (DTI) to right heel, initiated 1/25/23, with interventions including an air mattress to be set as ordered. Review of the activities of daily living (ADL) care plan indicated a self-care performance deficit related to chronic lumbar and thoracic compression fractures, initiated 1/25/23, with interventions including an assist of 1-2 staff for repositioning and turning in bed every two hours or as necessary. Review of the current Physician's Orders indicated the following: - Air mattress, set 2-3. Check inflation and function every shift (1/26/23) Review of the Initial Wound Evaluation & Management Summary, dated 1/27/23, indicated Resident #294 was admitted with a left buttock full thickness (extends below the epidermis and dermis, all layers of the skin) wound, an unstageable full thickness coccyx wound, and a stage 3 (full thickness skin loss) right buttock wound. Recommendations included to off-load (distribute the load to other areas which are not susceptible to pressure) the wounds and reposition per facility protocol. Review of the Wound Evaluation & Management Summary, dated 2/3/23 and 2/10/23, indicated no change to the stage 3 right buttock wound. Recommendations included to off-load the wounds and reposition per facility protocol. Review of the Physician's Notes indicated the following: 2/7/23 - turn and reposition frequently 2/13/23 - turn and reposition frequently During an observation with interview on 2/9/23 at 9:41 A.M., the surveyor observed Resident #294 lying on his/her left side. An air mattress was set at 6, normal pressure. Resident #294 said he/she had been at the facility for about two weeks now and had developed a pressure area between her buttocks while at the hospital. He/she complained of a 3/10 pain on his/her buttocks saying, It hurts. I'm sitting directly on it. Resident #294 said staff did not reposition him/her often and said, I stay on my left side. On 2/13/23 at 2:07 P.M. and 2/14/23 at 8:00 A.M., the surveyor observed Resident #294 lying in bed on his/her left side. The air mattress was set at 6, not 2-3 per the physician's order. During an interview on 2/14/23 at 9:37 A.M., Certified Nursing Assistant (CNA) #1 said she was assigned to the Resident today and had not been in yet to reposition him/her. She said the Resident was supposed to be repositioned every two hours, but she does not always do that. CNA #1 said the aides document repositioning on the flow record, and it should be consistently documented on even if the Resident refuses. Review of the February 2023 CNA Positioning/Restraint Sheet (spaces for documentation to indicate the Resident was repositioned every two hours each day), dated 2/1/23-2/14/23, indicated the following: -98 out of 156 opportunities documented which indicated the Resident was being repositioned every two hours 63% of the time During an interview on 2/14/23 at 9:40 A.M., Nurse #4 entered the Resident's room with the surveyor and said the air mattress was set at 6. Nurse #4 reviewed the physician's orders with the surveyor and said the order says to set it at 2-3. She said she was not sure how to set the air mattress or how it functioned and would have to call maintenance. Nurse #4 said she had been documenting on the Treatment Administration Record (TAR) that it was on and functioning but didn't pay attention to the part where it said to set at 2-3. During an interview on 2/14/23 at 10:01 A.M., Maintenance Staff #1 said they set up the resident's air mattresses, but nursing staff adjusts the setting per the doctor's order. During an interview on 2/14/23 at 10:59 A.M., Nurse #4 said the Resident should be turned and repositioned every two hours as he/she was at high risk for developing pressure areas. During an interview on 2/14/23 at 1:21 P.M., the Director of Nursing said the air mattress setting is supposed to be 2-3 and staff should follow the physician's orders. She said Resident #294 should be repositioned every two hours. The surveyor reviewed the positioning sheet with the DON who said they should be consistently documented on.

Based on record review and interview, the facility failed to provide care and service for an indwelling Foley catheter (urinary catheter which remains in the bladder to provide continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of the bladder after insertion) for one Resident (#244), out of a total sample of 22 residents. Specifically, for Resident #244, the facility failed to ensure the physician's order for changing/inserting the Foley catheter included catheter size/type and balloon size. Findings include: Review of Sepsis and Invasive Devices (Updated April 11, 2022) indicated but was not limited to the following: -An invasive device is any medical device introduced into the body. They enter either through a break in the skin or an opening in the body. Examples of common invasive devices include urinary catheters. Review of the Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide (reviewed October 2015) indicated but was not limited to the following: -Urinary catheters should be placed only under the direction of a physician order. The order should include catheter type/size and balloon size. Resident #244 was admitted to the facility in January 2023 with diagnoses including bacteremia and retention of urine. Record review indicated that the Resident's Foley catheter was inserted prior to admission, at the hospital, on 1/28/23. Review of the Hospital Discharge Summary failed to indicate what size Foley catheter had been inserted or the balloon size. Record review revealed no initial/admission documentation by the nursing staff addressing the Foley catheter size and balloon size that the Resident had in place when admitted . Review of the February 2023 Physician's Orders indicated the following: -Change Foley catheter as needed for blockage/dislodged. The physician's order did not indicate the size of the Foley catheter and balloon size to be reinserted if the Foley catheter needed to be changed. During an interview on 2/15/23 at 1:00 P.M., the Director of Nursing and Unit Manager #2 said when a resident has a Foley catheter in place, the physician's order needs to be specific as to the size/type of the catheter and balloon size and Resident #244's order for the Foley catheter did not.

Based on observation, interview, policy review, and record review, the facility failed to monitor the nutritional status of one Resident (#14), out of a total sample of 22 residents. Specifically, the facility failed to ensure a reweigh was obtained within 24 hours to verify a significant weight change in one month, to ensure weekly weights were obtained as ordered, and to ensure the Resident's significant weight loss was addressed in a timely manner. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, revised December 2022, indicated but was not limited to the following: -Residents are monitored for undesirable or unintended weight loss or gain -Residents are weighed upon admission, the next day and weekly thereafter, and at intervals established by the interdisciplinary team -The dietician, in conjunction with the nursing staff and provider, will determine the frequency of weight monitoring based on the clinical assessment and nutritional risk of the resident -Any weight change of greater than 3 pounds between consecutive weekly weights or 5 pounds between consecutive monthly weights requires a reweigh within 24 hours with licensed staff present to verify accuracy -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant -If the weight change is significant and unplanned, the physician will be notified, and notification documented in the EMR (electronic medical record) -Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met Resident #14 was admitted to the facility with diagnoses including dysphagia (difficulty swallowing), moderate protein-calorie malnutrition, and Parkinson's disease (disorder of central nervous system that affects movement, often including tremors). On 2/9/23 at 11:10 A.M., the surveyor observed Resident #14 sitting in a recliner next to his/her bed. His/her bilateral upper extremities and torso appeared very thin. Resident #14 said he/she was very tremulous from Parkinson's disease and maybe took up a lot of his/her energy. Review of current Physician's Orders indicated the following: -weekly weight monitoring (1/19/23) Review of the Weights and Vitals Summary on 2/13/23 indicated the following: 12/2/22 - 116 pounds (lbs.) 12/30/22 - 109 lbs. (loss of 7 lbs./ significant weight loss of 6% in 1 month) 1/10/23 - 108.6 lbs. Review of the medical record failed to indicate a reweigh was conducted within 24 hours per the facility policy to verify the 12/30/22 weight and failed to indicate weekly weights were obtained starting 1/19/23 per the physician's orders. Further review of the medical record failed to indicate the significant weight loss was addressed timely by the attending physician and the Dietitian. The attending physician addressed the weight loss on 1/20/23 (21 days later), and the Dietitian addressed the weight loss on 1/24/23 (25 days later). During an interview on 2/14/23 at 11:14 A.M., Unit Manager #2 said there was no reweigh for the 12/30/22 value or the 1/10/23 value but there should have been. She said there was not a physician's note until 1/20/23 that addressed the significant weight loss value. During an interview on 2/14/23 at 11:36 A.M., the Dietitian said the 12/30/22 weight value triggered a weight warning of a 6.8% loss in one month. She said there was not a reweigh but there should have been. She said she saw the warning and wrote a note about it, but not until 1/24/23. The Dietitian said it should not have taken that long. She said the physician/Nurse Practitioner wrote a note on 1/20/23 with the prior note being on 12/19/22. She further said weekly weights were ordered but not documented in the electronic record, however, Unit Manager #2 may have a paper record of them. During an interview on 2/14/23 at 1:34 P.M., the Director of Nursing (DON) said the Resident should have been reweighed within 24 hours and was unable to locate a physician's note after the 12/30/22 weight warning until 1/20/23 but they should have been notified within 24 hours. The DON said the new direction was that the Dietitian has been giving a sheet to Unit Manager #2 weekly to record weights to play with the process because things were being triggered incorrectly and to ensure accurate weights. During an interview on 2/14/23 at 1:49 P.M., Unit Manager #2 told the DON and surveyor she did not have a record of weekly weights for Resident #14 and the last documented weight in the electronic record was 1/10/23.

