**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00151153 Based on interview and record review, the facility failed to report a resident-to-resident physical assault to local law enforcement and a second-degree burn sustained from an avoidable hot liquid spill for 2 residents (R1 and R2) out of 4 residents reviewed for abuse and neglect. Findings included: Review of the facility abuse policy dated reviewed 1/2025 revealed, Possible Indicators of Physical Abuse Includes but not limited to Burns, blisters or scalds on hands or torso. Facial injuries ., failure of staff to implement resident interventions, when residents have been assessed and interventions are care planned, failure to monitor, provide adequate supervision to ensure environmental hazards are not present including but not limited to: a. Access to hot water of sufficient temperature to cause tissue injury Reporting/Response. All alleged or suspected violations are reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, Adult Protective Services, Local Public Safety, Licensure Boards, Regional Director of Operations or Regional Clinical Directors (representative of governing board) and any other agencies in accordance with State law through established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involved abuse or result in serious bodily injury. Not later than 24 hours if the event that cause the allegation do not involve abuse and does not result in serious bodily injury .j. Begin investigation of the allegation. Procedure. 1. When staff (staff here refers to covered individuals) suspect a crime has occurred against a resident at the facility, they must report the incident to SSA (State Survey Agency) and local law enforcement. 2. Staff must report a suspicion of a crime to the state survey agency, SSA (State Survey Agency) and at least one local law enforcement entity within a designated time frame by e-mail, fax or telephone. The individual does not need to determine which local law enforcement entity. This will meet the individual's obligation to report. R2 (Resident-to-Resident Assault Incident) Review of R2's face sheet no date revealed, he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Autistic disorder (neurodevelopmental disorder characterized by repetitive, restricted and inflexible patterns of behavior, interest and activities as well as difficulties in social interaction and social communication), falls and weakness. Review of the facility reported incident dated 3/1/25 at 4:30 AM revealed the Nursing Home Administrator (NHA) notified the State Survey Agency (SSA) of an incident between R1 and R2 that occurred on 3/1/25 at 4:30 AM where R1 was observed hitting his roommate R2 with his water mug while R2 was still in bed. R2 sustained cuts and bruises to his face. R2 was sent to the emergency room for evaluation and treatment. R1 said was upset that his wife was not in the bed and a stranger was in the bed and that's why he was hitting him. The report revealed both R1 and R2 were both severely mentally impaired. The report did not indicate that the police were notified of this incident. Review of R2's progress note dated 3/1/25 at 5:17 AM revealed, At 0431, nurse heard R2 yelling to knock it off and went into bedroom to find R2 sitting up in bed, and his roommate (R1) hitting him with a water mug. Roommate pulled away immediately, who stated that he was trying to kill him because he was in his wife's spot. Attempted to reorientate roommate with no success. R2 has 2 lacerations on his left eye, red spot on his cheek bone, and a scratch on his chest along with a reddened area on left upper chest. Cleaned laceration and sent to name of emergency room for evaluation. Emergency contact called and notified along with provider and NHA (Nursing Home Administrator). Upon return R2 was moved to (room number). Review of R2's progress note dated 3/1/25 at 6:17 AM revealed, Per NHA not necessary to call police regarding incident. Review of R2's progress note date 3/13/25 at 3:13 PM revealed, name of R2 's family member had told him about the incident from this weekend involving R2 and he was concerned about if it got reported to anyone (i.e. the police, etc.). I explained that we reported the incident to the state immediately and they do an investigation. I explained where things stand with the investigation, and we do not believe that we could have prevented this unfortunately. Review of R2's progress note dated 3/14/25 at 4:42 PM revealed he was discharged to an assisted living facility. R1 (2nd Degree Hot Liquid Injury) A second-degree burn damages the full thickness of the skin causing redness, swelling, blisters and intense pain. Review of R1's face sheet, no date, revealed he was [AGE] years old, admitted on [DATE]. He was on hospice. He had diagnoses that included dementia, metabolic encephalopathy (brain disorder causing brain dysfunction), burn of second degree of right thigh, diabetes mellitus type 2, and falls. Review of R1's progress note dated 3/25/25 at 8:35 PM revealed, At approximately 4:30 PM, ADON (Assistant Director of Nursing) got a cup of coffee for R1 from the kitchen. Coffee was poured from a less than half full pot and added 2 creams and 1 sweetener. Lid was placed on coffee cup and given to R1. Another resident wanted coffee so this nurse went to get a coffee for the other resident. When this nurse came out of the kitchen R1 was in the center of the dining room and coffee cup was on the floor. CNA (Certified Nurse Aide) changed R1, area on inner thigh was pink, she put cold washcloths on area. His nurse came in his room, seen it, notified (name of doctor) and was awaiting orders. 2030 (9:30 PM) returns to bed, tx (treatment) to heel completed, res (resident) with no c/o (complaint of) thigh areas/burn from earlier in day. Review of R1's altered skin integrity care plan dated 3/13/25 revealed, resident acquired altered skin integrity to right inner thigh-hot liquid spill. Approaches included 4/16/25 Resident, Family educated on risk benefit of regulated temperature to hot liquids & foods. Temps do not exceed 120 degrees. Review of R1's Wound Information Observation History dated 4/7/25 at 3:50 PM revealed the current Director of Nursing (DON) documented, Burn type Partial thickness: redness, blistered, moist, painful, 2 areas of blisters, open measuring 3 cm X 6x6 cm. Review of a Wound Management note for R1, Most Recent Documentation dated 4/17/25 at 11:15 AM, revealed, the wound was identified on 3/25/25 at 5:00 PM and measured 3.6 cm x 6.1 cm. During an interview with the Director of Nursing (DON) on 4/16/25 at 10:37 AM. The DON did not have any incident or accident reports for R1's thigh burn that occurred on 3/25/25. The DON said she started on 4/7/25 and became aware of the burn and started education and a plan of correction. The DON said R1's burn was not reported to the State and that she was not working in the facility at the time of the burn. The DON was not aware why the facility did not report the burn. The DON was asked if the facility reported the physical altercation between R1 and R2 on 3/1/25 at 4:30 am to the police. The DON reviewed the facility investigation and could not locate any police notification. The DON said she was not working in the facility at that time and if she was, she would have reported this event to the police and confirmed that the facility policy would be to report the incident. During a telephone interview with the Nursing Home Administrator (NHA) on 4/16/25 at 10:03 AM, the NHA confirmed that he was aware R1 had sustained