Based on interviews and record review, the facility failed to ensure its staff: 1) received consent from the activated Health Care Proxy (HCP- person designated to make health care decisions on behalf of a person determined to not be able to make those decisions) for one Resident (#129) out of a total sample of 32 residents, prior to administering a medication used to treat mood and behavior, and 2) have the designated HCP sign required written consents. Findings include: Review of the facility policy titled Psychotropic Medication Use, edited 2/2/23, included the following: -a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior -categories of medications that affect brain activity such as antihistamines (medications used to treat allergies), anti-cholinergic medications (drugs that block/inhibit activity of a neurotransmitter that inhibits involuntary muscle movements and other bodily functions), central nervous system (brain and spinal cord) medications that are prescribed as a substitute for or an adjunct to a psychotropic medication are monitored and managed as psychotropic medications -Residents, families and/or the representatives are involved in the medication management process; when a state requires, informed consent is obtained and documented in the medical record prior to the start of the therapy in accordance with state-specific requirements . Resident #129 was admitted to the facility in September 2020 with diagnoses including Paranoid Schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), psychotic disorder, Major Depression, Anxiety, Dementia and Anoxic Brain Injury (lack of oxygen to the brain resulting in the death of brain cells). Review of the facility form titled Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy, dated 3/2/21, indicated Resident #129's designated HCP was invoked (put into effect) by the Physician (or designee) for a duration of life long due to his/her diagnoses of Paranoid Schizophrenia and Dementia. 1) Review of a Psychiatric Consult and Medication Review, dated 2/23/23, indicated a recommendation to start Metoprolol (medication used to treat high blood pressure that can also be used off label [the practice of prescribing a medication for a different purpose then what it was approved for] to treat anxiety) 12.5 milligrams (mg) daily due to his/her paranoia and trust issues. Review of the February 2023 Physician's orders indicated the following: -Metoprolol 25.0 mg, give 1/2 tablet (12.5 mg) in the morning related to Paranoid Schizophrenia, initiated on 2/24/23. Review of the February 2023 Medication Administration Record (MAR) indicated that Metoprolol 12.5 mg was administered at 9:00 A.M. on 2/24/23. Review of the clinical record did not indicate that the Resident's activated HCP provided consent for the Metoprolol prior to its administration, as required. During an interview on 4/4/23 at 11:10 A.M., Nurse #5 said that consent would be obtained by the Resident or their guardian or responsible party if the Resident was not able to make their own healthcare decisions prior to administration of a psychotropic medication. Nurse #5 said when there was an order to start a new medication, the order would be entered into the electronic medical record (EMR) and put on hold until consent was obtained prior to administration of the medication. She further said that the Unit Manager (UM) was responsible for ensuring consent was obtained prior to administering psychotropic medications. During an interview on 4/4/23 at 11:13 A.M., UM #1 said consent must be obtained prior to administering a new psychotropic medication, and that the medication would be put on hold and not given until consent was obtained by the responsible party. During a follow-up interview on 4/4/23 at 2:41 P.M., UM #1 reviewed the February 2023 MAR with the surveyor. She said Metoprolol should not have been administered to Resident #129 on 2/24/23 without obtaining consent from his/her activated HCP. 2) Review of the April 2023 Physician's Orders included the following: -Clozaril (antipsychotic medication to treat Schizophrenia) at bedtime (HS) for Anxiety and Paranoid Schizophrenia -Lyrica (nerve pain medication used off label to treat anxiety) twice daily for psychotic disorder/delusions -Remeron (antidepressant) daily at HS for Depression Review of the Informed Consent for Psychotropic Administration Forms for the following medications: Clozaril, Lyrica and Remeron, indicated the following: -the forms did not indicate that the Resident/Resident Representative refused or consented to administration of the medications (the boxes to check off refusal of the medication or consent of the medication were unchecked), and -the forms were signed by Resident #129 even though his/her HCP was invoked 3/2/21. During an interview on 4/4/23 at 2:41 P.M., UM #1 reviewed the signed Informed Consent for Psychotropic Administration Forms with the surveyor. UM #1 said she was not aware that the Resident's HCP was invoked on 3/2/21. UM #1 said the Informed Consent forms for Remeron signed on 1/21/22, and Lyrica and Clozaril signed on 6/24/22, should not have been signed by Resident #129. During an interview on 4/4/23 at 3:05 P.M., the Director of Nurses (DON) said that Resident #129 should not have signed his/her paperwork after the HCP was invoked. She also said that consent should have been obtained by the Resident's HCP prior to the administration of Metoprolol on 2/24/23.