Based on record review and interview, the facility failed to ensure that PRN (as needed) orders for psychotropic medications were limited to 14 days and were not renewed unless the attending physician or prescribing practitioner evaluated the Resident for the appropriateness of that medication for one Resident (#244), in a sample of 22 residents. Findings include: For Resident #244, the facility failed to ensure that an as needed (PRN) medication order for Ativan (antianxiety medication) was limited to 14 days, then evaluated by the physician. Resident #244 was admitted to the facility in January 2023 with diagnoses including anxiety disorder. Review of the February 2023 Medication Administration Record (MAR) indicated a physician's order for the following: Ativan Oral Tablet 0.5 milligram (MG). Give 1 tablet by mouth every 24 hours as needed for anxiety for 30 days. Record review failed to indicate documentation that Resident #244's as needed order for Ativan was initially evaluated by the attending physician to determine that it was appropriate to extend beyond 14 days, as required. During an interview on 02/14/23 at 1:00 P.M., the Director of Nursing and Unit Manager #2 said that the Ativan should have been ordered initially for 14 days, and then revaluated and should not have been ordered for 30 days.

Based on observation, interview, and policy review, the facility failed to ensure medications were stored safely and securely. Specifically, the facility failed to: a. Ensure a medication cart was only accessible to the licensed nurse responsible for those medications; and b. Ensure a treatment cart was locked and the consultant wound physician's medical bag was secured. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated January 2018, indicated but was not limited to the following: - medications and biologicals are stored safely and securely - only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications are permitted access to medications - medication carts are to be locked when not attended by a person with authorized access a. On 2/10/23 at 9:22 A.M., the surveyor observed Medication Cart B on the North unit unlocked in the hallway with a small measuring cup of brown powder on top. The surveyor remained with the cart. During an interview on 2/10/23 at 9:26 A.M., Nurse #2 returned to the medication cart and said she was helping a resident and should not have left medications on top of her cart unattended or the cart unlocked. She said the facility policy and standard of practice is to keep the medications secured and locked in the cart at all times when not in direct view of the nurse on the cart. She said she did not follow this practice. During an interview on 2/14/23 at 10:18 A.M., the Director of Nurses said her expectation is for the medication carts to be locked and secured at all times when not in the nurse's view per standard of practice. She was made aware of the surveyor's observations and said this standard was not met. b. On 2/10/23 at 8:50 A.M., the surveyor observed the South Unit's treatment cart in the hallway, unlocked, and no nursing staff were in view of the unlocked cart. The surveyor observed an open medical bag, located on top of the unlocked treatment cart, which belonged to the consultant wound physician. Both the unlocked treatment cart and the unsecured medical bag contained topical medications. The surveyor observed the nurse and the consultant wound physician in a Resident's room with the door shut and not in view of the cart and medical bag. On 2/10/23 at 9:10 A.M. and 9:25 A.M., the surveyor observed the South Unit's treatment cart unlocked and no nursing staff were in view of the unlocked cart. The consultant wound physician's bag was not secured and topical medications remained accessible to residents. The nurse and the consultant wound physician were in residents' rooms and were behind closed doors and/or behind privacy curtains and were unable to view the treatment cart with the medical bag located on top. During an interview on 2/14/23 at 10:00 A.M., the Staff Development Coordinator (SDC) said she had done rounds with the consultant wound physician on 2/10/23. The SDC said she had not noticed the treatment cart and medical bag being unsecured. She said the medical bag and treatment cart should have been locked to prevent access to medications.

3. Review of the facility's policy titled Change in Resident's Condition or Status, last revised February 2021, included but was not limited to: -Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status Resident #69 was admitted to the facility in April 2021 with diagnoses including chronic kidney disease. On 2/14/23 at 8:28 A.M., the surveyor observed Resident #69 sitting upright in bed eating breakfast. The Resident's urinal was on the overbed table which contained a small amount of dark pink/red tinged urine. Nurse #4 entered Resident #69's room and placed bilateral hearing aids into his/her ears. The nurse did not notice the urinal containing dark pink/red tinged urine on the Resident's overbed table. The surveyor pointed to the urinal and asked the nurse if the color of the urine was normal for Resident #69. Nurse #4 said the urine was very dark pink and was not normal for the Resident. Review of the medical record on 2/14/23 at 2:00 P.M. failed to indicate Nurse #4 had conducted an assessment regarding Resident #69's dark pink tinged urine or documented any information about a change in the Resident's condition in the medical record. During an interview on 2/14/23 at 2:03 P.M., Nurse #4 said that she had not assessed Resident #69 and did not document the change of condition in the medical record. During an interview on 2/14/23 at 2:05 P.M., Unit Manager #2 said Nurse #4 should have further assessed the Resident and documented the change in condition in the medical record within one hour of identifying the change in condition. 4. Resident #75 was admitted to the facility in December 2022 with a Peripherally Inserted Central Catheter (PICC). Review of the medical record included but was not limited to the following current Physician's Orders: -Ertapenem Sodium Solution Reconstituted (antibiotic) 1 gram (gm) intravenously (IV) every 24 hours for prostatitis for 6 weeks in 100 milliliters (ml) sodium chloride 0.9% (1/6/23) -Transparent IV Site Dressing, apply to IV site topically as needed for soilage (1/5/23) -Transparent IV Site Dressing, apply to IV site topically one time a day every Friday for weekly dressing change (1/5/23) -Measure arm circumference with PICC dressing change at insertion site every Friday -Measure external IV catheter length every Friday with dressing change Review of the February 2023 Medication/Treatment Administration Records (MAR/TAR) indicated nursing staff did not sign off that Resident #75's arm circumference and external catheter length were measured on 2/3/23 as ordered by the Physician. During an interview on 2/14/23 at 8:50 A.M., the surveyor and the DON reviewed Resident #75's MAR/TAR. The DON said the nurse should have documented the measurements when she did the dressing change but did not. During an interview on 2/14/23 at 9:55 A.M., the DON said that she just spoke to the nurse that cared for Resident #75 on 2/3/23 and asked her to enter measurements onto the MAR/TAR. The DON provided the surveyor with a copy of the February MAR/TAR with measurements for arm circumference and external length of the catheter entered and signed off by the nurse. 5a. Resident #85 was admitted to the facility in January 2023 with a PICC. Review of the Physician's Orders included but was not limited to: -Measure arm circumference with PICC dressing change at insertion site, one time a day every Friday with dressing change (1/13/23). During an interview on 2/10/23 at 3:30 P.M., Nurse #3 said she measured the external length of Resident #85's PICC and it was 16 centimeters (cm). Review of a Nursing Progress Note, dated 2/10/23, indicated the external length of the catheter was 16 cm. Review of the February 2023 MAR/TAR indicated Nurse #3 documented the external length of the catheter on 2/10/23 as measuring 26 cm and not 16 cm. b. Review of the January 2023 MAR/TAR indicated the external length of the catheter was 24 cm and the Resident's arm circumference was 24 cm on 1/20/23. There were no prior measurements documented in the medical record by facility staff. Review of comprehensive care plans included, but was not limited to: -Focus: The resident is on IV medications via PICC line (1/18/23) -Interventions: IV Dressing: PICC dressing, measure external length and arm circumference on admit and weekly with dressing changes. Observe dressing as ordered. Change dressing and record observations of site every week (9 cm external length and 26 cm arm circumference) (1/18/23) The measurements identified on the care plan were inconsistent with measurements documented on the MAR/TAR. During an interview on 2/13/23 at 2:28 P.M., the surveyor and Unit Manager #2 reviewed Resident #85's medical record. She said nurses should make sure to accurately document the MAR/TAR and care plans. c. Review of the facility's policy titled Diabetes-Clinical Protocol, last revised November 2020, included, but was not limited to: -As indicated, the Physician will order appropriate lab tests (for example periodic finger sticks or A1C) Resident #85 was admitted to the facility in January 2023 with diagnoses including type 2 diabetes mellitus with hyperglycemia. Review of the most recent Minimum Data Set assessment, dated 1/25/23, indicated Resident #85 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 13 out of 15 and received insulin injections daily. Review of the February 2023 Physician's Orders included but was not limited to: -Capillary Blood Glucose (CBG-the level of circulating blood glucose as measured by glucometer analysis of a fingerstick sample) at bedtime, notify Physician (MD)/Nurse Practitioner (NP) if less than 70 or greater than 350 (undated) -Insulin Lispro Injection Solution 100 unit/milliliter (ml), inject subcutaneously (under the skin) three times a day as per sliding scale (1/19/23): -if 140-180= 2 units -181-220= 3 units -221-260= 4 units -261-300= 5 units -301-350= 6 units call MD/NP for blood glucose over 350 -Blood sugar as needed for hypoglycemic follow up (1/13/23) -Hypo/Hyperglycemia protocols were in place. The Physician's orders failed to include an order to obtain finger stick blood sugars (FSBS) three times a day to correlate with the administration of the sliding scale insulin to be administered three times a day as per the physician's orders. Review of the February 2023 Medication Administration Record (MAR) indicated that nursing staff obtained a blood glucose levels 52 times without a Physician's order for fingerstick blood sugar tests. 