**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 2 of 2 residents (R32, R17) reviewed for care planning. Findings include: R32: On 1/6/25 at 6:14 p.m., R32 stated blood sugars were up and down and sometimes low at night. R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had diagnoses which included chronic kidney disease stage 3 (a moderate level of kidney damage where the kidneys are less efficient at filtering waste from the blood, causing mild to moderate loss of kidney function), coronary artery disease, hypertension, and diabetes mellitus. R32's MDS identified R 32 was cognitively intact and received insulin injections. R32's Order Summary Report dated 1/9/25, identified R32's orders included the following: -consistent carbohydrate diet, regular texture, thin consistency -blood glucose test before meals and at bedtime -consistent carb (carbohydrate) every evening -for blood sugar less than 70 milligrams (mg) per deciliter (dl) administer six ounces fruit juice, milk, regular pop or other high carbohydrate beverage: like Ensure or Boost. Repeat blood sugar after 10 minutes, if blood sugar less than 70 mg/dl, give 15 grams glucose. Repeat blood sugar after 15 minutes, if below 70 repeat glucose oral gel 15 grams. Repeat blood sugar in another 15 minutes and if below 70 call -glucose 15 oral gel 40 percent, give 15 gram by mouth as needed for blood sugar less than 70 -Humalog insulin 100 units/milliliter (ml), inject seven units subcutaneously (injection into the fatty tissue beneath the skin) with meals -lantus insulin, inject 32 units subcutaneously in the morning R32's care plan initiated on 2/10/23, and revised on 9/24/24, identified R32 had nutritional problem or potential nutritional problem related to impaired skin integrity, new to this setting, therapeutic diet. Interventions included provide, serve diet as ordered. Monitor intake and record every meal. Consistent Carbohydrate. During an interview on 1/9/25 at 10:35 a.m., R32 stated her blood sugars were running at about 250 and she was unsure what they should be. During an interview on 1/9/25 at 12:32 p.m., the director of nursing (DON) verified R32 was diabetic and verified her current care plan did not address diabetic care. The DON verified the care plan would alert staff on what signs and symptoms they should be looking for for high and low blood sugars. The DON stated the care plan should have directions for diabetes care. R17: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction(stroke), acute transverse (extending from side to side) myelitis (inflammation of the spinal cord) in demyelinating (loss of protective fatty layer on nerves) disease of central nervous system, type 2 diabetes mellitus, and congestive heart failure. R17's care plan last revised on 12/18/24, contained a focus on activities of daily living (ADLs) deficits due to R17's medical condition. R17's care plan did not specify resident's level of functioning, level of assistance needed for ADLs, number of staff needed to assist with ADLs, or frequency of assistance needed for ADLs. During interview on 1/9/25 at 2:39 p.m., the DON stated care plans were typically reviewed quarterly with care conferences. DON stated being unsure of how R17's care plan did not get completed. DON further stated expectation of care plans needed to be complete to correctly care for the resident. 'Policy and Procedure: Care Plans for Aftenro Home' dated March 2023, identified it's purpose to ensure that all residents receive consistent, person-centered care tailored to their unique needs and preferences and care plans will address the physical, emotional, social, and medical needs of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to comprehensively reassess and develop interventions to reduce/prevent continued weight loss for 1 of 3 residents (R19) reviewed for nutrition and weight loss. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition, and diagnoses of dementia, chronic kidney disease, and type 2 diabetes mellitus. MDS further identified R19 needing set-up and clean-up assistance with eating, and was ordered to have a consistent carbohydrate diet. R19's care plan last revised 11/19/24, identified resident having a potential nutritional problem and having a goal of maintaining an adequate nutritional status as evidenced by maintaining weight within 5% of 178 pounds (lbs). Care plan further identified interventions of consistent carb diet, record daily meal intakes, weight per protocol, notify registered dietician (RD) and provider with significant weight change, and to encourage activity as able. R19's last quarterly nutritional