Based on observations, interview, and record review, the facility failed to ensure its staff provided reasonable accommodations based on individual preferences for one Resident (#129), out of a total sample of 32 residents. Specifically, the facility failed to provide a footboard that would prevent the mattress from sliding down and off the resident's bed. Findings include: Review of the facility policy titled Work Orders-Maintenance, revised April 2010, indicated maintenance work orders shall be completed in order to establish a priority of maintenance services. The policy included the following: -work orders must be filled out and forwarded to the Maintenance Director -supply of work orders is maintained at each nurses' station -work order requests should be placed in the appropriate file basket at the nurses' station. -Work orders are picked up daily -emergency requests will be given priority in making necessary repairs Review of the Environmental/Safety Sheet, undated and provided by the facility on 4/4/23, included the following: -scan environment for safety concerns throughout shift! -does the identified issue pose a safety risk to the residents/staff? If so- correct immediately! -notify maintenance right away (as appropriate) . -for non-emergent issues, please fill out a maintenance slip including a detailed description, location and name of the person that identified issue. Resident #129 was admitted to the facility in September 2020 with diagnoses including Amblyopia (lazy eye: decreased eyesight due to abnormal visual development) and bilateral cataracts (cloudy area in the lens of the eye that leads to decreased vision). Review of the Minimum Data Set (MDS) Assessment, dated 2/24/23, indicated Resident #129 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15. On 3/30/23 at 1:48 P.M., the surveyor observed Resident #129 lying in bed. The mattress was observed hanging approximately one foot off the bed and the Resident's legs were angled towards the floor. On 4/4/23 at 9:24 A.M., the surveyor observed Resident #129 lying in bed. The head of the bed was elevated, approximately one foot of the bed frame was exposed at the head of the bed and the lower part of the mattress was observed hitting the floor. There was no foot board on the end of the bed. During an interview at this time, Resident #129 said that his/her bed had been this way for a while and that he/she always needed to move the mattress up onto the bed frame because it slides. Resident #129 further said that he/she would like to have this problem fixed. Review of the Resident's Care Plan and clinical record indicated no documented evidence that he/she requested to have the footboard to the bed removed. During an interview on 4/4/23 at 9:28A.M. and 9:40 A.M., Nurse #4 said she noticed that the Resident's mattress slides off the bed and that there was no footboard present. She said she noticed the footboard was not there weeks ago, had verbally mentioned it to someone and said there was someone going room to room checking equipment and beds at that time. Nurse #4 said maintenance requests should be written on a form in the maintenance book, which was located at the nurse's station, so that it can be followed up on. She further said that she was not sure what happened after she verbally mentioned the status of the Resident's mattress and footboard, but it was still not fixed. Review of the Maintenance Book located on the unit indicated no documented evidence that there was a request submitted relative to Resident #129's bed. During an interview on 4/4/23 at 10:16 A.M., Certified Nurses Aide (CNA) #1 said that she could not recall a time when Resident #129 had a footboard located on his/bed and that it had been this way (missing the footboard) as long as she could remember. During an interview on 4/4/23 at 11:13 A.M., Unit Manager (UM) #1 said that she was not aware of the status of Resident #129's mattress and footboard. She said that if the Resident had requested to have the footboard removed from the bed, it would be on the Resident's Care Plan. UM #1 said that if a maintenance concern or request arises, maintenance are notified and check in with the unit daily. During an interview on 4/4/23 at 11:33 A.M., the Director of Maintenance said that he was not made aware of the issue with Resident #129's bed until today when nursing notified him that a footboard was needed. He said a maintenance slip should have been completed when the issue was identified, that this was never completed, and that if he had been notified earlier, it would have been addressed immediately as it was a quick fix. During an interview on 4/4/23 at 3:05 P.M., the Director of Nurses (DON) said that she was made aware of the concern about Resident #129's bed. She said there was a process for maintenance requests and that the process was not followed as it should have been.