a burn when he spilled hot coffee on himself on 3/25/25. The NHA said he was not aware of the extent of injury and the time. When he returned from his vacation, he was aware of the severity of burn, and he did not report it to the State Agency, and he should have reported the burn. The NHA was asked if he reported physically altercation between R1 and R2 on 3/1/25 at 4:30 am to the police. The NHA said he did not report the incident due to the mental condition of the residents. The NHA was asked if the Criminal Justice Act or the facility policy gave exception to reporting to the police based on mental capacity he said, no. The NHA confirmed that physical assault with an object resulting in injury was suspicious of a crime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00148940 Based on interview and record review, the facility failed to initiate an investigation into an allegation of an injury of unknown origin for one of three residents (Resident #1) reviewed. Findings: Resident #1 (R1) Review of a Face Sheet revealed R1 was an [AGE] year old female, admitted to the facility on [DATE] by Hospice for a two day respite stay, with pertinent diagnoses of Alzheimer's and Parkinson's. During an interview on 12/17/24 at 11:54 AM, the complainant/R1's DPOA (durable power of attorney) A stated that R1 was at the facility for two nights starting 12/6/24, and returned home on [DATE] with a swollen lip and bruising that R1 did not have prior to going to the facility. The complainant/R1's DPOA Aalso stated (a) that hospice was contacted the evening of 12/8/24 and a hospice nurse was sent to the home to assess the injuries that evening and (b) the facility was called and made aware of the concerns related to the injury of unknown origin. Review of a Hospice Encounter Note dated 12/08/24 at 9:06 PM revealed: PRN (as needed) visit for report of unaccounted bruising to right forearm and swelling to right lower lip. Patient (R1) noted to have swelling to right medial (middle) quarter of lower lip .no documentation of falls in chart or per facility staff. R1 did answer affirmative to the question of if she had fallen but unable to account for details. Review of a Hospice Encounter Note dated 12/09/24 at 1:30 PM revealed: (Hospice) Nurse asked to assess patients (R1) face and arm where the wounds were after patient (R1) being at (facility name) .Patient (R1) had a fat lip on the mouth, some bruising to the left side of the face and all up and down the right arm. (Complainant/DPOA A) had called the facility on 12/08/24 and spoke with (Medical Records Manager) MRM D who stated she would relay the concerns to the manager and social worker .(Complainant/DPOA A) told the hospice worker that the facility had not called her back .Hospice Social Worker (HSW) B reached out to the facility on [DATE] and was told there were no noted fall or injuries concerning R1 per facility records .hospice had tried contacting the facility many times without good report or response in phone calls and this has become an issue .patient (R1) not able to voice for sure what happened at the facility, (R1) has stories on if it was a fall or from being moved in the bed and is not going to be a good historian for this type of questions .(R1) has been having a harder time with ambulating and transfers since coming home from the facility. During an interview on 12/18/24 at MRM D stated that she may have heard something about R1 falling at the facility but could not recall for sure. MRM D acknowledged speaking with Complainant/DPOA A on 12/08/24 after R1 returned home. MRM D stated that the concerns were sent to the Administrator (ADM) and told Complainant/DPOA A that the Administrator would follow up with her tomorrow (12/09/24). During an interview on 12/18/24 at 12:30 PM, the Administrator stated that he did not call back R1's DPOA on 12/09/24, rather asked Social Worker (SW) E to handle it. The ADM also stated that an investigation into the allegation of an injury of unknown origin was not initiated. During an interview on 12/18/24 at 12:45 PM, Social Worker (SW) E stated that (a) she received a telephone call from HSW B on 12/09/24 about concerns regarding R1's care at the facility, and (b) then spoke with the Director of Nursing (DON) on 12/09/24, and the DON stated that R1 had not fallen at the facility. During an interview on 12/18/24 at 11:35 AM, the DON stated they following: (a) she was asked by SW E if R1 had sustained a fall or injuries while at the facility from 12/06/24 to 12/08/24, (b) she advised SW E that R1 had not fallen or sustained injuries while at the facility, (c) the DON did not interview any staff persons who worked 12/06/24 through 12/08/24, and (e) the DON did not initiate an investigation into an allegation of an injury of unknown origin. Review of the facility Abuse prevention Program Policy & Procedure reflected: (a) Injuries of unknown source-An injury will be classified as an injury of unknown source when the following criteria is met: (1) the source of the injury was not observed by any person, and (2) the source of the injury could not be explained by the resident, and (3) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time. Review of the facility policy Abuse Prevention Program 7 Components reflected: INVESTIGATION- The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call light systems were within reach for 2 of 6 resident's reviewed (Resident #142 and Resident #30). Findings: Resident #142 (R142) Review of a Face Sheet revealed R142 was an [AGE] year-old female, admitted to the facility on [DATE] for a 5 day hospice respite stay, and with pertinent diagnoses of vascular dementia. R142 required assistance from 1 staff person for bed mobility, transfers, and ambulating. During an observation on 10/07/24 at 10:43 AM, R142 laid in bed resting with eyes open and the call light sat at the foot of the bed tucked between the mattress and footboard, out of sight and out of reach of the resident. During an observation on 10/07/24 at 1:59 PM, R142 laid in bed resting with eyes open and the call light sat at the foot of the bed tucked between the mattress and footboard, out of sight and out of reach of the resident. During an interview on 10/08/24 at 8:40 AM, Certified Nurse Aide (CENA) H indicated that the expectation regarding call light placement was that anytime staff went into a room, staff were to check and make sure that the call light was within reach of the resident. Review of a Fall Risk Assessment completed 10/04/24 revealed that R142 was at high risk for a fall. Review of the EHR (electronic health record) for R142 reflected that the resident sustained an unwitnessed fall on 10/06/24. Review of R142's Care Plans showed the following interventions put in place by the facility to promote safety for the resident: (a) call light to be within reach, (b) encourage and remind to use call light to ask for assistance, and (c) provide verbal reminders to resident to call when needing assistance. Review of email communication from the Administrator on 10/09/24 at 3:09 PM reflected that the facility did not have a policy in place specific to the placement of call lights. Resident #30 Review of a Face Sheet reflected R30 was an [AGE] year old female with pertinent diagnoses of dementia and a recent fall with a spinal fracture and multiple rib fractures. During an observation on 10/07/24 at 11:14 AM, R30 laid in bed resting with her eyes open. The call light laid on the floor between the foot of the bed and the wall, out of sight and out of reach of the resident. Review of a Care Plan for R30 revealed the following safety interventions: (a) call light to be within reach and (b) encourage and remind the resident to use the call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) and Contact-Based Precautions were implemented for two residents (R5 and R144) of 39 residents reviewed for infection control. Findings include: R5 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R5 was admitted to the facility on [DATE], with diagnosis of (but not limited to) Alzheimer's (short and long-term memory impairment), delusional disorder and pain in the right arm. Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which represented R5 had severe cognitive impairment. R6 required the assistance of 1-2 staff member with all activities of daily living. According to the physician orders with a start date of 10/3/24 a created date of 10/8/2024 reflected, Enhanced Barrier Precautions (targeted gown and gloves use) during high contact resident care activities. During an observation and interview on 10/7/24 at approximately 11:00 AM, R5 had a stop sign posted on the wall next to the door that indicated providers and staff must wear gloves and gowns for the following high-contact resident care activity, Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central lines, urinary catheter, feeding tubes, tracheostomy, wound care: any skin opening requiring a dressing. After entering R5's room this Surveyor observed Certified Nurse Assistant (CNA) B and CNA C completing a 2-assist transfer from the bed to the wheelchair. Both CNA's were wearing gloves and no gown (as the sign by the door instructed). When asked if they needed gowns while providing physical assistance to transfer, CNA B stated that they did not need to wear a gown and R5 was only on precaution for his foot wound. When asked to review the posting on the door with the Surveyor, CNA B stated that she didn't know she was supposed to wear a gown with transfers as the sign reflects. R144 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R144 was admitted to the facility on [DATE], with diagnosis of (but not limited to) subacute osteomyelitis, right ankle and foot. The admission assessment reflected R144 was alert and oriented and required staff assistance with all activities of daily living. During an observation on 10/07/24 at 10:55 AM, Licensed Practical Nurse (LPN) A entered R144's room, discontinued an antibiotic bulb from the PICC ( peripherally inserted central catheter) and flushed the catheter. LPN A did not don any PPE (personal protective equipment) prior to providing care and handling the PICC. During an observation on 10/7/24 at approximately 11:55 AM, a sign was posted on the entrance of R144's room that reflected Enhanced Barrier Precautions. During an observation on 10/8/24 at approximately 3:15 PM, the sign for Enhanced Barrier Precautions was removed and now R144 had a new sign that reflected, Contact Precautions that required gown and glove use for all providers upon entry to the room. According to the physician orders with a created date of 10/8/24 and a start date of 10/7/2024 reflected, Contact Precautions (gown and glove use with all cares) d/t (due to) right foot wound infection. During an interview on 10/9/24 at 9:15 AM, the Infection Control Preventionist (ICP) D stated that R144 was admitted on [DATE] with a MRSA (Methicillin-resistant Staphylococcus aureus) infection to the right foot. ICP D stated that EBP were implemented upon admission but after looking at the admission information should have been Contact based precautions so it was updated on 10/8/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure monthly pharmacy drug regimen review recommendations were reviewed by the physician and/or acted upon in a timely manner for 3 of 6 residents reviewed (R3, R13, and R34), resulting in the potential for the physician not knowing of a pharmacy recommendation, the potential for a delay in implementing a pharmacy recommendation, and the potential for adverse effects from medications that the pharmacy identified as potential medication issues. Findings include: Resident #3 (R3) A review of R3's Face Sheet, dated 11/9/23, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Face Sheet revealed multiple diagnoses that included dementia and anxiety. R3's Face Sheet also revealed he was on hospice services. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 8/3/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which indicated R3 was severely cognitively impaired. A review of R3's Pharmacy Consultation Report, dated 1/25/23, revealed the pharmacist recommended that R3's physician discontinue ABH cream (a combination cream containing lorazepam (Ativan), Benadryl, and Haldol used to decrease nausea in hospice residents) because this topical formulation is not FDA (Food and Drug Administration) approved and has not been adequately studied in controlled clinic trials to determine safety and effectiveness. However, R3's Pharmacy Consultation Report was not signed by a physician and there was not a physician response to the recommendation on the report. A review of R3's physician order, dated 6/13/23, revealed an order to discontinue R3's ABH cream (approximately 4.5 months after the pharmacist made the recommendation). However, there was not any indication of why the ABH cream was discontinued (e.g., a pharmacy recommendation, non-use over a period of time, or some other reason). A review of the facility's Medication Regimen Review policy and procedure, dated 12/1/07 and last revised on 8/17/23, revealed, Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided copies of the MRRs (Medication Regimen Reviews). 8. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR . 12. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. A review of the State Operations Manual (SOM), revised 2-3-23, revealed, Frequency of physician visits . The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter (F712- Effective: 10-21-22, Implementation: 10-24-22, p.461). Therefore, R3's physician should have addressed the Pharmacy Consultation Report, dated 1/25/23, no later than 3/26/23 (instead of on 6/13/23, purposefully or inadvertently). Resident #13 (R13) A review of R13's face Sheet, dated 11/9/23, revealed R13 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R13's Face Sheet revealed multiple diagnoses that included a cerebral infarction (brain bleed) and post-traumatic stress disorder (PTSD). A review of R13's MDS, dated [DATE], revealed a BIMS score of 14 which indicated R13 was cognitively intact. A review of R13's Pharmacy Consultation Report, dated 9/25/23, revealed the pharmacist recommended that R13's physician provide an indication for the use of diphenhydramine (Benadryl) on a prn (as needed) basis and consider an alternative to its use due to the fact that diphenhydramine has strong and sedating effects and it stays in the bodies of older adults longer. R13's Pharmacy Consultation Report was signed by the physician on 11/8/23 (44 days after the pharmacist made the recommendation) and the physician noted medication D/c'd (discontinued) as never used in the Physician's Response section of the form. A review of R13's Pharmacy Consultation Report, dated 9/25/23, revealed the pharmacist recommended that R13's physician discontinue her prn Ativan (lorazepam) (a medication for anxiety) or add a date to stop the medication because the Centers for Medicaid and Medicare Services (CMS) requires that prn orders for non-antipsychotic psychotropic medications (medications that affect a resident mentally) be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. R13's Pharmacy Consultation Report was signed by the physician on 11/8/23 (44 days after the pharmacist made the recommendation) and the physician noted PRN D/c'd in the Physician's Response section of the form. A review of R13's physician order, dated 11/8/23, revealed an order to discontinue diphenhydramine due to non-use. A review of R13's physician order, dated 11/8/23, revealed an order to discontinue lorazepam due to it being past 14 day stop date (33 days past). During an interview on 11/09/23 at 10:01 AM, the Director of Nursing (DON) stated R13's Pharmacy Consultation Reports were in the physician's book waiting to be signed. She indicated that was the reason why R13's Pharmacy Consultation Reports were addressed late. A review of the facility's Medication Regimen Review policy and procedure, dated 12/1/07 and last revised on 8/17/23, revealed, 12. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. A review of the State Operations Manual (SOM), revised 2-3-23, revealed, Frequency of physician visits . The resident must be seen by a physician at least once every 30 days for the first 90 days after admission . (F712- Effective: 10-21-22, Implementation: 10-24-22, p.461). Therefore, both of R13's Pharmacy Consultant Reports, dated 9/25/23, should have been addressed by R13's physician no later than 10/25/23 (instead of on 11/8/23). Resident #34 (R34) A review of R34's Face Sheet, dated 11/9/23, revealed R34 was a [AGE] year-old resident admitted to the facility on [DATE] and re-admitted on [DATE]. In addition, R34's Face Sheet revealed multiple diagnoses that included a history of a pulmonary embolism (blood clot in the lungs), chronic (long-term) respiratory failure (when the air sacs in the lungs cannot release enough oxygen into the blood), acute (short-term) respiratory failure with hypoxia (inadequate oxygen level in the tissues due to low blood supply or low oxygen content in the blood), pneumonia, and pulmonary emphysema (a lung disease). A review of R34's MDS, dated [DATE], revealed a BIMS score of 9 which indicated R34 was moderately cognitively intact. A review of R34's Pharmacy Consultation Report, dated 9/20/23, revealed the pharmacist recommended that R34's physician reevaluate the continued use of clopidogrel (a medication used to prevent blood clots) because R34 was also receiving Eliquis (apixaban) (another medication used to prevent blood clots) and using both medications at the same time may further increase the risk for serious, potentially fatal bleeding. The pharmacist indicated that R34's physician either discontinue R34's clopidogrel or document an assessment of the risk versus benefit of its use with Eliquis and have the facility interdisciplinary team ensure ongoing monitoring of R34 for its effectiveness and potential adverse consequences (e.g., unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling, bleeding gums or nose). A further review of R34's Pharmacy Consultation Report related to the use of clopidogrel and Eliquis, dated 9/20/23, revealed the consultation report was signed by the physician on 11/8/23 (49 days after the pharmacist made the recommendation) and the physician checked the box I accept the recommendation(s) above, please implement as written in the Physician's Response section of the form. However, R34's physician did not indicate which recommendation that they wanted implemented (discontinue clopidogrel or continue its use with Eliquis with a risk versus benefit assessment and ongoing monitoring). A review of R34's physician order, dated 11/8/23, revealed an order to discontinue R34's clopidogrel due to a pharmacy recommendation (49 days after the recommendation was made). A review of R34's Pharmacy Consultation Report, dated 9/20/23, revealed the pharmacist recommended that R34's physician discontinue his prn alprazolam (a medication for anxiety and panic disorders) or add a date to stop the medication because the Centers for Medicaid and Medicare Services (CMS) requires that prn orders for non-antipsychotic psychotropic medications (medications that affect a resident mentally) be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. R34's Pharmacy Consultation Report was signed by the physician on 11/8/23 (49 days after the pharmacist made the recommendation) and the physician checked the box I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: change to scheduled TID (three times a day). A review of R34's physician order, dated 11/8/23, revealed an order to discontinue R34's prn alprazolam (49 days after the pharmacist made the recommendation) because it was changed from as needed to scheduled. A review of R34's physician order, dated 11/8/23, revealed an order to administer alprazolam 1 milligram (mg) every 8 hours (three times a day) for anxiety. During an interview on 11/09/23 at 10:01 AM, the Director of Nursing (DON) stated R34's Pharmacy Consultation Reports were in the physician's book waiting to be signed. She indicated that was the reason why R34's Pharmacy Consultation Reports were addressed late. A review of the facility's Medication Regimen Review policy and procedure, dated 12/1/07 and last revised on 8/17/23, revealed, For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected 12. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. A review of the State Operations Manual (SOM), revised 2-3-23, revealed, Frequency of physician visits . The resident must be seen by a physician at least once every 30 days for the first 90 days after admission . (F712- Effective: 10-21-22, Implementation: 10-24-22, p.461). Therefore, both of R34's Pharmacy Consultation Reports, dated 9/20/23, should have been addressed by R34's physician no later than 10/20/23 (instead on on 11/8/23).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's medication regimen was free from unnecessary medications for 1 of 5 residents (R34) reviewed for unnecessary medications, resulting in R34 receiving an unnecessary medication for an excessive duration of time and the potential for serious adverse effects. Findings include: Resident #34 (R34) A review of R34's Face Sheet, dated 11/9/23, revealed R34 was a [AGE] year-old resident admitted to the facility on [DATE] and re-admitted on [DATE]. In addition, R34's Face Sheet revealed multiple diagnoses that included a history of a pulmonary embolism (blood clot in the lungs), chronic (long-term) respiratory failure (when the air sacs in the lungs cannot release enough oxygen into the blood), acute (short-term) respiratory failure with hypoxia (inadequate oxygen level in the tissues due to low blood supply or low oxygen content in the blood), pneumonia, and pulmonary emphysema (a lung disease). A review of R34's MDS, dated [DATE], revealed a BIMS score of 9 which indicated R34 was moderately cognitively intact. A review of R34's Pharmacy Consultation Report, dated 9/20/23, revealed the pharmacist recommended that R34's physician reevaluate the continued use of clopidogrel (a medication used to prevent blood clots) because R34 was also receiving Eliquis (apixaban) (another medication used to prevent blood clots) and using both medications at the same time may further increase the risk for serious, potentially fatal bleeding. The pharmacist indicated that R34's physician either discontinue R34's clopidogrel or document an assessment of the risk versus benefit of its use with Eliquis and have the facility interdisciplinary team ensure ongoing monitoring of R34 for its effectiveness and potential adverse