assessment progress note dated 5/1/24, identified R19's current weight on 5/1/24 was 172.8 lbs. There were no follow up nutritional notes or assessment identified in R19's record. R19's medical record, identified on 12/2/24 R19 weighed 173 lbs., and on 1/2/25 R19 weighed 163.6 lbs. R19 had a significant weight loss of 9.4 lbs or a 5.4% loss in one month. R19's orders included on 9/24/24, 'weights must be obtained in AM prior to food/drink, attempt to use same scale/technique to ensure accuracy. Notify TCP if weight gain of >3 pounds in 24 hours or 5 pounds in one week.' During interview on 1/9/25 at 8:47 a.m., nursing assistant (NA)-C stated nursing assistants weigh residents and chart weights in the resident's chart. NA-C further stated the resident's chart would show the resident's previous weight and aides would alert the nurse if there was a change. During interview on 1/9/25 at 9:46 a.m., registered nurse (RN)-A stated nursing assistants entered weights into the resident's chart. RN-A further stated the resident's chart would show the previous weight taken. RN-A stated if there was a significant weight change the nurse would notify the provider. During interview on 1/9/25 at 9:54 a.m., NA-D stated nursing assistants weighed residents and charted the weight in the resident's chart. NA-D further stated it was possible to see the last weight taken for a resident and if there was a big change the nurse would be notified. During interview on 1/9/25 at 2:44 p.m., director of nursing (DON) stated staff were expected to pass on significant weight changes to the provider. DON stated tracking weight changes was important to make sure resident's were getting enough nutrition and if their care plan needed to be modified. DON confirmed R19's care plan identified a maintenance weight of 178 lbs and expectation staff would notify provider with significant weight changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 6.7 percent with 2 errors out of 30 opportunities for error involving 2 of 5 residents (R50, R22) who were observed during the medication passes. Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and a diagnosis of acute respiratory failure with hypoxia. R50's care plan dated 9/18/24, identified R50 had shortness of breath related to respiratory failure with interventions to administer inhaler medications as ordered. R50's provider order dated 3/11/24, identified an order for Symbicort two puffs two times per day. Rinse mouth after use. During an observation and interview on 1/8/25 at 8:25 a.m., trained medication aid (TMA)-A primed and handed R50 the Symbicort inhaler. R50 took two puffs close together. TMA-A stated she always took her inhaler like that but sometimes she rinsed her mouth afterward. R22's quarterly MDS dated [DATE], identified intact cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). R22's care plan dated 5/7/24, identified R22 had shortness of breath related to emphysema with interventions to administer inhaler medications as ordered. R22's provider order dated 5/6/24, identified an order for Wixela one puff two times per day. Rinse mouth after each use. During an observation and interview on 1/9/25 at 8:36 a.m., TMA-B primed and handed R22 the Wixela inhaler. R22 took one puff and then a sip of water. TMA-B stated he didn't know if this was an inhaler you needed to rinse your mouth after using. After looking at the order, TMA-B confirmed the mouth should be rinsed after using the inhaler. During an interview on 1/9/25 at 12:54 p.m., the assistant director of nursing (ADON) stated it was her expectation would be that the TMA offer and encourage the resident to rinse their mouth after using the inhaler, and to follow the directions on the order, to help prevent complications like thrush. Facility policy and procedure regarding administration of inhaled medications requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure therapeutic diets per physician's orders were followed for 2 of 2 residents (R1, R32) reviewed for therapeutic diets. Finding include: R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and was receiving insulin injections. In addition, R1 had diagnoses which included diabetes mellitus with hyperglycemia and mild nonproliferative diabetic retinopathy without macular edema, hypertension, depression, and chronic pain. R1's Active Orders as of 1/9/25, identified the following: Consistent Carbohydrate diet regular texture, thin consistency 2 a.m., finger poke if greater than 400 or less than 70 as needed Check blood sugar four times a day Humalog insulin 100 units per milliliter (ml) inject 32 units subcutaneously (sq [an