Based on observation, interview and record review, the facility failed to ensure its staff implemented a plan of care related to pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) for one Resident (#66) out of a total sample of 32 residents. Specifically, the facility staff failed to implement the Physician's orders for ensuring: A. treatment to prevent further skin breakdown was applied as ordered, B. weekly skin assessments were completed as ordered, and C. air mattress settings were set appropriately. Findings include: Review of the facility policy titled Prevention of Pressure Injuries, revised April 2020, indicated the following: -To conduct a comprehensive skin assessment .with each risk assessment, as indicated according to the resident's risk factors. Resident #66 was admitted to the facility in May 2012 with diagnoses including Parkinson's Disease, Hemiplegia (weakness of one entire side of the body), and malnutrition. Review of the most recent wound consult progress note dated 3/29/23 indicated the following: -Pressure ulcer of right and left buttock, Stage Four (involves full-thickness skin and tissue loss, exposing muscle, bone, and sometimes tendons, ligaments, or cartilage) -Pressure ulcer of left hip, Stage Four -Resident has chronic pressure ulcers -Resident has severe contractures A. Review of the April 2023 Physician's orders indicated an order to replace the lamb's wool between the Resident's right toes every day and evening shift for protection, initiated on 10/28/21. During an observation and interview on 4/3/23 at 9:57 A.M., the surveyor and Nurse #2 observed Resident #66 to not have lamb's wool in between his/her toes. She said that he/she should have lamb's wool in between his/her right toes for protection, but it was not there, as required B. Review of the April 2023 Physician's orders indicated an order to complete the skin observation tool (an observation tool utilized by licensed nursing staff and completed in the electronic medical record [EMR]) every day shift on Thursday, initiated on 7/15/21. Review of the EMR from 1/1/23 - 3/30/23, indicated only six of the 13 required skin observations were completed during this time. During an interview on 4/3/23 at 1:22 P.M., the Director of Nurses (DON) said that the skin assessments are completed only on the skin observation tool and are not noted anywhere else. The surveyor and the DON both reviewed the skin observation tools that were completed from 1/1/23 - 3/30/23. The DON said that from January to April, seven of the weekly skin observations had not been completed as required. During a follow up interview on 4/4/23 at 10:04 A.M., the DON said that when the staff performed a skin assessment it is from head to toe. She further said that when the wound doctor comes in to see a resident, they are typically only looking at what the facility staff have asked them to look at and it is not a full head to toe skin assessment. C. Review of the April 2023 Physician's orders indicated an order to check the air mattress setting every shift, keep it on therapy mode, soft setting second light from the bottom, every shift for pressure relief, initiated on 12/21/21. During an interview and observation on 4/4/23 at 2:11 P.M., Nurse #2 and the surveyor observed Resident #66's air mattress was set to the fifth light from the bottom (bottom indicating soft setting). Nurse #2 said that the air mattress should be set to the second light from the bottom per the Physician's orders, especially because Resident #66 currently has wounds, and the air mattress was not set as required.