6. Resident #246 was admitted to the facility in February 2023 with diagnoses including type 2 diabetes mellitus. Review of the February 2023 Physician's Orders included but was not limited to: -Obtain fasting CBG one time a day for seven days, notify MD if less than 70 or greater than 300 (2/7/23) -Blood sugar check two times a day (undated) Hyper/Hypo glycemia blood sugar protocols were in place. The Physician's orders failed to include an order for finger stick blood sugars to obtain blood glucose levels to potentially implement the hypoglycemic protocol and staff failed to monitor for signs and symptoms of hyper/hypoglycemia. Review of the February 2023 Medication Administration Record (MAR) indicated that nursing staff obtained blood glucose levels 18 times without a Physician's order for fingerstick blood sugar tests. During an interview on 2/13/23 at 2:28 P.M., the surveyor and Unit Manager #2 reviewed Residents #85 and #243's medical records. Unit Manager #2 said there should be orders in place for finger stick blood sugar tests to obtain capillary blood glucose levels as well as to implement the hypoglycemic protocols and there should be monitoring for signs and symptoms of hypo/hyperglycemia. Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and treatment according to acceptable standards of clinical practice for six Residents (#244, #243, #69, #75, #85, and #246), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #244, to ensure that Lorazepam (anti-anxiety medication) was administered per the physician's orders; 2. For Resident #243, to ensure that medications were reconciled upon admission to the facility per the facility policy; 3. For Resident #69, to ensure that a change in the Resident's condition was further assessed and documented in the medical record within one hour of the identification of the change in condition; 4. For Resident #75, to ensure that arm circumference and external catheter length of a Peripherally Inserted Central Catheter (PICC) was documented when the dressing change had been completed; 5. For Resident #85, to ensure that a. PICC documentation was accurately documented, b. inconsistent information regarding the arm circumference and external catheter length was investigated to ensure the catheter had not migrated out of the superior vena cava and the facility continued to infuse antibiotics, and c. Physician's orders included an order to obtain finger stick blood sugars (FSBS) three times a day to correlate with the administration of the sliding scale insulin three times a day; and 6. For Resident #246, to ensure that the physician's orders included an order for a. FSBS needed to assess blood glucose levels to potentially implement the hypoglycemic protocol and b. monitoring for signs and symptoms of hyper/hypoglycemia. Findings include: 1. Resident #244 was admitted to the facility in January 2023 with diagnoses including bacteremia, anxiety disorder, and retention of urine. Review of the Physician's Orders indicated the following: Lorazepam oral tablet 0.5 milligrams (mg). Give 0.25 mg by mouth every 24 hours as needed for anxiety at bedtime. Order Date: 1/31/23 at 9:58 P.M. Review of the February 2023 Medication Administration Record (MAR) indicated that the Resident received a dose of the Lorazepam 0.25 mg at 10:46 A.M. on 2/1/23. The medication had not been administered at bedtime as per the physician's order. Further review of the February 2023 Physician's Orders indicated the following: Lorazepam oral tablet 0.5 milligrams (mg). Give 0.25 mg by mouth every 24 hours as needed for anxiety for 30 days at bedtime. Order Date: 2/1/23 at 12:01 A.M. Review of the February 2023 MAR indicated that the Resident was administered a dose of the Lorazepam 0.25 mg on 2/1/23 at 9:50 P.M. The first dose was administered on 2/1/23 at 10:46 A.M. and the second dose was administered at 9:50 P.M. There was 10 hours and 4 minutes between the doses and not 24 hours as per the physician's order. During an interview on 2/14/23 at 1:00 P.M., the Director of Nursing (DON) and Unit Manager #2 said that the Resident had not received the Lorazepam every 24 hours as ordered by the physician. 2. Resident #243 was admitted to the facility in February 2023 with multiple diagnoses including but not limited to sepsis and had a PICC line inserted at the hospital prior to admission to the facility. Review of the facility's policy titled Reconciliation of Medications on admission (revised July 2017) indicated but was not limited to the following: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications routes and dosages upon admission or readmission to the facility. Steps in the procedure: -Using an approved medication reconciliation form or other record list all medications from the medication history the discharge summary the previous MAR if applicable and the admitting orders sources; -List the dose route and frequency for all meds -Review the list carefully to determine if there are any discrepancies or conflicts; for example, is there a potential medication interaction between a medication from the admitting orders and a supplement; the medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication -If there is a discrepancy or conflict in medications, dose, route or frequencies determine the most appropriate action to resolve the discrepancy -Document the medication discrepancy on the medication reconciliation form -Document what actions were taken by the nurse to resolve the discrepancy -If the discrepancy was unresolved document how the discrepancy was communicated to the charge nurse physician pharmacy or next shift and -If the discrepancy was resolved document how the discrepancy was resolved Review of Resident #243's paper medical record indicated the facility's document for medication reconciliation was blank except for the Resident's name. The document had not been completed as per the facility policy. During an interview on 2/14/23 at 12:25 P.M., the surveyor presented the blank medication reconciliation document to the DON and Unit Manager #2 for their review. The DON and Unit Manager said that the medication reconciliation form should be completed in its entirety when a Resident is admitted as per the facility policy and Resident #243's was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #75 was admitted to the facility in January 2023 following a hospitalization and had diagnoses including prostatitis. Review of hospital discharge documentation indicated Resident #75 had a single lumen Power PICC placed on 1/5/23. An x-ray was taken immediately after the catheter was placed and confirmed placement. Further review of hospital documentation included but was not limited to: -Initial Extremity Circumference: 28 centimeters (cm) -Initial Exposed Catheter: 0 cm Review of the medical record included but was not limited to the following Physician's orders: -Ertapenem Sodium Solution Reconstituted (antibiotic) 1 gram (gm) intravenously (IV) every 24 hours for prostatitis for 6 weeks in 100 milliliters (ml) sodium chloride 0.9% (1/6/23) -Heparin Lock Flush Solution (anticoagulant) 10 unit/ml, use 5 ml IV one time a day for IV medication use after IV medication administration (1/5/23) -IV sets-tubing kit, use 1 unit IV one time a day (1/5/23) -Normal Saline Flush Solution 0.9%, use 10 ml IV one time a day for IV medication administration after IV medication (1/5/23) -Normal Saline Flush Solution 0.9%, use 10 ml IV one time a day for IV medication administration before IV medication (1/5/23) -Transparent IV Site Dressing, apply to IV site topically as needed for soilage (1/5/23) -Transparent IV Site Dressing, apply to IV site topically one time a day every Friday for weekly dressing change (1/5/23) -Measure arm circumference with PICC dressing change at insertion site every Friday -Measure external IV catheter length every Friday with dressing change Review of January 2023 and February 2023 Medication/Treatment Administration Records (MAR/TAR) indicated: -1/6/23: external catheter length= 6 cm (6 cm longer than the length indicated in the hospital discharge documentation); -1/13/23: external catheter length= 0.5 cm (5.5 cm shorter than the previous measurement); -1/20/23: external catheter length= 5 cm (4.5 cm longer than the previous measurement); -1/27/23: external catheter length= 0.5 cm (4.5 cm shorter than the previous measurement); -2/3/23: external catheter length= blank; arm circumference=blank -2/10/23: external catheter length= 5 cm (4.5 cm longer than the previous measurement). Further review of the medical record failed to indicate nursing staff identified a discrepancy in their measurements of the external catheter length compared to the initial external length of the catheter documented in the hospital discharge documentation (0 cm), verified the accuracy of their measurements, and contacted the Physician according to facility policy. 