injection that delivers medication into the fatty tissue beneath the skin]) in the evening insulin glargine inject 45 units sq in the morning insulin glargine inject 50 units sq in the evening Trulicity 1.5 milligrams (mg) per ml inject 1.5 mg sq one time a day every Friday R1's care plan dated 1/1/25, identified R1 had a nutritional problem or potential nutritional problem related to diabetes. Interventions included to administer medications as ordered to explain and reinforce to the resident the importance of maintaining the diet ordered. To provide, serve as ordered consistent carbohydrate diet. R1's blood sugars for January 2025 revealed the following: 1/1/25, highest 321 mg per deciliter (dl) lowest 163 mg/dl 1/2/25, highest 236 mg/dl lowest 198 mg/dl 1/3/25, highest 361 mg/dl lowest 270 mg/ dl 1/4/25, highest 326 mg/dl lowest 234 mg/dl 1/5/25, highest 316 mg/dl lowest 262 mg/dl 1/6/25, highest 272 mg/dl lowest 199 mg/dl 1/7/25, highest 350 mg/dl lowest 280 mg/dl 1/8/25, highest 339 mg/dl lowest 273 mg/dl 1/9/25, highs 309 mg/dl lowest 200 mg/dl During an interview on 1/6/25 at 1:35 p.m., R1 stated she was diabetic but wasn't getting diabetic meals, just getting what everyone else is eating. During an observation and interview on 1/8/25 at 2:40 p.m., R1 stated she thought her blood sugar goal was 100-300, then said maybe it was 100-200. R1's lunch tray was in her room she had not eaten yet, she had a large portion of ravioli, salad and regular french dressing, soup, and vanilla ice cream. Her lunch was late because she had been at a meeting at 1:00 p.m R1 looked at her meal ticket which listed her diet as Regular, LCS. R1 stated she did not know what LCS meant. R32: R32's quarterly MDS dated [DATE], identified R32 had diagnoses which included chronic kidney disease stage 3 (a moderate level of kidney damage where the kidneys are less efficient at filtering waste from the blood, causing mild to moderate loss of kidney function), coronary artery disease, hypertension, and diabetes mellitus. R32's MDS identified R 32 was cognitively intact and received insulin injections. R32's active orders as of 1/9/25, identified R32's orders included the following: -consistent carbohydrate diet, regular texture, thin consistency -blood glucose test before meals and at bedtime -consistent carb (carbohydrate) every evening -for blood sugar less than 70 mg/dl administer six ounces fruit juice, milk, regular pop or other high carbohydrate beverage: like Ensure or Boost. Repeat blood sugar after 10 minutes, if blood sugar less than 70 mg/dl, give 15 grams glucose. Repeat blood sugar after 15 minutes, if below 70 repeat glucose oral gel 15 grams. Repeat blood sugar in another 15 minutes and if below 70 call -glucose 15 oral gel 40 percent, give 15 gram by mouth as needed for blood sugar less than 70 -Humalog insulin 100 units/ml inject seven units subcutaneously with meals -Lantus insulin, inject 32 units subcutaneously in the morning R32's care plan initiated on 2/10/23, and revised on 9/24/24, identified R32 had nutritional problem or potential nutritional problem related to impaired skin integrity, new to this setting, therapeutic diet. Interventions included provide, serve diet as ordered. Monitor intake and record every meal. Consistent Carbohydrate. R32's blood sugars for January 2025 revealed the following: 1/1/25, highest 245 mg/dl lowest 131 mg/dl 1/2/25, highest 211 mg/dl lowest 135 mg/dl 1/3/25, highest 206 mg/dl lowest 120 mg/dl 1/4/25, highest 227 mg/dl lowest 120 mg/dl 1/5/25, highest 243 mg/dl lowest 139 mg/dl 1/6/25, highest 212 mg/dl lowest 114 mg/dl 1/7/25, highest 185 mg/dl lowest 107 mg/dl 1/8/25, highest 128 mg/dl lowest 119 mg/dl 1/9/25, highest 234 mg/dl lowest 101 mg/dl During an interview on 1/6/25 at 6:14 p.m., R32 stated her blood sugars where up and down and sometimes low overnight. R32 stated she had to regulate her own diet and was not getting a diabetic diet. During an observation and interview on 1/7/25 at 11:55 a.m., R32 was seated in the dining room, she had been served lemon chicken, a double portion of rice, mixed vegetables, jello with whipped cream, milk, juice, and water. During an observation on 1/7/25 at 12:40 p.m., R32 had eaten 100% of her meal. She stated she did not think the jello or juice was sugar free. During an interview on 1/8/25 at 10:20 a.m., dietary aide (DA)-A reviewed R32's diet ticket. The ticket had the resident's name and room number in the upper left corner. The diet was listed as Regular, CCHO. In the bottom right corner was a picture of what appeared to be a spoon with a white substance on it and a red circle with a red line