consequences (e.g., unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling, bleeding gums or nose). A further review of R34's Pharmacy Consultation Report related to the use of clopidogrel and Eliquis, dated 9/20/23, revealed the consultation report was signed by the physician on 11/8/23 (49 days after the pharmacist made the recommendation) and the physician checked the box I accept the recommendation(s) above, please implement as written in the Physician's Response section of the form. A review of R34's physician order, dated 11/8/23, revealed an order to discontinue R34's clopidogrel due to a pharmacy recommendation (49 days after the recommendation was made). A review of R34's Medication Administration Records, dated 9/20/23 to 11/9/23, revealed R34 received clopidogrel daily from 9/20/23 to 11/8/23. During an interview on 11/09/23 at 10:01 AM, the Director of Nursing (DON) stated R34's Pharmacy Consultation Reports were in the physician's book waiting to be signed. She indicated that was the reason why R34's Pharmacy Consultation Reports were addressed late. A review of the facility's Medication Regimen Review policy and procedure, dated 12/1/07 and last revised on 8/17/23, revealed, 12. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. A review of the State Operations Manual (SOM), revised 2-3-23, revealed, Frequency of physician visits . The resident must be seen by a physician at least once every 30 days for the first 90 days after admission . (F712- Effective: 10-21-22, Implementation: 10-24-22, p.461). Therefore, R34's Pharmacy Consultation Report, dated 9/20/23, should have been addressed by R34's physician no later than 10/20/23 (instead on on 11/8/23). Further more because the physician did not address R34's Pharmacy Consultation Report timely, R34 received both clopidogrel and Eliquis at the same time from at least 10/20/23 to 11/8/23 (19 days) which unnecessarily further increased his risk for serious, potentially fatal bleeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for 3 of 15 residents (R3, R13, and R34), resulting in incomplete and inaccurate medical records and the potential for providers not having an accurate and complete picture of the resident's stay at the facility. Findings include: Resident #3 (R3) A review of R3's Face Sheet, dated 11/9/23, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Face Sheet revealed multiple diagnoses that included dementia and anxiety. R3's Face Sheet also revealed he was on hospice services. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 8/3/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which indicated R3 was severely cognitively impaired. A review of R3's Pharmacist Drug Regimen Review forms, dated 12/1/22 to 1/9/23, revealed the pharmacist had made recommendations on 12/12/22 and 1/25/23. However, the pharmacy recommendations were not located in R3's electronic medical record. During an interview on 11/08/23 at 03:45 PM, the Director of Nursing (DON) confirmed R3's pharmacy recommendations for 12/12/22 and 1/25/23 were not in his medical record. The DON stated the pharmacy recommendations should be filed under the sub tab Pharmacy in the Documents section of R3's electronic medical record. The DON stated she would see if she could locate the recommendations that the pharmacist made for R3. A copy of those recommendations, if they could be located, were requested from the DON. The DON verbally confirmed the request. During a second interview on 11/09/23 at 10:01 AM, the DON was able to provide a copy of R3's Pharmacy Consultation Report (the pharmacy recommendation form) for 1/25/23 which recommended that the physician discontinue R3's ABH cream (a combination cream containing lorazepam (Ativan), Benadryl, and Haldol used to decrease nausea in hospice residents) because this topical formulation is not FDA (Food and Drug Administration) approved and has not been adequately studied in controlled clinic trials to determine safety and effectiveness. The DON stated that R3's Pharmacy Consultation Report had been found in the physician's book waiting to be signed. The DON confirmed that the physician's book was not a part of any resident's medical records. She further stated she could not locate R3's Pharmacy Consultation Report for 12/12/22. I don't know what happened to that one. The DON stated she would continue to look for it. A copy of R3's Pharmacy Consultation Report for 12/12/22 was requested from the DON, if it could be located. As of the completion of the survey and exit from the facility, the facility failed to provide this documentation. Resident #13 (R13) A review of R13's face Sheet, dated 11/9/23, revealed R13 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R13's Face Sheet revealed multiple diagnoses that included a cerebral infarction (brain bleed) and post-traumatic stress disorder (PTSD). A review of R13's MDS, dated [DATE], revealed a BIMS score of 14 which indicated R13 was cognitively intact. A review of R13's Pharmacist Drug Regimen Review forms, dated 12/1/22 to 1/9/23, revealed the pharmacist had made recommendations on 9/25/23 and 10/11/23. However, the pharmacy recommendations were not located in R13's electronic medical record. During an interview on 11/08/23 at 03:45 PM, the Director of Nursing (DON) confirmed R13's pharmacy recommendations for 9/25/23 and 10/11/23 were not in her medical record. The DON stated the pharmacy recommendations should be filed under the sub tab Pharmacy in the Documents section of R13's electronic medical record. The DON stated she would see if she could locate the recommendations that the pharmacist made for R13. A copy of those recommendations, if they could be located, were requested from the DON. The DON verbally confirmed the request. During a second interview on 11/09/23 at 10:01 AM, the DON was able to provide a copy of two Pharmacy Consultation Reports on 9/25/23 for R13 which recommended that R13's physician provide an indication for the use of diphenhydramine (Benadryl) on a prn (as needed) basis and consider an alternative to its use due to the fact that diphenhydramine has strong and sedating effects and it stays in the bodies of older adults longer and that R13's physician discontinue her prn (as needed) Ativan (lorazepam) (a medication for anxiety) or add a date to stop the medication because the Centers for Medicaid and Medicare Services (CMS) requires that prn orders for non-antipsychotic psychotropic medications (medications that affect a resident mentally) be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. During the same interview on 11/9/23 at 10:01 AM, the DON was able to provide a copy of R13's Pharmacy Consultation Report for 10/11/23 which recommended that R13's physician discontinue her antipsychotic medication, Seroquel, or document a diagnosis for its use if he wanted R13 to continue taking the Seroquel. The DON stated that both of R13's Pharmacy Consultation Reports for 9/25/23 and R13's Pharmacy Consultation Report for 10/11/23 had been located in the physician's book waiting to be signed. The DON confirmed that the physician's book was not a part of any resident's medical records. Resident #34 (R34) A review of R34's Face Sheet, dated 11/9/23, revealed R34 was a [AGE] year-old resident admitted to the facility on [DATE] and re-admitted on [DATE]. In addition, R34's Face Sheet revealed multiple diagnoses that included a history of a pulmonary embolism (blood clot in the lungs), chronic (long-term) respiratory failure (when the air sacs in the lungs cannot release enough oxygen