4. Resident #85 was admitted to the facility in January 2023 following a hospitalization and had diagnoses including sepsis. Review of hospital discharge documentation indicated Resident #85 had a single lumen Power PICC placed on 1/9/23. An x-ray was taken immediately after the catheter was placed and confirmed appropriate placement. Further review of hospital documentation included but was not limited to: -Initial Extremity Circumference: 27 centimeters (cm) -Initial Exposed Catheter: 0 cm Review of the medical record included but was not limited to the following Physician's Orders: -Measure arm circumference with PICC dressing change at insertion site, one time a day every Friday with dressing change (1/13/23); -Measure arm circumference with PICC dressing change at insertion site as needed with dressing change (1/13/23); -Heparin Lock Flush Solution 10 unit/ml, use 5 ml IV two times a day for IV medication use after IV medication administration (1/13/23); -Heparin Sodium Injection Solution 5000 unit/ml, inject 1 milliunit subcutaneously every 8 hours for deep vein thrombosis prophylaxis (1/13/23); -IV sets-Tubing Kit, use 1 unit intravenously one time a day for septic knee (1/13/23); -Normal Saline Flush Solution 0.9%, use 10 ml IV as needed to maintain catheter patency (1/13/23); -Normal Saline Flush Solution 0.9%, use 10 ml IV every 8 hours for IV patency; -Normal Saline Flush Solution 0.9%, use 10 ml IV two times a day for IV medication administration after IV medication (1/13/23); -Vancomycin HCI IV Solution 1250 mg/250 ml, use 250 ml IV two times a day (1/14/23) -Vancomycin HCI IV Solution 750 mg/150 ml, use 750 mg IV two times a day (1/27/23) Review of January 2023 and February 2023 Medication/Treatment Administration Records (MAR/TAR) indicated: -1/13/23: external catheter length= blank -1/20/23: external catheter length= 24 cm (24 cm longer than the length indicated in the hospital discharge documentation); -1/27/23: external catheter length= 24 cm (24 cm longer than the length indicated in the hospital discharge documentation); -2/3/23: external catheter length=16 cm (16 cm longer than the length indicated in the hospital discharge documentation and 8 cm shorter than the previous measurement). During an interview on 2/10/23 at 2:30 P.M., the surveyor asked Nurse #3 how she measures the external length of Resident #85's PICC line. She said she was going to do the dressing change in a few minutes and invited the surveyor to observe with the Resident's consent. On 2/10/23 at 2:43 P.M., after obtaining consent from Resident #85 for the surveyor to observe, Nurse #3 began the procedure for a dressing change to the Resident's PICC. The Nurse measured the Resident's arm circumference and told the surveyor it was 26 cm. She then placed the tape measure, inches side up, at the insertion site and placed her thumbnail on the one-inch measure and said the length was 0.5 cm. The surveyor asked the Nurse to confirm the measurement and she reiterated it was 0.5 cm. After the dressing change was complete, Nurse #3 did not compare the newly obtained measurement to the previously documented measurement in the medical record. The surveyor asked Nurse #3 what the baseline external length measurement was, and she said it is not in the electronic record and she would have to go into the Resident's paper record at the nursing station and look through hospital documentation to find that measurement. Nurse #3 said that she didn't think she measured it correctly and wanted to re-take the measurement. During an interview on 2/10/23 at 3:15 P.M., the Director of Nursing said there is no procedure for measuring external length of catheters in the facility's PICC policy and people measure differently. She said if she were to do it, she would measure from the insertion site, down the entire length to the end. At 3:20 P.M., the DON and surveyor met Nurse #3 at the Resident's room. Nurse #3 told the DON that she was confused. The DON pointed out the centimeter side of the measuring tape and the inch side. The DON said the external catheter length is to be measured from the insertion site to the top of the hub .the outside of the hub in centimeters. On 2/10/23 at 3:30 P.M., Nurse #3 said she measured the external length of the catheter again with the DON and it was 16 cm. On 2/10/23 at 4:00 P.M., the DON confirmed Resident #85's external catheter measured 16 cm and provided the surveyor with a copy of the February 2023 MAR/TAR. Review of the documentation indicated Nurse #3 documented the external length of the catheter on 2/10/23 as 26 cm and not 16 cm. Further review of the medical record failed to indicate either Nurse #3 or the DON compared the measurement to the baseline measurement (0 cm) and notified the Physician of the discrepancy. During an interview on 2/14/23 at 8:50 A.M., the DON said when she observed Nurse #3 measure the external length of Resident #85's PICC, she realized the nurse did not measure the external length correctly. She said she did not start at 1 on the tape measure. The surveyor asked if she had reviewed the previous measurements, notified the Physician of discrepancies or determined whether or not the PICC had migrated, and she said she had not done that yet. Based on observation, record review, policy review, and interview, the facility failed to ensure that care and treatment of a peripherally inserted central catheter (PICC- intravenous catheter inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava which is one of the central venous system veins that carries blood to the heart) was provided in accordance with current standards of practice and the facility policy/protocols for 4 of 4 Residents (#244, #243, #75, and #85) with PICCs in place, out of a total sample of 22 residents. Specifically, the facility failed to ensure that: 1. For Resident #244, a. The IV administration set/tubing was changed every 24 hours, b. The needleless connector was changed on admission and every 7 days thereafter, c. A baseline external catheter length and arm circumference was obtained on admission and every 7 days thereafter, d. Transparent dressings were changed on admission and every 7 days thereafter, and e. The type/brand of PICC, inserted at the hospital, was obtained to determine whether the PICC was valved or not valved to determine the flushing protocol, f. The PICC flushes were not ordered timely and not ordered between two different antibiotics; 2. For Resident #243, a. A baseline external catheter length and arm circumference was obtained on admission and completed every 7 days thereafter, b. Transparent dressings were changed on admission and every 7 days thereafter, c. The type/brand of PICC, inserted at the hospital was obtained to determine whether the PICC was valved or not valved to determine the flushing protocol, d. The IV administration set/tubing was changed every 24 hours, e. The needleless connector was changed on admission; and 3. For Resident #75, the external catheter length of the PICC was measured and the physician notified of a discrepancy; and 4. For Resident #85, the external catheter length of the PICC was measured and the physician notified of a discrepancy. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, last revised March 2022 and the IV Protocols reference sheet which was created based on the 2018 Partners Pharmacy IV policies, procedures, and IV forms (effective 11-1-2018), included, but was not limited to: -The purpose of the procedure is to reduce the risk of infections and minimize contamination of the catheter; -Care and maintenance of a central line dressing will be performed by a qualified nurse; -The transparent dressing will be changed every 7 days and as needed (prn), 24 hours after insertion if gauze utilized or bleeding/drainage from site **Measurement required -PICC Measurements: Document total catheter length and external catheter length (along with landmarks) obtained from discharge facility or insertion; nurse then measures external catheter length on admission, every dressing change and prn and compare to previous measurement, or immediately if the dressing is loose or soiled; -For PICC measure arm circumference and compare to baseline when clinically indicated to assess for edema and possible deep-vein thrombosis. -During each dressing change and prn, observe the site for signs and symptoms of complications. If PICC, measure the external length with every dressing change and prn and compare with the length documented at insertion and to the previous measurement; Notify the physician with any changes to discuss clinical plan which may include chest x-ray for tip-re-confirmation. -Tubing changes: Intermittent Medication infusion, every 24 hours and prn Review of the facility's policy titled Central Line Catheter Flushing, Central Venous Access Device-Needleless Connector Change, and Central Venous Access Device-Catheter Dressing Change (effective date: June 2016) included but was not limited to the following: a. Central Venous Access Device Flushing -The purpose-to maintain patent of a central venous access device (CVAD). -The CVAD will be flushed with 10 milliliters (ml) 0.9% sodium chloride (normal saline (NS)) flushes before and after each infusion unless contraindicated or incompatible with the medication or solution. -Closed ended or valved catheter do not require heparin flush to maintain patency -To maintain the patency of a PICC; the catheter will be flushed every 8 hours or once per shift with 10 ml of 0.9% NS flush followed by 5 ml heparin 10 units/ml flush unless closed ended or valve catheter then only 10 ml 0.9% NS flush every 8 hours or once per shift is required to maintain patency. b. Central Venous Access Device-Needleless Connector Change -The purpose is to aseptically (free from contamination) change a needleless connector on a CVAD. -Needleless connector will be changed upon Admission, every 7 days and as needed (prn) for any complications c. Central Venous Access Device-Catheter Dressing Change -The purpose is to provide specific intervals and technique for CVAD dressing changes -Transparent dressing changes will occur according to the IV order and when the dressing is compromised. If at time of admission the transparent dressing is clean, dry, intact dated, and not due to be changed it is not necessary to change the dressing at that time. If the catheter is newly inserted: Every 7 days and as needed (prn) the transparent dressing is clean, dry, intact and dated, it is not necessary to change the dressing 24 hours post insertion. -Securement devices (used to stabilize the catheter in place) must be changed with each dressing change if present. If the catheter is sutured in place, a securement may not be necessary. Sterile securement devices are to be applied for all PICC/midlines that are not sutured. 