through the picture of the spoon. DA-A stated she was not sure what the picture meant. DA-A was not sure which residents were diabetic. DA-A stated juices were not sugar free and the jello that was served was regular jello not sugar free. DA-A verified both R1 and R32 received regular juice and regular jello and the diabetic residents were served the regular meal and dessert. During an interview on 1/8/25 at 1:46 p.m., cook (C)-A stated a diabetic diet was no different than a regular diet. C-A stated if a resident was diabetic they should not have the dessert, instead they should receive fresh fruit. C-A stated there would not be any portion size changes for residents with diabetes. C-A stated the process was the DAs would pick up the meal tickets from the tables and bring them to the serving window. The residents who did not eat in the dining room would have their meal tickets placed on trays that were placed in the carts, C-A would not see those meal tickets. The DAs would just tell her regular, soft and bite sized, or minced and moist. During an interview on 1/8/25 at 2:08 p.m., registered dietician (RD)-D stated the facilities menu system would have specialty diets and it would be her expectation that the facility would follow those. RD-D stated a consistent carbohydrate diet would be about 60-75 grams of carbohydrate per meal and tracking the carbohydrates would be figured into the menu system. RD-D stated she would expect to be alerted if blood sugars were not being controlled. During an interview on 1/8/25 at 2:51 p.m., licensed practical nurse (LPN)-A stated he thought R1's blood sugar goal was 150. During an interview on 1/9/25 at 8:51 a.m., DA-B reviewed R1's meal ticket, she thought the picture of what appeared to be a spoon with a white substance on it and a red circle with a red line through the picture of the spoon meant no sugar but then said could mean no sodium. DA-B stated the cooks did not see any of the meal tickets for residents who did not eat in the dining room. The DA staff would just tell the cook how many regular diets, pureed, they needed. DA-B was asked what Regular, CCHO meant and regular LCS meant, she was not sure. DA-B thought CCHO might have something to do with cholesterol. During an interview on 1/9/25 at 9:04 a.m., cook (C)-B stated she would see the meal tickets for residents who ate in the dining room. C-B was asked what Regular CCHO meant, she was unsure and said they would just be given the regular meal. When asked what Regular LCS meant she thought it might mean lactose intolerant and again the resident would receive the regular meal. C-B stated they would not give a resident a half portion of the dessert unless they requested a half portion. C-B stated there were a couple of residents who only wanted half portions (R13, R31 and R44). C-B stated fresh fruit was available at breakfast and then any time a resident requested fresh fruit. C-B stated the juices were not sugar free and the jello served at lunch was not sugar free. Sugar free jello came from a company and was usually served at the evening meal. C-B stated diabetic residents received fruit or a small dessert but couldn't think of any residents who were diabetic. C-B stated the cooks would not see the meal tickets on the cart. The DAs would tell them how many they needed starting with the cut ups, minced and moist, then regular diets. During an interview on 1/9/25 at 9:35 a.m., dietary manager (DM)-E stated diabetic residents would receive a smaller portion of the entree and a larger portion of the non-starchy vegetables. DM-E stated the cooks would look at the meal ticket, see the ordered diet and then the resident would get a smaller portion if they were diabetic. DM-E stated diabetic residents would get the same dessert just a smaller portion. DM-E stated it was his expectation that the cooks would see every meal ticket at meals. During an interview on 1/9/25 at 1:03 p.m., the administrator stated residents received a therapeutic diet based on the their orders. The administrator stated she was unsure if the cooks looked at each resident meal ticket at every meal, but stated the dietary aides would call out the order. The administrator declined to say if this was best practice. A review of the meal tickets for 1/9/25, lunch revealed: Ten residents were receiving a Regular, CCHO diet, one of which was R32 Three residents were receiving a Regular, LCS diet, one of which was R1 Optima Solutions 2 Dietary Management Systems dated 2024-25 Fall/Winter Menus identified the following diets: Regular, Mechanical Soft, Puree, Low Con Sweet, Liberal Renal. No CCHO diet was identified