Based on record review, policy review, and interviews, the facility failed to ensure that its staff provided adequate supervision and clinical intervention for one Resident (#70), out of a sample of 32 residents. Specifically, the facility staff failed to provide one-on-one supervision and assessment by clinical staff to evaluate for level of risk following an expression of suicidal ideation by the resident. Findings include: Resident #70 admitted to the facility in June 2020 with diagnoses including Schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), Major Depressive Disorder and Anxiety. Review of Resident #70's progress note dated 1/2/23, indicated that the Resident was weeping and felt that his/her suicidal thoughts were being triggered. Further review of the Resident's clinical record did not reveal that the Resident was being monitored or assessed for suicidal ideation risk by staff following the suicidal statement. Review of the facility policy for Suicide/Self-Harm Precautions, last revised February 2023, indicated: -Any suicidal statement or acts of self-harm are to be taken seriously and are to be reported immediately to the nurse in charge or neuro-rehab supervisor. -The resident is not to be left unattended. -When a resident expresses a wish or intention to harm or kill him or herself, he or she will be placed on close visual supervision until the level of risk can be assessed. -The Program Director will assign a licensed/trained person to assess the Resident, interview staff and review chart. Review of Resident #70's Mood Care Plan, last revised 3/2/23, indicated that the Resident has a history of overdosing on prescription medication and tying a blanket to a bed rail in an attempt to self-harm. The care plan intervention indicated to follow the facility policy for self-harm behaviors. During an interview on 4/4/23 at 9:09 A.M., Social Worker #1 said that residents with suicidal ideation are to be supervised by staff until they can be assessed by a Clinical Therapist for their level of risk. During an interview on 4/4/23 at 11:56 A.M., Social Worker #1 said that a staff member should have clarified if Resident #70 was suicidal and written a progress note, which they did not. During an interview on 4/4/23 at 12:12 P.M., the Administrator said that they did not follow their policy for self-harm precautions and they did not document any follow-up regarding Resident #70's suicidal ideation being triggered, which should have been completed by a Social Worker or Clinician. He further said that the Resident should have been on one-to-one supervision per the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that one Resident (#82), out of a total sample of 32 residents, was free of significant medication errors per facility policy and professional standards. Specifically, the facility staff administered unauthorized medications to Resident #82, that was intended for another resident. Findings include: Resident #82 was admitted to the facility in June 2015. Review of the facility policy for Adverse Consequences and Medication Errors, last revised February 2023, indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards of the professionals providing services. Professional standards in preventing medication errors that compromise patient safety are included in Nursing Rights of Medication Administration, authored by [NAME], A and [NAME], L. M (last updated September , 2022), https://www.ncbi.nlm.nih.gov/books/NBK560654/ The traditional 'five rights' or 'five R's' of medication administration are as follows: -Right patient - ascertaining that the patient being treated is the correct recipient for whom the medication was prescribed . -Right drug - ensuring the medication to be administered is identical to the drug prescribed . -Right route - how medications are safely delivered to patients -Right time - administering medications at a time that was intended by the prescriber . -Right dose - checking to ensure the dosage is the correct strength for the patient Review of Resident #82's progress note, dated 3/27/23 indicated that the Resident was administered another resident's medication, the Physician was notified and that the Resident's vital signs were to be monitored by staff for the following 72 hours. Review of the Medication Error Report, dated 3/27/23, indicated that Nurse #3 had administered the following medications to Resident #82 in error: -Eliquis 5 milligrams (mg) (anti-coagulant) -Pepcid 40 mg (gastric acid secretion reducer) -Percocet 5-325 mg (analgesic opioid oxycodone combination) -Olanzapine 5 mg (antipsychotic) During an interview on 4/4/23 at 7:15 A.M., the Director of Nurses (DON) said that Nurse #3 gave Resident #82 his/her roommate's medications without confirming who the Resident was prior to administration. She further stated that the Resident should have only received medications as ordered by the Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure its staff maintained safe storage of medications. Specifically, facility staff failed to ensure: 1. an unattended medication cart was locked on one unit ([NAME]), out of four units, and 2. food was kept separate from medications in one unit (Deerfield), out of four medication storage rooms. Findings include: Review of the facility policy titled, Storage of Medications, revised November 2020 indicated the following: - Drugs and biologicals used in the facility are stored in locked compartments - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. - Medications are stored separately from food and are labeled accordingly. 1. On 3/31/23 at 11:34 A.M., the surveyor observed an unattended, unlocked medication cart on the [NAME] unit. The surveyor also observed a resident seated approximately four feet away from the cart and there was no staff within view of the medication cart at the time. At 11:36 A.M., the surveyor observed Nurse #6 quickly walk by the cart, engage the locking mechanism, and continue down the hallway. During an interview on 3/31/23 at 11:40 A.M., Nurse #6 said the unlocked cart was not within her view when she left it to attend to a resident. 2. During an observation and interview on 4/4/23 at 8:47 A.M., the surveyor accompanied Nurse #2 to the Deerfield unit medication room to look for a medication in the emergency medication kit. When Nurse #2 removed the emergency kit box off of the electronic medication dispensing system, the surveyor and Nurse #2 observed a takeout container with onion rings on top of the medication dispensing system. Nurse #2 said the onion rings should not have been there and there should not be food in the medication room.