into the blood), acute (short-term) respiratory failure with hypoxia (inadequate oxygen level in the tissues due to low blood supply or low oxygen content in the blood), pneumonia, and pulmonary emphysema (a lung disease). A review of R34's MDS, dated [DATE], revealed a BIMS score of 9 which indicated R34 was moderately cognitively intact. A review of R34's Pharmacist Drug Regimen Review forms, dated 12/1/22 to 1/9/23, revealed the pharmacist had made a recommendations on 9/20/23. However, the pharmacy recommendations were not located in R34's electronic medical record. During an interview on 11/08/23 at 03:45 PM, the Director of Nursing (DON) confirmed R34's pharmacy recommendation for 9/20/23 was not in his medical record. The DON stated the pharmacy recommendations should be filed under the sub tab Pharmacy in the Documents section of R34's electronic medical record. The DON stated she would see if she could locate the recommendation that the pharmacist made for R34. A copy of that recommendation, if it could be located, was requested from the DON. The DON verbally confirmed the request. During a second interview on 11/09/23 at 10:01 AM, the DON was able to provide a copy of two Pharmacy Consultation Reports on 9/20/23 for R34 which recommended that R34's physician reevaluate (possibly discontinue) the continued use of clopidogrel (a medication used to prevent blood clots) because R34 was also receiving Eliquis (apixaban) (another medication used to prevent blood clots) and using both medications at the same time may further increase the risk for serious, potentially fatal bleeding and that R34's physician discontinue his prn alprazolam (a medication for anxiety and panic disorders) or add a date to stop the medication because the Centers for Medicaid and Medicare Services (CMS) requires that prn orders for non-antipsychotic psychotropic medications (medications that affect a resident mentally) be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. The DON stated that both of R34's Pharmacy Consultation Reports for 9/20/23 had been located in the physician's book waiting to be signed. The DON confirmed that the physician's book was not a part of any resident's medical records. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care . High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings . (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org). Timely documentation of the following types of information should be made and maintained in a patient's EHR to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care- Assessments; Clinical problems; Communications with other health care professionals regarding the patient . Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 40 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, malodorous conditions, and decreased illumination. Findings include: On 11/08/23 at 08:55 A.M., An environmental tour was conducted with Nursing Home Administrator NHA. The following items were noted: Entrance Foyer: 8 of 16 overhead 4-foot-long fluorescent light bulbs were observed non-functional. Beauty Shop: The return-air ventilation exhaust grill was observed soiled with dust and dirt deposits. Occupational Therapy/Physical Therapy: The blue therapy table cushion was observed (worn, etched, scored, torn), exposing the inner Styrofoam padding. The therapy table cushion measured approximately 4-feet-wide by 8-feet-long. Living Room: The carpeting surface was observed stained and soiled, adjacent to the love seat. The soiled carpeting surface measured approximately 6-feet-wide by 8-feet-long. Nursing Station: The laminate countertop edge was observed missing at the corner. The missing laminate surface measured approximately 2-inches-wide by 18-inches-long. Team 1 Shower Room: 3 of 6 overhead 4-foot-long fluorescent light bulbs were observed non-functional. Team 1 Corridor: The drywall surface was observed damaged, adjacent to resident room [ROOM NUMBER]. The damaged surface measured approximately 6-inches-wide by 8-inches-long. The drywall surface was also observed damaged, adjacent to resident rooms [ROOM NUMBERS]. The damaged surface measured approximately 12-inches-wide by 12-inches-long. Soiled Utility Room: 3 of 4 overhead light assemblies were observed non-functional. Public Restroom: The hand sink cold water faucet valve was observed actuating extremely hard. The entire valve body assembly was also observed loose-to-mount. On 11/08/23 at 11:15 A.M., An interview was conducted with Nursing Home Administrator (NHA) regarding the facility maintenance concern request system. (NHA) stated: We have maintenance request forms at the nurses station. (NHA) further indicated: Staff sometimes will speak directly to the Maintenance Director for immediate assistance. On 11/08/23 at 02:40 P.M., An environmental tour of sampled resident rooms was conducted with NHA and Maintenance Director A. The following items were noted: 6: The restroom return-air-exhaust ventilation was observed non-functional. The drywall surface was observed (etched, scored, particulate), adjacent to Bed A. The Bed A landing strip was also observed soiled with encrusted food debris. 1 of 2 overhead light assemblies were additionally observed non-functional. Maintenance Director A indicated he would complete necessary repairs as soon as possible. 7: The restroom return-air-exhaust ventilation was observed non-functional. 11: The restroom return-air-exhaust ventilation was observed non-functional. 12: Two 12-inch-wide by 12-inch-long vinyl tile squares were observed severely worn and chipped, adjacent to Bed B. 13: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed B headboard. The oscillating desk fan was also observed heavily soiled with dust and dirt deposits. 14: 2 of 2 overhead light assemblies were observed non-functional. The hand sink basin was also observed draining very slow. 15: 1 of 2 restroom overhead light assemblies were observed non-functional. 17: One 12-inch-wide by 12-inch-long vinyl flooring tile was observed (etched, scored, particulate). Three 12-inch-wide by 12-inch-long vinyl flooring tiles was also observed soiled with adhesive residue. The restroom return-air-exhaust ventilation was further observed non-functional. The restroom hand sink basin was additionally observed draining very slow. Maintenance Director A indicated he would complete necessary repairs as soon as possible. 19: The restroom hand sink basin was observed draining very slow. 1 of 2 restroom overhead light assemblies were also observed non-functional. The restroom return-air-exhaust ventilation was further observed non-functional. 20: The Bed A landing strip was observed (etched, scored, particulate), exposing the inner Styrofoam padding. 1 of 2 restroom overhead light assemblies were also observed non-functional. 22: The ceiling drywall surface was observed (moist, chipped, cracked). The damaged drywall surface measured approximately 12-inches-wide by 24-inches-long. Maintenance Director A indicated he would repair the damaged drywall ceiling surface as soon as possible. 25: The ceiling drywall surface was observed (chipped, cracked, stained) from previous moisture exposure. The damaged ceiling drywall surface measured approximately 24-inches-wide by 30-inches-long. The restroom hand sink faucet assembly aerator was also observed very loose-to-mount. 