in the definitions. Regular diet no restrictions, no definition for Low Con Sweet. The Low Con Sweet did however specify ounces to be served which were not different from the regular diet. The dessert however was indentified to be one half of pie or would identify seasonal fresh fruit. No definition or explanation for the picture of the spoon with the white substance and red circle and line through the red circle. Resident Council notes no date, identified residents were being served to many carbs, too many noodles, and identified they had many diabetic residents. An additional comment was, fruit is not a dessert. Therapeutic Diets dated 3/2023, identified the purpose was to ensure the nutritional needs of residents requiring therapeutic diets are met in accordance with their medical conditions, preferences, and physician orders while promoting optimal health and well-being. The policy further indicated residents would receive individualized meal plans. Definition of a therapeutic diet was as follows: A meal plan prescribed to manage a medical condition, which may include alterations in nutrient content, texture, or volume. The policy identified there would be regular training for dietary and nursing staff on therapeutic diet preparation and delivery. In addition, the registered dietician would review therapeutic diets monthly and adjust plans as needed.

Based on interview and record review the facility failed to develop an infection prevention control program with an annual review that included written standards, policies and procedures that included when and to whom possible incidents of communicable disease or infections should be reported, when and how transmission-based precautions (TBP) and enhanced barrier precautions (EBP) should be implemented to prevent infections, and hand hygiene procedures to be followed by staff involved in direct resident care. This had the potential to affect all 54 residents who reside in the facility. Findings include: On 1/6/25, at entrance the infection control program was requested. A document titled Nursing Services Policy and Procedure Manual for Long-Term Care Infection Control dated 10/2023, was provided. The document was a policy and procedure manual. During an interview on 1/8/25 at 12:56 a.m., with the director on nursing (DON) and the assistant director of nursing (ADON) both verified they did not have an infection control program that they reviewed annually. On 1/9/25 at 9:55 a.m., the DON stated they did not have a formal written program for infection control that was reviewed annually. The DON stated the benefit of an infection control program would be to see what changes for infection prevention would be needed to be made year to year.

Based on interview and document review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment. This deficient practice had the potential to affect all residents in the facility who used a bed. Findings include: During an interview on 1/9/25 at 12:49 p.m., the assistant director of nurses (ADON) stated if a resident requested a side rail, the first thing they did was get physical therapy involved to see if that would be functional for that resident. If that was affirmative, then they do the side rail and grab bar assessments. The ADON stated she was not responsible for this task and wasn't as familiar with the process for measuring. During an interview on 1/9/25 at 1:12 p.m., registered nurse (RN)-B stated she was responsible for performing resident assessments and measurements for bed rails. RN-B stated she followed the FDA guidelines and compressed the mattress and measured the gaps. RN-B stated she would involve maintenance if something didn't seem right or wasn't working properly. During an interview on 1/9/25 at 2:06 p.m., maintenance worker (MW)-A stated they put together the beds and did the initial measuring using the Food and Drug Administration's (FDA) guide for measurements, making sure the space between the head and footboards and any rails didn't measure more than four and three-quarter inches when compressing the mattress. MW-A stated nursing looked at the beds after they were put together. MW-A stated they didn't do any routine inspecting or measuring of beds, mattresses, or bed rails. During an interview on 1/9/25 at 2:28 p.m., the director of nursing (DON) stated the nursing department didn't have a program for inspecting beds on a routine basis. During an interview on 1/9/25 at 2:46 p.m., the administrator stated it would be important to have an ongoing system for inspecting and maintaining beds to avoid entrapment. Maintenance records for bed inspections was