2. For Resident #66, the facility failed to ensure their staff provided wound care in such a way to avoid contamination putting the resident at risk for further infection. Resident #66 was admitted to the facility in May 2012. Review of the medical record indicated the Resident had three pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin, also known as bed sores) and was prescribed intravenous antibiotics to treat a wound infection. Review of the facility titled, Clean Dressing Change, revised 4/29/16 indicated the following: - Clean dressing change technique will be used as clinically appropriate - Purpose: to promote wound healing, prevent infection. Procedure: - Remove soiled dressing - perform hand hygiene, don clean gloves, loosen soiled dressing, inspect color, odor, consistency, appearance and quantity of drainage present, observe appearance of wound, place soiled dressing in moisture proof bag, remove gloves and discard in bag, perform hand hygiene. - Prepare supplies - once preparation of supplies is completed, perform hand hygiene and don (apply) clean gloves. - Clean the wound - after cleansing wound as indicated, remove gloves, perform hand hygiene and don a new pair of gloves. - Treat the wound - after treating wound remove gloves and wash hands with soap and water. During a wound care observation on 4/4/23 at 10:09 A.M., the Surveyor observed Nurse #1 perform hand hygiene, apply a pair of clean gloves, and position the Resident to his/her left side. She then removed the contaminated dressing that was saturated with drainage from the wound, cleansed the wound, then applied the new dressing as ordered. While still wearing the same gloves she applied prior to changing the first dressing, Nurse #1 then assisted the Resident to his/her right side. Nurse #1 then removed the contaminated dressing saturated with drainage from the second wound, cleansed the wound, then applied the new dressing as ordered. While continuing to wear the same gloves she applied prior to changing the first and second dressings, Nurse #1 then moved onto the third wound. The surveyor observed Nurse #1 remove the contaminated dressing saturated with drainage, cleanse the wound, then apply the new dressing as ordered. Throughout the process, the surveyor did not observe Nurse #1 performing appropriate hand hygiene and change into clean gloves between dressing changes, after handling soiled dressings, prior to cleansing the wounds or prior to applying clean dressings. During an interview on 4/4/23 at 10:35 A.M., Nurse #1 said she should have removed her contaminated gloves and performed hand hygiene after handling the soiled dressings. She further said she should have performed hand hygiene and applied new gloves prior to cleansing the wounds as well as prior to performing the dressing change, and she did not as required. Based on observation, interview, and policy review, the facility failed to ensure its staff used proper hand hygiene techniques on one unit (Deerfield) out of four units observed, and for one Resident (#66) out of a total sample of 32 residents. Specifically, Nursing staff failed to: 1. properly handle medications in a way as to reduce the risk for the spread of possible contaminates from bare hands to pills being distributed to residents on the Deerfield unit, and 2. properly don (put on), doff (take off), and perform hand hygiene per facility policy when providing wound care treatments for Resident #66 who had multiple wounds and a diagnosed wound infection. Findings include: 1. Review of the facility policy titled Administering Medications, edited 5/21/19, indicated the following: -Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 4/3/23 at 8:13 A.M., on the Deerfield Unit, the Surveyor observed Nurse #5 transferring pills with her bare hands from one medication cup to another medication cup. During an interview following the observation Nurse #5 said she should not be touching pills with her bare hands and that she should have donned (put on) gloves if she needed to touch the pills. During a follow up interview on 4/4/23 at 3:00 P.M., the Director of Nursing (DON) provided the surveyor with the facility policy titled Administering Medications. She said the policy did not specifically address touching pills with bare hands, but it was facility practice that if pills needed to be handled with bare hands a nurse should don gloves to touch the pills. She further said touching pills with bare hands was an infection control issue and increased the risk of contaminating the pills with any contaminants that may have been on the nurse's hands.