26: The restroom return-air-exhaust ventilation was observed non-functional. The drywall surface was observed (etched, scored, particulate), adjacent to the Bed A headboard. The damaged drywall surface measured approximately 20-inches-wide by 30-inches-long. The drywall surface was further observed (etched, scored, particulate), adjacent to Bed B. The damaged drywall surface measured approximately 12-inches-wide by 20-inches-long. Maintenance Director A indicated he would repair the damaged drywall surfaces as soon as possible. On 11/09/23 at 09:06 A.M., Record review of the Policy/Procedure entitled: Housekeeping Cleaning Schedules dated 01/2023 revealed under Policy: It is the policy of this facility to ensure residents live in a safe, clean, and sanitary environment and that staff are available to meet this need. Therefore, cleanings schedule will be posted to ensure a plan for the frequency and degree of cleaning is conducted per facility policy. On 11/09/23 at 09:15 A.M., Record review of the facility Maintenance Request Log Sheets for the last 90 days reflected no specific entries related to the aforementioned maintenance concerns. On 11/09/23 at 09:25 A.M., Record review of the Policy/Procedure entitled: Cleaning and Disinfecting Resident's Room dated (no date) revealed under Policy: To provide guidelines for cleaning and disinfecting resident's room to ensure sanitary conditions are maintained, to assist in preventing the spread of disease-causing organisms by keeping resident care equipment clean. Record review of the Policy/Procedure entitled: Cleaning and Disinfecting Resident's Room dated (no date) further revealed under Procedure: (1) Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. (2) Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to account for all controlled substances within the emergency drug kit. This deficient practice resulted in a staff member not following the policy to have two nurses check the tag seals during shift-to-shift count and did not account for controlled substances that were removed from the emergency drug kit. Findings include: The facility provided the policy for Control Substances Standard of Practice Chapter 31.0 dated 3/2019 last updated on 9/2022 for review. The policy reflected, Both on-going and off-going nurses reconcile the Narcotic EDK (emergency drug kit) and Narcotic Refrigerator EDK by checking and signing that the tag numbers on the boxes to ensure accuracy of safekeeping. Counts will occur with each change in ownership of narcotic keys, at shift change and change in assignment. If the Emergency Controlled Substance Box (EDK) is opened, nurse must sign the removal on an EDK Usage sheet, a new tag is placed on the box, and the number of the tag is documented on the Emergency Controlled Substance Inventory Kit from the EDK box requires signature and update on the usage sheet. During a telephone interview on 1/12/23 at 12:20 PM, Registered Nurse (RN) A stated that she did a shift-to-shift count on 12/17/22 at approximately 6 PM with RN G (who was the off going nurse) before starting her shift. RN A stated that she failed to check the tag seals on the EDK before signing that the count was correct and taking over the narcotic keys. RN A stated at approximately 7:30 PM she noted the tags on the EDK did not match the tag log and called the Director of Nursing (DON). A call was placed to RN G who stated that she was in fact in the EDK and forgot to sign out a slip for 2 tablets of Hydrocodone-acetaminophen 5/325 mg for Resident #3 (R3). The DON advised RN A that RN G would sign the medications out and update the log with the correct tag numbers upon her return in the morning. At approximately 2:30 AM, RN A stated that she noted that someone had taped a Hydrocodone-acetaminophen 5/325 mg into R1 and R2's medication cards which should have been Hydrocodone-acetaminophen 10/325 mg. RNS stated she immediately reported it to the DON. RN A stated that the DON asked RN A and RN F to open the EDK together and do a full audit of it. RN A reported 2 tablets of Hydrocodone-acetaminophen 5/325 mg were unaccounted for. RN A stated that the DON called the police and suspended RN G. RN A stated that she was given counseling on 12/18/22 for not checking the tag seals on the EDK at shift change on 12/17/22. During a telephone interview on 1/12/23 at 12:00 PM, RN G stated that on 12/17/22 she was distracted several times during her shift being pulled in different directions. Towards the end of the shift RN G reported that she checked the narcotic count of her medication cart and found she had made two mistakes in which she gave two residents their medications before the next doses were actually due. RN G stated that she went to the emergency drug kit and retrieved 2 tablets of Hydrocodone-acetaminophen 5/235 mg and taped them back into the cards she made the mistakes on (R1 and R2's card). RN G stated she did not follow the policy to enter the emergency drug box with another nurse, did not completed the form to remove the drugs and did not have a doctor's order to do so. RN G stated when she realized she had made the mistakes in administration of the medication earlier in the shift she panicked. RN G stated she taped the medication back into the cards to correct the count of her cart. RN G stated that she understood it was wrong and there is no excuse for it. RN G stated it was a hard lesson but had to take accountability for it. RN G stated she submitted to a drug test which was negative and went to the police station as she was asked to be interviewed. RN G stated that the facility immediately suspended her and then after the investigation terminated her employment. According to the Facility's investigation the DON did a full audit on 12/18/22 at approximately 10 AM. The DON audited the controlled substance proof of use sheets with the medication administration records. DON discovered six residents' controlled substances were documented on the proof of use sheets and not documented on the mediation administration record. All instances were from one nurse, RN G. The facility provided a copy of Personnel Action Form dated 12/21/22 that reflected RN G was terminated for failure to meet professional standards with reference to the Facility Reported Incident #49404. The facility provided a copy of the report made by the facility to the local law enforcement dated 12/18/22 at 4:04 AM for review. The police report #2212600962 was consistent with the facility's investigation submitted to the State Agency, Facility Reported Incident #49404. On 1/11/23 at approximately 11:15 AM this Surveyor observed RN E and Licensed Practical Nurse (LPN) D count the controlled substances in medication cart 1 and 2, count the refrigerated controlled substances and check the EDK log seals for accuracy. The nurses also reviewed a new step in the process of 2 nurses checking that all medications were not only signed out on the proof of use sheet ([NAME]) but also on the medication administration record (MAR). The form was signed by 2 nurses and turned in after each shift was completed. The policy was observed to be followed by the staff and the counts were 100% accurate. On 1/12/23 the surveyor verified the following interventions were put into place and were effective to bring the facility into compliance: 1. Report to local law enforcement and state agency. 2. Report to physician. 3. Suspend employee pending investigation and subsequently terminated. 4. Report to Consultant Pharmacist. 5. Review the medical records of all residents to identify who receives narcotics for identification of any ill effects. 6. Complete pain assessments on residents who receive narcotics. 7. Complete an audit of narcotics documented on the [NAME] sheet to the MAR. 8. Interview residents with a BIMs greater than 9 to assess if there is any problems with receiving pain medication. 