requested but not received. Side Rail Use Policy dated March 2023, identified its purpose to ensure the safe, appropriate, and compliant use of side rails in the care of residents while balancing safety, dignity, and individual needs in accordance with federal and state regulations. Under item number 4, Monitoring and Evaluation, the policy identified staff will perform routine checks to ensure the side rails were properly maintained and securely fastened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store a portable oxygen tank for 1 of 1 resident (R9) who utilized oxygen. R9's significant change Minimum Data Set (MDS) dated [DATE] indicated that R9 had moderately impaired cognition. R9's diagnoses included chronic obstructive pulmonary disease, shortness of breath and chronic systolic (congestive) heart failure. On 10/23/23 at 3:08 p.m., a portable oxygen tank, with regulator attached, was freestanding next to the heating vent near the window in R9's room. Portable oxygen tank was not stored in a secure cart. On 10/24/23 at 11:30 a.m. and 2:29 p.m., portable oxygen tank remained in same location, freestanding and not secured. On 10/24/23 at 11:55 a.m., nursing assistant (NA)-A stated portable oxygen tanks should be stored in the oxygen room. On 10/24/23 at 6:14 p.m., director of nursing (DON) stated portable oxygen tanks should be stored in the oxygen room. If a resident utilized a portable oxygen tank, it should be stored in a secure wheeled cart. DON confirmed that the portable tank, in R9's room, was unsecured and removed tank from room. DON stated it was important for a portable oxygen tank to be stored in a secure cart because if a tank fell down or get knocked over, it could explode like a weapon. A policy for Storage of Portable Oxygen was requested and was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE] indicated R9 was cognitively intact, had diagnoses of non-Alzheimer's dementia, depression, and psychotic disorder. A review of R9's medication orders (print date of 10/24/23) indicated R9 received Zyprexa (antipsychotic) 15 milligrams (mg) in total daily. R9's Consultant Pharmacist's monthly Medication Review, from 1/05/23 through dated 10/23, did not include recommendations for an abnormal involuntary movement scale (AIMS) assessment. to be completed. In review of R9's electronic medical record, R9 had AIMS assessments completed on 11/3/21 and 8/29/22 and has not had another assessment completed since 8/29/22. R42's annual MDS dated [DATE] indicated R42 had severe cognitive impairment, had diagnoses of Alzheimer's disease, anxiety, and depression. A review of R42's medication orders (print date of 10/24/23) indicated R42 received Seroquel (antipsychotic) 125 mg in total daily. R42's Consultant Pharmacist's monthly Medication Review, from 1/05/23 through dated 10/23, did not include recommendations for an AIMS assessment to be completed. In review of R42's electronic medical record, the only AIMS assessment was completed on 12/19/22 and has not had another assessment completed since 12/19/23. On 10/25/23 at 9:45 a.m., RN-A stated he is the person responsible for completing the AIMS assessments and that they should be completed on admission and every 6 months if a resident is receiving an antipsychotic medication. RN-A confirmed that R9 last AIMS assessment was completed on 8/29/22 and R42's was completed on 12/19/23. In review of another facility policy, entitled: Pharmacy Services - Consultant Pharmacist Services Requirements - Thrifty [NAME] Pharmacy (revised January 2020) indicated the following: Section E., subsection 6: Assist in identifying current medication references to facilitate medication information on contraindications, side effects and/or adverse effects, dosage levels and other information. Section F, subsection 2: Communicating to leadership the potential or actual problems detected and other findings related to medication use at least monthly. Based on interview and document review, the facility failed to ensure pharmacist consultant monitored facility's ongoing psychotropic side effect monitoring for 3 of 5 residents (R26, R9, R42) reviewed for unnecessary medications. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE] indicated R26 was cognitively intact, had diagnoses of stroke, peripheral vascular disease, dementia, anxiety, depression and psychotic disorder. R26's MDS further indicated resident was not receiving antipsychotic medications. A review of R26's medication orders (print date of 10/25/23) indicated R26 received Risperdal (antipsychotic) 1.25 milligrams (mg) in total daily. R26's Consultant Pharmacist's monthly Medication Review, from 1/05/23 through dated 10/23, indicated only one recommendation was made for a gradual dose reduction of R26's duloxetine (antidepressant - Cymbalta) in February 2023 . R26's physician orders dated (print date of 10/25/23) indicated R26 had an order for Risperdal 1.25 mg on 8/14/23. In review of R26's medication history the following was noted. R26 was admitted [DATE] with the order for Risperdal 1.25 mg daily. In May 2023, R26's Resperdal wad discontinued and then restarted on 8/14/23 at the same dose. In review of R26's electronic medical record, the only AIMS (Abnormal Involuntary Movement Scale - a tool used to monitor for tardive dyskinesia - side effected from psychotropic medications), dated 5/24/22, when R26 was admitted to the facility. During interview on 10/25/23 at 8:35 a.m., MDS coordinator (RN)-A stated the facility only had evidence of one AIMS being completed for R26 at the time of resident's admission. RN-A stated that he knew the AIMS assessment should be completed at the time of admission and every 6 months when a resident is receiving an antipsychotic medication, but relied on the pharmacy consultant to remind him through monthly recommendations. In a telephone interview on 10/25/23 at 3:19 p.m., consultant pharmacist (PharmD) stated residents should have an AIMS completed upon initiation of an antipsychotic medication and then every 6 months after. PharmD stated he generally makes recommendation for AIMS to be completed by doing 'spot checks' when performing monthly medication reviews. PharmD stated the facility should have polices in place to director AIMS assessments. PharmD further stated he would be keeping a closer watch on this and add to his to do list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R9's quarterly Minimum Data Set (MDS) dated [DATE] indicated R9 was cognitively intact, had diagnoses of non-Alzheimer's dementia, depression, and psychotic disorder. A review of R9's signed physician medication orders (print date of 10/24/23) indicated R9 received Zyprexa (antipsychotic) 7.5 milligrams (mg) twice daily. R9's electronic medical record (EMR) included AIMS assessment compled on 11/3/21 and 8/29/22. The EMR lacked additional AIMS assessments. R42's annual MDS dated [DATE] indicated R42 had severe cognitive impairment, had diagnoses of Alzheimer's disease, anxiety, and depression. A review of R42's signed physician medication orders (print date of 10/24/23) indicated R42 received Seroquel (antipsychotic) 125 mg in total daily. R42's electronic medical record (EMR) included AIMS assessment compled 12/19/22. The EMR lacked additional AIMS assessments. On 10/25/23 at 9:45 a.m., RN-A stated he is the person responsible for completing the AIMS assessments and that they should be completed on admission and every 6 months if a resident is receiving an antipsychotic medication. RN-A confirmed that R9 last AIMS assessment was completed on 8/29/22 and R42's was completed on 12/19/22. The facility policy, entitled: AIMS Assessment for Dyskinesias (reviewed 8/31/23) indicated the following: This policy and procedure for AIMS assessment for dyskinesias will be followed by Registered Nurses in our facility as part of routine clinical evaluations for patients taking neuroleptic medications. The results will be used for monitoring and providing appropriate care to patients experiencing dyskinesias. This will be completed on admission, every 6 months (per pharmacist), or as needed if a change in neuroleptic medications. Based on interview and document review, the facility failed to ensure residents were routinely assessed for tardive dyskinesia were collected to allow adequate monitoring of potential side effects for physician ordered antipsychotic medications for 3 of 5 residents (R26, R9, R42) reviewed for unnecessary medication use. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE] indicated R26 was cognitively intact, had diagnoses of stroke, peripheral vascular disease, dementia, anxiety, depression and psychotic disorder. R26's MDS further indicated resident was not receiving antipsychotic medications. A review of R26's medication orders (print date of 10/25/23) indicated R26 received Risperdal (antipsychotic) 1.25 milligrams (mg) in total daily (oder date of 8/14/23). In review of R26's medication history the following was noted. R26 was admitted [DATE] with the order for Risperdal 1.25 mg daily. In May 2023, R26's Resperdal wad discontinued and then restarted on 8/14/23 at the same dose. In review of R26's electronic medical record, the only AIMS (Abnormal Involuntary Movement Scale - a tool used to monitor for