1. Resident #244 was admitted to the facility in January 2023 with diagnoses including bacteremia, anxiety disorder and retention of urine. The Resident had a PICC line inserted at the hospital on 1/24/23 for the administration of IV antibiotics. Review of the February 2023 Physician's Orders related to the care of the Resident's PICC indicated but not limited to the following with start date of 2/1/23 and revised on 2/2/23: -Measure arm circumference with PICC dressing change at insertion site one time a day every Wednesday with the dressing change (3:00 P.M.-11:00 P.M. shift) -Measure arm circumference with PICC dressing change at insertion site one time only on admission for 1 day (one time) -Measure arm circumference with PICC dressing change at insertion site as needed for dressing change /abnormality (prn) -Measure external IV catheter length one time a day every Wednesday with weekly dressing change (3:00 P.M.-11:00 P.M. shift) -Measure external IV catheter length one time only on admission for 1 day -Measure external IV catheter length as needed (prn) a. The physician's order failed to address changing the IV tubing/set every 24 hours, per the facility policy. b. The physician's order failed to address changing the needleless connector upon admission, every 7 days, and as needed (prn) for any complications. c. Review of the Physician's Orders, dated 2/1/23 and revised on 2/2/23, indicated but was not limited to: -Measure arm circumference with PICC dressing change at insertion site one time a day every Wednesday with the dressing change (3:00 P.M.-11:00 P.M. shift) -Measure arm circumference with PICC dressing change at insertion site one time only on admission for 1 day (one time) -Measure arm circumference with PICC dressing change at insertion site as needed for dressing change /abnormality (prn) -Measure external IV catheter length one time a day every Wednesday with weekly dressing change (3:00 P.M.-11:00 P.M. shift) -Measure external IV catheter length one time only on admission for 1 day -Measure external IV catheter length as needed (prn) Review of the February 2023 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) indicated the following: -External IV catheter length (one time only on admission) was documented as 5 centimeters on 2/2/23 at 5:17 A.M. -Arm circumference with PICC dressing change at insertion site (one time only on admission for 1 day (one time)) was documented as 30 centimeters on 2/2/23 at 5:25 A.M. The MAR failed to indicate the baseline external IV catheter length and the arm circumference were obtained upon admission to the facility per the physician's order or per the facility policy. Baseline measurements should have been completed on 1/31/23. Review of the medical record failed to indicate a baseline measurement of the external catheter length, arm circumference or the last time the dressing was changed at the hospital. By obtaining this information it would dictate the frequency of the dressing changes at the facility and would be an indicator for the facility to know whether the arm circumference had increased and the PICC had migrated. d. Review of the Physician's Order, start date 2/1/23, indicated: -Transparent IV set Dressing (Transparent Dressings) Apply to IV site topically one time a day every Wednesday for weekly dressing change -Transparent IV set Dressing (Transparent Dressings) Apply to IV site topically one time for 24 hours after insertion for 1 day -Transparent IV set Dressing (Transparent Dressings) Apply to IV site topically as needed for dressing Review of the 2/1/23 MAR/TAR indicated the following: -The Transparent IV site Dressing was changed on 2/1/23 at 10:14 P.M. The MAR/TAR failed to indicate the external catheter measurement or arm circumference measurement were completed at the time of the dressing change. Review of the 2/8/23 MAR/TAR indicated the dressing change, arm circumference, and external catheter measurement had been completed. The MAR/TAR failed to indicate documentation of the arm circumference measurement or external catheter length measurement. Review of the Nurse's Notes, dated 2/8/23, failed to indicate measurements. Review of the Nurse's notes, dated 2/1/23- 2/13/23, indicated a comprehensive assessment which included measurements of the Resident's PICC had not been completed and documented until 2/13/23. e. Review of the medical record failed to indicate the facility obtained information from the hospital as to whether the PICC was a closed ended or valved catheter to determine if a heparin flush was required to maintain patency. f. Review of the February 2023 Physician's Orders and the MAR indicated the following: -Use 100 mg IV one time a day -Gentamycin in Saline IV solution 1.2 mg/ml in 100 ml normal saline (100 mg in 100 ml) one time a day at 10:00 A.M. until 2/26/23 -Oxacillin Sodium Injection Solution 2 grams Use 2 grams intravenously every 4 hours until 2/27/23 Mixed in normal saline 100 ml scheduled at 2:00 A.M., 6:00 A.M., 10:00 A.M., 2:00 P.M., 6:00 P.M. and 10:00 P.M. -Normal Saline Flush Solution Use 10 ml Intravenously every 4 hours for IV flush with 10 ml NS before and after every IV medication scheduled at 2:00 A.M., 6:00 A.M., 10:00 A.M., 2:00 P.M., 6:00 P.M. and 10:00 P.M. (order start date 2/7/23) Review of the MAR and TAR indicated that there had not been a 10 ml NS flush every 4 hours before and after every IV medication until 2/7/23 at 6:00 P.M. The Resident had been receiving IV antibiotics at the facility since admission on [DATE]. Further review indicated that the Resident was receiving two antibiotics administered together at 10:00 A.M. and there had not been an additional flush ordered between the administration of the two antibiotics. During an interview on 2/14/23 at 1:30 P.M., the surveyor, Director of Nursing (DON) and Unit Manager #2 reviewed the documentation of the PICC and the concerns of the surveyor. The DON and Unit Manager #2 said that the facility failed to care and treat Resident #244's PICC per the facility's policy/protocol. 2. Resident #243 was admitted to the facility in February 2023 with multiple diagnoses including but not limited to sepsis. The Resident had a PICC inserted at the hospital for the administration of IV antibiotics a. Review of the hospital discharge information indicated but was not limited to the following: -PICC was inserted on 2/7/23. Initial exposed catheter was 0 cm. Flushed: Saline locked. Review of Resident #243's medical record failed to document a baseline external catheter length or arm circumference. b. Review of the February 2023 Physician's Orders, MAR, and TAR indicated the following: -Measure arm circumference with PICC dressing change at insertion site one time a day every Thursday (order date 2/13/23) -Measure arm circumference with PICC dressing change at insertion site as needed for dressing change/abnormality (order date 2/10/23) -Measure external IV catheter length one time a day every Thursday with weekly dressing change (no date of order indicated) -Change PICC line dressing and CAP (needleless connector) every 7 days, label with date and every day shift every Thursday (no date of order indicated) Review of the MAR and TAR indicated the dressing was changed on 2/9/23. Further review indicated no measurements of the arm circumference or external catheter length were documented with the dressing change on 2/9/23, per facility policy. c. Review of the February 2023 Physician's Orders, MAR, and TAR indicated the following: -Heparin Lock Flush Solution 10 Units/ml Use 5 ml intravenously two times a day for IV medication use after IV medication administration -Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) Use 10 ml two times a day for IV med administration before IV med -Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) Use 10 ml two times a day for IV med administration after IV med Review of the medical record failed to indicate the facility obtained information from the hospital as to whether the PICC was a closed ended or valved catheter to determine if a heparin flush was required to maintain patency. d. There was no physician's order in place to change the IV tubing/set every 24 hours e. Review of the February 2023 Physician's Orders, MAR, and TAR indicated the following: -Needleless Connectors as need for PICC dressing change -Needleless connector one time a day every Thursday for with weekly dressing change There was no physician's order in place to change the needleless connector upon admission as required. During an interview on 2/14/23 at 1:30 P.M., the Director of Nursing and Unit Manager #2 reviewed the documentation for Resident #243's PICC and said the orders were not consistent/standardized and that numerous orders were either not implemented or implemented incorrectly. The DON and Unit Manager #2 that the facility failed to provide Resident #243's care and treatment of the PICC according to the facility's policy/protocol.