9. Notification of physician, pharmacy, and responsible parties if discrepancies are identified. 10. Educate all licensed nurses on the process for administration, documentation, and reconciliation of narcotics. 11. Provide education to licensed nurses on revised end-of-shift reconciliation process and documentation. 12. Any discrepancies or deficient practice will be reported to the DON immediately. 13. Ad Hoc QAPI was completed 12/31/22 to ensure compliance. 14. The DON or designee will audit the narcotic [NAME] sheet with [DATE] times a week for 4 weeks, then 3 times weekly, ongoing. 15. All audits and information will be presented to the facility QAPI committee monthly for further monitoring, recommendations, or follow-up to ensure ongoing compliance. During this survey, this surveyor reviewed documentation, conducted interviews, and made observations the preceding interventions were completed prior to the abbreviated survey and no continuing issues related to this citation were noted. A determination of past non-compliance was approved by the state agency as of 12/31/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that medication carts were secured, that expired medication had been removed from the medication cart, and failed to ensure Purified Protein Derivative (PPD) solution was stored in accordance with manufacturers recommendations resulting in the potential for accidental consumption of medication by cognitively impaired residents, medication diversion, and the administration of outdated medication of decreased efficacy. Findings: On [DATE] at 10:34 AM the Sage Hall medication cart was observed to be unlocked and the nurse assigned to the medication cart was not in the area. While awaiting return of the assigned nurse an unimpeded review of the Sage Hall medication cart was conducted. An opened vial of Novolog labeled for Resident #15 (R15) was observed to have been dated as placed in service on [DATE] with a written expiration (Exp) date of [DATE]. On [DATE] at 10:59 AM an interview was conducted with Licensed Practical Nurse (LPN) F when she was summoned to the Sage Hall medication cart. LPN F reported that she had the only keys to the medication cart and acknowledged the medication cart should have been locked. LPN F reported that the Novolog insulin for R15 should have been discarded twenty-eight days after it had been placed in service. Resident #2 (R2) was admitted to the facility [DATE] with diagnoses that included Alzheimer's Disease. The Minimum Data Set (MDS) of R2 dated [DATE] reflected severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 4 out of 15 and that R2 is independent with locomotion in his wheelchair. Resident #23 (R23) was admitted to the facility [DATE] with diagnoses that included Alzheimer's Disease. The MDS for R23 dated [DATE] reflected severe cognitive impairment with a BIMS score of 5 out of 15. R23 had been observed self-ambulating with a walker regularly throughout the facility. On [DATE] at 3:47 PM the Sage Hall medication cart was again observed to be unlocked. R2 and R23 were observed to be in the common area adjacent to the medication cart. The Nursing Home Administrator (NHA) who was in the area was informed that this was the second observation of the day of an unsecured medication cart. On [DATE] at 12:02 PM a review of the facility medication room was conducted with LPN F. Review of the medication refrigerator revealed two multi dose vials of PPD solution that had been opened but the vials were not labeled with the date placed in service. LPN F reported that the vials should have been dated when they were opened and placed in service. During an interview conducted [DATE] at 1:00 PM the Director of Nursing (DON) reported that the facility follows the manufacturer's recommendations regarding the use and storage of insulins and the PPD solution. Review of the Manufacturer's instructions for Storage of PPD solution reflected, A vial of (PPD solution) which has been entered and in use for 30 days should be discarded. This indicated that the date a vial of PPD solution that had been placed in service (entered) should be a date known to the staff so that a discard date can be determined. Review of the Manufacturer's instructions for the storage of Novolog insulin reflected, . Punctured vials and cartridges can be stored unrefrigerated at temperatures below 86°F (30°C) and protected from light for up to 28 days. This indicated a vial or cartridge of Novolog should be discarded 28 days after it is placed in service. The policy provided by the facility titled Maintenance of Medication Storage Areas dated 5-2019 was reviewed. The facility policy reflected, A. Cart .2. Cart security is maintained during entire med pass. And 6. Expiration dates are to be monitored with medication usage. And 7. Insulins . are to be dated on date opened, which indicated that expiration dates are to be monitored. The facility policy on medication storage also reflected, B. Med Room, 3 Multiple dose vials must be dated when first opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the potable water supply system, resulting in discolored water and potential for a contaminated water supply. These deficient practices affect all residents in the facility. Findings include: On 11/13/22 at 10:30 AM, the water coming out of the kitchen hand sink was observed to be discolored, appearing to be a grey/brown color. At this time, Dietary [NAME] U stated that the water isn't normally that color. On 11/13/22 at 11:05 AM, the water coming out of the bathroom sink of room [ROOM NUMBER] and 31 was observed to be discolored. During an interview on 11/13/22 at 11:23 AM, Certified Dietary Manager B was queried on the water color and stated that the Maintenance Director was working on the water system and that it isn't normally discolored. During an interview on 11/13/22 at 1:15 PM, the Administrator was queried on the discolored water in the facility and stated that the Maintenance Director had rebuilt the central mixing valve on 11/12/22. On 11/14/22 at 9:49 AM, Maintenance Director J was queried on if he has changed the in-line water filter prior to the ice machine and stated, I didn't know it had a filter. Additionally, Maintenance Director J was asked if they had flushed the water after rebuilding the central mixing valve, and stated, No, I didn't even think to flush the water. On 11/14/22 at 1:13 PM, the Janitor's closet mop sink fixture was observed to be provided with an atmospheric vacuum breaker (a plumbing device used to prevent backflow of contaminated water into the domestic water supply). The mop sink fixture was observed to have a shut-off valve downstream from the atmospheric vacuum breaker. This plumbing arrangement allows for the atmospheric vacuum breaker to remain on and under contact pressure for an extended period of time, which may cause the atmospheric vacuum breaker to fail. According to the 2015 Michigan Plumbing Code, Incorporating the 2015 International Plumbing Code, Section 608 Protection of Potable Water Supply - 608.13.6 Atmospheric-type vacuum breakers. Pipe applied atmospheric-type vacuum breakers shall conform to ASSE 1001 or CSA B64.1.1. Hose-connection vacuum breakers shall conform to ASME A112.21.3, ASSE 1011, ASSE 1019, ASSE 1035, ASSE 1052, CSA B64.2, CSA B64.2.1, CSA B64.2.1.1, CSA B64.2.2 or CSA B64.7. These devices shall operate under normal atmospheric pressure when the critical level is installed at the required height.