Based on record review, policy review and interview, the facility failed to prevent a significant medication error for one sampled Resident (Resident #35), out of a total sample of 30 residents. Findings include: Resident #35 was admitted to the facility in April of 2020 with diagnoses including dementia with behavioral disturbance. Review of facility Administering Medications Policy, revised in April of 2019, included: -Medications are administered in accordance with prescriber orders, including any required time frame. -The following information is checked/verified for each resident prior to administering medications: -Allergies to medications -Vital signs if necessary Review of the medical record indicated a Physician Order, dated 04/25/20, for propranolol (a medication used to treat high blood pressure, heart failure and irregular heartbeat which also can be used to manage anxiety symptoms) 10 milligrams (mg), give one tablet by mouth one time per day, hold for systolic blood pressure less than 100 millimeters of mercury (mm/Hg) or for a pulse less than 60 beats per minute. Review of the June 2021 Medication Administration Record (MAR) indicated administration of propranolol on 06/21/22 with a recorded systolic blood pressure of 93 mm/Hg which was outside of the parameters set forth in the physician's order. During an interview on 07/30/21 at 08:56 A.M., the surveyor asked Unit Manager (UM) #1 what the procedure would be if the resident's blood pressure or pulse were outside of the parameters ordered by the Physician. UM #1 said the medication should be held and the Physician should be notified. Upon review of the Resident's MAR for 6/23/21, UM #1 said the Resident should not have received the propranolol on that date based on the recorded blood pressure reading. Review of the MAR for 07/12/21 and 07/25/21 indicated the administration of propranolol with no recorded blood pressure or pulse readings. Further review of the Resident's clinical record indicated that there were no recorded vital signs, including blood pressure and pulse on 07/12/21. Review of the progress notes indicated the Resident refused having vital signs taken on 07/12/21. During an interview on 07/30/21 at 03:14 P.M., the surveyor asked the Director of Nursing (DON) what the procedure was if a medication was dependent upon vital sign parameters for administration and the resident refuses to have their vitals measured. She said the medication should not be given, the Physician should be notified and the clinical record noted. The DON further said the medication should not be given at all if the resident's blood pressure and pulse were not measured prior to medication administration.

Based on policy review, observations, record reviews and interviews, the facility failed to ensure infection control guidelines were maintained during 1.) The preparation of medications for an administration pass and 2.) A dressing change procedure. Findings include: 1. The facility failed to ensure medications were handled with gloved hands. Review of the facility Administering Medication Policy, edited 5/21/19, indicated: -staff follows established facility infection control procedures (ex. handwashing, antiseptic technique, gloves, isolation precautions, etcetera) for the administration of medication, as applicable. On 7/29/21 at 1:30 P.M., the surveyor observed the medication preparation for administration. The surveyor observed Nurse #4 place her hand behind each medication bubble card and push the medication out from the card while using her ungloved fingers to remove each pill from the bubble card and place each pill into the medication cup. Nurse #4 obtained four different medications in this same manner. She did not wear gloves and touched each pill with her ungloved fingers. During an interview on 7/29/21 at 1:35 P.M., Nurse #4 said she touched each pill with her bare hands and did not wear gloves, as required. 2. The facility failed to sanitize hands prior to donning (putting on) on new gloves during a wound clean dressing change procedure. Review of the facility Clean Dressing Change Policy, revised 4/29/16, indicated: -after removing a soiled dressing to remove gloves and perform hand hygiene according to local requirements. After cleaning a wound, to remove gloves, perform hand hygiene according to local requirements and don a new pair of gloves. On 7/30/21 at 11:08 A.M., the surveyor observed a clean dressing change procedure. The surveyor observed Nurse #5 remove her soiled gloves three times and, prior to donning a new pair of gloves, failed to sanitize her hands. During an interview on 7/29/21 at 11:15 A.M., Nurse #5 said the requirement was to sanitize her hands prior to donning new gloves during the dressing change procedure and she