Based on observation, interview, policy review, and record review the facility failed to ensure all nurses (staff or agency) providing care to 4 of 4 Residents (#75, #85, #243 and #244) with PICC lines, had completed training and competencies for Intravenous (IV) Therapy and for care and management of Peripherally Inserted Central Catheter (PICC)/Midlines. Findings include: Review of the facility's policy, Competency of Nursing Staff, last revised October 2017, included, but was not limited to: -Licensed nurses employed (or contracted) by the facility will demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents as identified through resident assessments and described in the plans of care; -The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents; -The following factors are considered in the creation of the competency-based staff development and training program: -an evaluation of the current program to ensure basic nursing competencies; -any gaps in education or training that may be contributing to poor outcomes; -specialized skills or training needed based on the resident population; -a method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions; -The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population; -Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based in the facility assessment; -Facility and resident-specific competency evaluations will include: a. lecture with return demonstration for physical activities; b. a pre- and post-test for documentation issues; c. demonstrated ability to use tools, devices, or equipment used to care for residents; d. reviewing adverse events that occurred as an indication of gaps in competency; or e. demonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform -Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge. Review of the Facility Assessment, dated as reviewed on 11/23/21, indicated medication needs would include awareness of any limitations of administering medications; administration route of medications included: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic. Review of the facility's policies titled Central Venous Catheter Care and Dressing Changes, last revised March 2022, and Partners Pharmacy Central Line Dressing Change, last revised August 2018, included but was not limited to: -The purpose of the procedure is to reduce the risk of infections and minimize contamination of the catheter; -Care and maintenance of a central line dressing will be performed by a qualified nurse; -The transparent dressing will be used over the insertion site and it will be changed every 7 days or immediately if the dressing is loose or soiled; -Securement devices will be changed every 7 days, with each dressing change, or according to manufacturer's directions; -Needleless connectors will be attached to every lumen of the catheter and will be changed every 7 days, daily with TPN/PPN, after lab draws and as needed (PRN); -During each dressing change and prn, observe the site for signs and symptoms of complications. If PICC, measure the external length with every dressing change and prn and compare with the length documented at insertion and to the previous measurement; -Notify the physician for any changes and discuss clinical plan which may include chest x-ray for tip-re-confirmation. Review of the medical records indicated the following residents were admitted and being administered IV antibiotics on the South Unit: -Resident #75 -Resident #85 -Resident #243 -Resident #244 Review of hospital discharge documentation indicated Resident #85 had a single lumen Power PICC with: -Initial Extremity Circumference: 27 centimeters (cm) -Initial Exposed Catheter: 0 cm On 2/10/23 at 2:43 P.M., after obtaining consent from Resident #85 for the surveyor to observe, Nurse #3 began performing a dressing change to the Resident's PICC. The Nurse measured the Resident's arm circumference and told the surveyor it was 26 centimeters (cm). She then placed the tape measure, inches side up, at the insertion site and placed her thumbnail on the one-inch measure and said the length was 0.5 cm. The surveyor asked the Nurse to confirm the measurement and she reiterated it was 0.5 cm. After the dressing change was complete, Nurse #3 did not compare the newly obtained measurement to the previously documented measurement in the medical record. Nurse #3 said that she didn't think she measured it correctly and wanted to re-take the measurement. During an interview on 2/10/23 at 3:15 P.M., the Director of Nursing said there is no procedure for measuring external length of catheters in the facility's PICC policy and people measure differently. She said if she were to do it, she would measure from the insertion site, down the entire length to the end. At 3:20 P.M., the DON and surveyor met Nurse #3 at the Resident's room. Nurse #3 told the DON that she was confused. The DON pointed out the centimeter side of the measuring tape and the inch side. The DON said the external catheter length is to be measured from the insertion site to the top of the hub .the outside of the hub in centimeters. On 2/10/23 at 3:30 P.M., Nurse #3 said she measured the external length of the catheter again with the DON and it was 16 cm. On 2/10/23 at 4:00 P.M., the DON confirmed Resident #85's external catheter measured 16 cm and provided the surveyor with a copy of the February 2023 MAR/TAR. Review of the documentation indicated Nurse #3 documented the external length of the catheter on 2/10/23 as 26 cm and not 16 cm. Further review of the medical record failed to indicate either Nurse #3 or the DON compared the measurement to the baseline measurement (0 cm) and notified the Physician of the discrepancy. During an interview on 2/14/23 at 8:50 A.M., the DON said when she observed Nurse #3 measure the external length of Resident #85's PICC, she realized the nurse did not measure the external length correctly. She said she did not start at 1 on the tape measure. During an interview on 2/13/23 at 10:38 A.M., the Staff Development Coordinator (SDC) said no nurses, staff or agency, have IV competency assessments in care and management of PICC lines (including dressing changes, assessment and catheter measurement).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #44 was admitted to the facility in June 2022 with a diagnosis of atrial fibrillation. Review of the Medication Administration Record indicated Resident #44 received Apixaban (Anti-coagulant) 2.5MG given by mouth two times a day for Atrial Fibrillation January 2023 through February 2023. Review of the Treatment Administration Record indicated the following: -Monitoring for signs and symptoms of bleeding/bruising was discontinued on 1/13/23. It was later resumed on 2/13/23. The signs and symptoms of bruising and bleeding were not monitored for 31 days. Review of the care plans indicated Resident #44 was on anticoagulant therapy related to Atrial Fibrillation. The goal is to be free from discomfort or adverse reactions related to anticoagulant use. Review of the Medical record failed to indicate a reason for discontinuing the monitoring for signs and symptoms of bleeding/bruising. During an interview on 2/14/23 at 11:55 A.M., Nurse #2 said Resident #44 should have been checked for signs and symptoms of bruising/bleeding while on an anticoagulant. She did not know why it had been discontinued from 1/13/23 to 2/13/23. During an interview on 2/14/23 at 12:50 P.M., Unit Manager #1 reviewed the electronic medical record and noted that monitoring for signs and symptoms of bruising/bleeding was discontinued and removed from the Treatment Administration Record from 1/13/23 to 2/13/23. She did not know why this happened and would review this with the Director of Nurses. During an interview on 2/14/23 at 1:06 P.M., Unit Manager #1 said that after reviewing Resident #44's record with the Director of Nurses, they concluded that monitoring for signs and symptoms of bruising/bleeding should not have been discontinued. She further said that the error was found during a review and then corrected on 2/13/23. Based on interview, policy review, and record review, the facility failed to ensure for four Residents (#294, #293, #245, and #44), out of a total sample of 22 residents, that each resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to monitor for potential adverse consequences related to the use of anticoagulant (blood thinner) medications. Findings include: Review of the facility's policy titled Queen [NAME] Anticoagulation - Clinical Protocol, revised November 2018, indicated but was not limited to the following: -As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of deep vein thrombosis (DVT), heart valve replacement, atrial fibrillation, or those who have had recent joint replacement surgery -Assess for any signs or symptoms related to adverse drug reactions due to the medications alone or in combination with other medications -The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems - If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant 1. Resident #294 was admitted to the facility with diagnoses including paroxysmal atrial fibrillation (Afib- irregular, often rapid heart rate that commonly causes poor blood flow). Review of current Physician's Orders indicated the following: -Apixaban (Eliquis) Oral Tablet 2.5 milligrams (mg), give 2.5 mg by mouth two times a day for blood clot prevention (1/24/23) Review of the February 2023 Medication Administration Record (MAR) indicated the following: -Apixaban Oral Tablet, administered twice daily from 2/1/23 through 2/12/23 Further review of the medical record failed to indicate a physician's order for staff to monitor for signs or symptoms of bleeding related to the use of an anticoagulant. Review of the Bristol-[NAME] Squibb Apixaban (Eliquis) package insert, revised September 2021, indicated the following: -Eliquis is a factor Xa inhibitor indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation and for the prophylaxis of DVT, which may lead to pulmonary embolism (PE) Warnings and Precautions: -Eliquis can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. During an interview on 2/13/23 at 2:05 P.M., Resident #294 said he/she bruises very easily. During an interview on 2/14/23 at 10:54 A.M., Unit Manager #2 said there was not an order to monitor for signs and symptoms of bleeding but there should have been. During an interview on 2/14/23 at 1:15 P.M., the Director of Nursing (DON) said any resident who is on an anticoagulant should have an order for monitoring and be monitored for signs and symptoms of bleeding. She said Resident #294 did not have an order until yesterday. 2. Resident #293 was admitted to the facility with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, presence of prosthetic heart valve, presence of automatic (implantable) cardiac defibrillator, and atrial fibrillation. Review of the current Physician's Orders indicated the following: -Warfarin Sodium Tablet 2 mg, give 1 tablet by mouth one time a day for treating/preventing blood clots until 2/14/23, start date 2/11/23 Review of the February 2023 Medication Administration Record (MAR) indicated the following: -Warfarin Sodium Tablet, administered once daily from 2/11/23 through 2/13/23 Further review of the medical record failed to indicate a physician's order to monitor for signs or symptoms related the use of an anticoagulant medication. Review of the Bristol-[NAME] Squibb Coumadin (warfarin sodium) package insert, revised August 2017, indicated the following: Coumadin is a vitamin K antagonist indicated for: - prophylaxis and treatment of venous thrombosis and its extension, pulmonary embolism - reduction in the risk of death, recurrent myocardial infarction, and thromboembolic events such as stroke or systemic embolization after myocardial infarction -prophylaxis and treatment of thromboembolic complications associated with atrial fibrillation and/or cardiac valve replacement Adverse Reactions: - most common adverse reactions to Coumadin are fatal and nonfatal hemorrhage from any tissue or organ During an interview on 2/13/23 at 1:25 P.M., Resident #293 said he/she takes Warfarin for atrial fibrillation. He/she said sometimes he/she has bleeding gums and will bruise if he/she significantly bumps his/her arms. During an interview on 2/14/23 at 11:06 A.M., Unit Manager #2 said there was not an order to monitor for signs and symptoms of bleeding but there should have been. During an interview on 2/14/23 at 1:30 P.M., the DON said there should have been an order for anticoagulation monitoring and monitoring done for signs and symptoms of bleeding. 3. Resident #245 was admitted to the facility in December 2022 with diagnoses including deep vein thrombosis (DVT). Review of the Minimum Data Set (MDS) assessment, dated 12/12/22, indicated Resident #245 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15, and received anticoagulant (blood thinner) medication daily. Review of the medical record indicated a Physician's Order for Apixaban (anticoagulant) 5 milligrams (mg) two times a day for DVT (12/6/22) Review of interdisciplinary care plans includes, but is not limited to: -Focus: Resident is on anticoagulant therapy related to history of DVT (12/6/22) -Interventions: Administer anticoagulant medication as ordered by the Physician. Monitor for side effects and effectiveness every shift (12/6/22); monitor all extremities for signs/symptoms of DVT (increased pain, warmth, edema, redness)-notify MD of abnormal findings (12/6/22); monitor/document/report as needed (prn) adverse reactions of anticoagulant therapy (12/6/22) -Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use (12/6/22) Further review of the medical record failed to indicate Resident #245 was monitored for potential symptoms/side effects of anticoagulant use. During an interview on 2/13/23 at 2:28 P.M., the surveyor reviewed Resident #245's medical record with Unit Manager #2 and she said Resident #245 has not been monitored for potential symptoms/side effects of anticoagulant use but should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy titled Specific Medication Administration Procedures, dated February 2019, indicated but was not limited to the following: -Cleanse hands using soap and water or facility-approved sanitizer before beginning a med pass, before handling medication, and before contact with resident -When finished with each resident, wash hands with soap and water or use facility-approved hand sanitizer Review of the facility's policy titled Queen [NAME] Personal Protective Equipment - Using Gloves, revised September 2010, indicated but was not limited to the following: -Wash hands after removing gloves (Note: gloves do not replace handwashing) On 2/13/23 at 8:40 A.M., the surveyor observed Nurse #4 insert her index finger inside a clear plastic medication pouch to open it to add medication tablets to be crushed. Nurse #4 did not perform hand hygiene prior to preparing the medications. Nurse #4 administered the medications to the resident then began to prepare the next resident's medications without performing hand hygiene before the previous administration or after. During an interview on 2/13/23 at 8:52 A.M., Nurse #4 said she should not have touched the inside of the medication pouch and should have performed hand hygiene before and after administration of the resident's medications. On 2/13/23 at 9:43 A.M., the surveyor observed Nurse #2 touch the inside of a medication cup with her index finger while preparing medications. Once done, Nurse #2 donned (put on) a pair of gloves to verify the medication count inside the cup with the surveyor. Nurse #2 doffed (took off) her gloves, disposed of them, then cut open a medication patch placing it on top of her medication cart. Nurse #2 administered the oral medications to the resident who was seated in a wheelchair next to the medication cart. Nurse #2 then cut open a second medication patch then carried the two in her right hand while wheeling the resident back to his/her room. Nurse #2 applied the medication patches on the resident's shoulders. Nurse #2 did not perform hand hygiene until after the medication patches were applied. During an interview on 2/13/23 at 10:09 A.M., Nurse #2 said she should not have touched the inside of the medication cup and should have performed hand hygiene before and after administering medications. She said she got distracted doing a lot of different things and didn't think to perform hand hygiene. During an interview on 2/14/23 at 8:34 A.M., the Director of Nursing (DON) said she was overseeing infection control and said staff should perform hand hygiene before beginning a med pass, before handling medications, and before contact with a resident. The DON further said staff are expected to perform hand hygiene before and after donning gloves and should not touch the inside of medication cups or pouches. 