did not sanitize her hands for three opportunities during the procedure, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations and interviews, the facility failed to 1.) Ensure one medication cart on two of four units observed were clean and orderly and 2.) The facility failed to ensure one of two medication refrigerators inspected were at the required temperature setting. Findings include: Review of the facility Storage of Medications Policy, revised November 2020, included: - The facility stores all drugs and biologicals in a safe, secure and orderly manner. - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. - Drugs and biologicals are stored in packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 1.) A. On 7/29/21 at 8:45 A.M., the surveyor observed the [NAME] Unit Medication Cart B with Nurse #1. The surveyor observed numerous different colored loose pills and white tabs (these tabs are punched out when a medication is removed from a blister card) found on the floor of a medication drawer. During an interview on 7/29/21 at 8:50 A.M., Nurse #1 said the medication drawer was not clean and should not have had the loose pills and white tabs in the drawer. B. On 7/29/21 at 8:55 A.M., the surveyor observed the Deerfield Unit Medication Cart B with Nurse #6. The surveyor observed one container of Anti-Itch Cream and numerous different colored loose pills and white tabs were found on the floor of a medication drawer. During an interview on 7/29/21 at 9:00 A.M., Nurse #6 said the Anti-Itch cream did not belong in the medication cart and she said the medication drawer was not clean and should not have had the loose pills and white tabs on the floor of the medication drawer. 2.) On 7/29/21 at 8:20 A.M., the surveyor observed the [NAME] Unit medication refrigerator with Nurse #3. The surveyor observed the refrigerator thermometer temperature to be 32 degrees Fahrenheit (F). The refrigerator contained numerous unopened insulin's and eye medications. Review of the Nursing 2016 Drug Handbook indicated: -Unopened insulin's should be stored in the refrigerator at 36-46 degrees Fahrenheit During an interview on 7/29/21 at 8:20 A.M., Nurse #3 showed the surveyor a Medication Room Refrigerator log sheet that indicated the refrigerator temperature reading should be between 35-41 degrees F. On 7/29/21 at 10:35 A.M., the surveyor observed the [NAME] Unit medication refrigerator with Nurse #3 and the refrigerator thermometer indicated the temperature to be 32 degrees F. During an interview on 7/29/21 at 10:45 A.M., the Director of Nurses (DON) said the refrigerator temperature range on the log sheet indicated an incorrect range and she further said the refrigerator temperature of 32 degrees was too low and not within the required range of 36 - 46 degrees Fahrenheit.

3. For Resident #57, the facility failed to indicate a stop date for an, as needed (PRN), psychotropic medication. Resident #57 was admitted to the facility in February of 2020 with a diagnosis of Cerebral Infarction (a stroke). Review of the medical record indicated a Physician Order, dated 5/11/21, for Valium (an anti-anxiety) 5 milligram, give 0.5 tablet orally every 8 hours PRN for increased anxiety related to Generalized Anxiety Disorder. There was no stop date indicated in the Physician Order. Review of the medical record indicated a Consultant Pharmacist Recommendation, dated 5/28/21, for the Medical Doctor (MD) to address the Valium PRN order and please add a stop date after which the order can be re-evaluated. The form did not contain a response from the Physician to either agree, disagree or document a response. Review of the Medication Administration Records (MAR) indicated the Resident received the PRN Valium doses in May, June and July of 2021. During an interview on 7/30/21 at 1:12 P.M., the Director of Nurses (DON) gave a copy of the Consultant Pharmacist Recommendation form, dated 5/28/21, that indicated a response, dated 6/01/21, to review the PRN Valium order in 90 days. The DON said the stop date should have been indicated on the MARs and it was not. 4. For Resident #35, the facility failed to accurately document the pulse and blood pressure in relation to the administration of a medication which was dependent upon this data. Resident #35 was admitted to the facility in April of 2020 with diagnoses including dementia with behavioral disturbance. Review of the medical record indicated a Physician Order, dated 04/25/20, for propranolol (a medication used to treat high blood pressure, heart failure and irregular heartbeat which also can be used to manage anxiety symptoms) 10 milligrams (mg), give one tablet by mouth one time per day, hold for a systolic blood pressure less than 100 millimeters of mercury (mm/Hg) or a pulse less than 60 beats per minute. Review of the June 2021 Medication Administration Record (MAR) for the propranolol order indicated a dedicated area to document the Resident's blood pressure and pulse prior to the administration of the medication. Further review of the June 2021 MAR indicated Not Applicable (NA) under both the blood pressure and pulse column for a total of 10 out of 30 days. Review of the July 2021 MAR indicated NA under both the blood pressure and pulse column for a total of 17 out of 30 days. During an interview on 07/29/21 at 02:09 P.M., the surveyor asked Unit Manager (UM) #1 what NA indicated in the blood pressure and pulse column. She said it appeared that nursing staff entered NA meaning 'not applicable' because the nursing staff may have been obtaining the daily vital sign data that had already been recorded elsewhere in the medical record prior to administering the medication. The surveyor said the MAR data appears as though the medication was being administered without first checking the Resident's blood pressure and pulse to which UM #1 said the information was confusing. Review of the Resident's medical record indicated documented pulse and blood pressure after the medication administration time in 8 out of 30 days in June of 2021 and 13 out of 30 days in July of 2021. During an interview on 7/30/21 at 1:30 P.M., the surveyor asked the DON why the time of the recorded blood pressure and pulse readings were well after the administration of the medication. The DON said that the times listed in the computer are likely when the nurse gets around to data entering the information versus the time the information was obtained. She said the nurse generally keeps track of the information on a piece of paper and enters that information later on in the shift. The DON further said the electronic Medical Administration Record prompts the nurse to enter the blood pressure and pulse readings at the time of medication administration and they should have been doing this. Based on observations, record reviews and interviews, the facility failed to ensure accurate and/or complete medical records for four sampled Residents (#23, #66, #57 and #35), out of a total sample of 30 residents. Findings include: 1. For Resident #23, the facility failed to ensure an accurate medical record relative to the administration of oxygen therapy. Resident #23 was admitted to the facility in March of 2016 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- condition involving constriction of the airways and difficulty or discomfort in breathing). On 7/27/21 at 9:27 A.M., the surveyor observed Resident #23 seated in a wheelchair in his/her room. Oxygen (O2) therapy was observed being administered to Resident #23, via a nasal cannula (tube inserted within the nose), which was connected to a concentrator set at a flow rate of 2 liters/minute or LPM (the percentage or concentration of O2 that a person inhales). Review of the Respiratory Care Plan, revised 3/24/16, indicated to administer oxygen as needed at 2 LPM to maintain an oxygen saturation level greater than 98% (O2 saturation measures the percentage of O2 in the blood). Review of the Certified Nurse Aide (CNA) Care Card, revised 6/9/20, indicated oxygen was to be administered at 2 LPM as needed to maintain an O2 saturation level greater than 92%. Review of the July 2021 Physician's Orders, indicated an order, initiated (2/5/21), for oxygen to be administered as needed (PRN) for O2 saturation levels less than 88%. During an interview on 7/30/21 at 10:11 A.M., the Director of Nurses (DON) said that the Respiratory Care Plan, Physician's Orders and CNA Care Card should match relative to when oxygen therapy was to be administered. 2. For Resident #66, the facility failed to ensure an accurate Physician's Order relative to the setting of an air mattress. Resident #66 was admitted to the facility in May of 2020 with diagnoses including traumatic brain injury and multiple contractures of the hips and knees. On 7/28/21 at 12:35 P.M. and on 7/29/21 at 8:42 A.M. and 12:02 P.M., the surveyor repeatedly observed Resident #66 lying in bed on an air mattress which was set at 5. Review of Resident #66's July 2021 Physician's Orders, indicated the following: -air mattress to be set at 6 (third light from the top), check every shift to assure appropriate comfort level. During an interview on 7/29/21 at 1:51 P.M. and subsequent interview at 2:32 P.M., the Director of Nurses (DON) said that that the company who supplied the air mattress for Resident #66 initially set it up for him/her. She later said that the company was contacted and indicated that the Resident's air mattress should be set at 5, not at 6. The DON said that the Physician's Orders would be adjusted to reflect to correct setting.