3. During an observation with interview on 2/14/23 at 10:15 A.M., the surveyor observed Nurse #4 perform dressing changes to Resident #294's coccyx and right buttock. Nurse #4 donned and doffed gloves four times while performing the dressing changes and did not perform hand hygiene until the procedure was completed. Nurse #2 said she should have washed her hands before and after each glove use. During an interview on 2/14/23 at 1:21 P.M., the DON said staff are expected to perform hand hygiene in between glove changes. Based on observations, interviews, policy review, and record review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to: 1. Monitor respiratory symptoms and implement transmission-based precautions for two Residents (#43 and #55); 2. Follow infection control standards during a medication pass, including hand hygiene; and 3. Follow infection control practices during a wound dressing change for Resident #294. Findings include: 1. Review of the facility's policy titled COVID-19- Testing Residents, dated as revised in September 2022, indicated the following: -Negative antigen tests (such as Binax) are considered presumptive. They are not used to rule out SARS-CoV-2 infection and are not used as the sole basis for infection control, treatment or management decision. -While test results are pending, symptomatic residents are placed on transmission-based precautions (TBP) according to CDC guidance -The decision to discontinue empiric TBP for symptomatic residents can be made based upon having negative results from at least one viral test. If using an antigen test, a negative result should be confirmed by either a negative molecular or second negative antigen test taken 48 hours after the first negative test. A. Resident #43 was admitted to the facility in October 2021. During an interview on 2/9/23 at 8:23 A.M., Resident #43 said, I'm not feeling so hot. The Resident said he/she had a cough. He/she said they thought they had been tested for COVID-19 a couple of days prior. On 2/9/23 at 12:41 P.M., the surveyor observed Resident #43 in the unit hallway, coughing into his/her hand. During an interview at this time, the Resident said he/she had been coughing for about a week; the cough would get better and then get worse. Review of the medical record indicated Resident #43 presented with a cough on 2/2/23 and was administered cough medicine. On 2/5/23 the Resident continued to have a cough, was administered cough medicine, and tested for COVID-19 with a Binax test. On 2/7/23 Resident #43 continued with a cough and was administered cough medicine. On 2/10/23 at 2:50 P.M., the surveyor observed Resident #43 sitting in the lobby area, coughing into his/her hand. Review of the medical record indicated Resident #43 was only tested with an antigen test on 2/5/23, and was not placed on TBP. B. Resident #55 was admitted to the facility in November 2021. During an interview on 2/9/23 at 9:15 A.M., Resident #55 said he/she had a cough. The surveyor observed the Resident to have a productive cough at this time. Review of the medical record indicated Resident #55 presented with a runny nose, cold symptoms, and a cough on 2/4/23 and was administered cough medicine. On 2/5/23, the Resident continued with a runny nose, a cough, and had loose stool twice and tested negative for COVID-19 with a Binax test. On 2/11/23, a slight cough continued. On 2/12/23, the Resident had an occasional cough. Review of the medical record indicated Resident #55 was only tested with an antigen test on 2/5/23 and was not placed on TBP. During an interview on 2/10/23 at 8:25 A.M., Resident #55 said their cough persists and he/she continued to have stuff come up with the cough. During an interview on 2/9/23 at 11:50 A.M., Unit Manager #2 said the process for symptomatic residents was to test once with the Binax test, monitor the symptoms, and re-test again at the discretion of the physician. During an interview on 2/14/23 at 10:35 A.M., the Director of Nurses said the process for symptomatic residents was to Binax test at symptom onset and then at the discretion of the physician. She said she was not aware the policy and the CDC indicated to place the residents on TBP and to re-test again in 48 hours. She said neither resident had been placed on TBP. The Director of Nurses said both residents with respiratory symptoms should have been monitored on the facility line listing (infection control monitoring). Review of the line list with the Director of Nurses failed to indicate either resident with respiratory symptoms had been monitored through this process.

Based on document review and interview, the facility failed to ensure the Facility Assessment was updated annually to accurately reflect the current status of the facility and to determine what resources are necessary to competently care for its residents during both day-to-day operations and emergencies. Findings include: Review of the Facility Assessment document indicated that it was completed/updated on 11/22/21 by previous leadership staff who were no longer employed at the facility. The current Administrator and Director of Nursing had started at the facility in 10/2022. There were no indications or documentation that the current facility leadership had reviewed/updated the Facility Assessment since 11/22/21. During an interview on 2/14/23 at 1:32 P.M., the Administrator said the current Facility Assessment had not been updated and/or reviewed since 11/22/21 and should have been updated/reviewed annually as required.

Based on observations, interviews, policy review, and record review, the facility failed to ensure COVID-19 testing was conducted per facility policy and Centers for Disease Control and Prevention (CDC) guidance for two Residents (#43 and #55) with respiratory symptoms, in a total sample of 22 residents. Findings include: Review of the facility's policy titled COVID-19- Testing Residents, dated as revised in September 2022, indicated the following: -Negative antigen tests (such as Binax) are considered presumptive. They are not used to rule out SARS-CoV-2 infection and are not used as the sole basis for infection control, treatment or management decision. -While test results are pending, symptomatic residents are placed on transmission-based precautions (TBP) according to CDC guidance -The decision to discontinue empiric TBP for symptomatic residents can be made based upon having negative results from at least one viral test. If using an antigen test, a negative results should be confirmed by either a negative molecular or second negative antigen test taken 48 hours after the first negative test. A. Resident #43 was admitted to the facility in October 2021. During an interview on 2/9/23 at 8:23 A.M., Resident #43 said I'm not feeling so hot. The Resident said he/she had a cough. He/she said they thought they had been tested for COVID-19 a couple of days prior. On 2/9/23 at 12:41 P.M., the surveyor observed Resident #43 in the unit hallway, coughing into his/her hand. During an interview at this time, the Resident said he/she had been coughing for about a week; the cough would get better and then get worse. Review of the medical record indicated Resident #43 presented with a cough on 2/2/23 and was administered cough medicine. On 2/5/23, the Resident continued to have a cough, was administered cough medicine, and tested for COVID-19 with a Binax test (three days after symptom onset). On 2/7/23, Resident #43 continued with a cough and was administered cough medicine. On 2/10/23 at 2:50 P.M., the surveyor observed Resident #43 sitting in the lobby area, coughing into his/her hand. Review of the medical record indicated Resident #43 was only tested with an antigen test on 2/5/23. B. Resident #55 was admitted to the facility in November 2021. During an interview on 2/9/23 at 9:15 A.M., Resident #55 said he/she had a cough. The surveyor observed the Resident to have a productive cough at this time. Review of the medical record indicated Resident #55 presented with a runny nose, cold symptoms, and a cough on 2/4/23 and was administered cough medicine. On 2/5/23, the Resident continued with a runny nose, a cough, and had loose stool twice and tested negative for COVID-19 with a Binax test (one day after symptom onset). On 2/11/23, a slight cough continued. On 2/12/23, the Resident had an occasional cough. Review of the medical record indicated Resident #55 was only tested with an antigen test on 2/5/23. During an interview on 2/10/23 at 8:25 A.M., Resident #55 said their cough persists and he/she continued to have stuff come up with the cough. During an interview on 2/9/23 at 11:50 A.M., Unit Manager #2 said the process for symptomatic residents was to test once with the Binax test, monitor the symptoms, and re-test again at the discretion of the physician. During an interview on 2/14/23 at 10:35 A.M., the Director of Nurses said the process for symptomatic residents was to Binax test at symptom onset and then at the discretion of the physician. She reviewed the medical record for Resident #43 and Resident #55 and said neither Resident had been tested on the day of symptom onset. She said she was not aware the policy indicated to place the residents on transmission-based precautions and to re-test again in 48 hours. The Director of Nurses said neither Resident had been re-tested after 48 hours.

Based on interview, the facility failed to develop, implement, and maintain a comprehensive Compliance and Ethics program as required. Findings include: The Administrator was unable to provide the surveyor with the facility's Compliance and Ethics program for review. During an interview on 2/14/23 at 1:32 P.M., the Administrator said he had not instituted any Compliance and Ethics program nor did he have any policies, as he was still getting acclimated to the facility.