tardive dyskinesia - side effected from psychotropic medications), dated 5/24/22, when R26 was admitted to the facility. During interview on 10/25/23 at 8:35 a.m., MDS coordinator (RN)-A stated the facility only had evidence of one AIMS being completed for R26 at the time of resident's admission. RN-A stated that he knew the AIMS assessment should be completed at the time of admission and every 6 months when a resident is receiving an antipsychotic medication, but relied on the pharmacy consultant to remind him through monthly recommendations. In a telephone interview on 10/25/23 at 3:19 p.m., consultant pharmacist (PharmD) stated residents should have an AIMS completed upon initiation of an antipsychotic medication and then every 6 months after. PharmD stated he generally makes recommendation for AIMS to be completed by doing 'spot checks' when performing monthly medication reviews. PharmD stated the facility should have polices in place to direct AIMS assessments. PharmD further stated he would be keeping a closer watch on this and add to his to do list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, during 1 of 1 quarters (Quarter 3: April 1 - June 30, 2023), reviewed for payroll based journal (PBJ). Findings include: Review of the staffing schedules and timecard verifications for Quarter 3 identified the facility had licensed nursing staff, 24 hours per day 7 days per week, and 8 consecutive hours per 24 hours of registered nurse (RN) coverage documented. However, during interview on 10/26/23 at 10:30 a.m., administrator and and business office lead ([NAME]) both stated they used SimplePBJ (a Payroll Based Journal computer application) when submitting their staffing levels on a quarterly basis. Both staff members stated that [NAME] was the responsible staff person that submitted the PB&J data for the facility. Both staff stated they were unable to provide a verification email, which would indicate the facility's 2023 3rd quarter PB&J had been submitted. At 2:15 p.m., [NAME] was able to show the data had been completed, however was undated, and [NAME] was unable to provide the standard verification email letter which SimplePBJ send out, verifying a facility's data had been received. On 10/25/23 at 4:15 p.m., exit conference was held. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure medications were properly labeled with current medication orders for one of seven residents (R9) observed for medication administration. In addition, the facility failed to ensure medication fridge temperatures were monitored to ensure safe medication storage and that the emergency kit (e-kit) did not have expired insulin. This deficient practice had the potential to impact any residents that required emergency insulin and or received medications stored in the fridge. Findings included: Labeling R9's Face Sheet provided [DATE], indicated he had diagnosis that included Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Hypertenson, and unspecified peripheral vascular disease. On [DATE], at 1:30 p.m. trained medication adminstartion (TMA)-A stated R9's Medication Administration Record (MAR) for Albuterol did not match the pharmacy sticker on the inhaler: Proventil HFA 90 mcg one puff every four hours as needed. TMA-A clarified the order with the assistant director of nursing (ADON) before administering the medication. During an interview with the director of nursing (DON) on [DATE], at 10:41 a.m. the DON confirmed R9's Inhaler label read: Ventolin one puff every four hours as needed for shortness of breath. The DON further stated when the order changed, staff should have put a label on the medication to indicate the MAR and medication label did not match. On [DATE], at 12:05 p.m. the consultant pharmacist (CP) stated it was okay to use the proventil inhaler because albuterol and proventil are the same drug. The CP stated when the inhaler dose changed, the facility should have placed a sticker on the inhaler to indicate that the label did not match the order. The facility policy Labeling of Medication Containers dated [DATE], indicated that medication labels should include the name, strength, and directions for use. The policy did not address placing a sticker on the medication card/bottle/inhaler to indicate the order changed, but it did direct nursing staff to notify the pharmacist of provider ordered changes to medications. Medication Refridgeration Temperatures At approximately 10:35 a.m. on [DATE], during the medication storage review, it was noted the facility's medication fridge did not have a temperature log on the front of the fridge. On [DATE], at approximately 10:35 a.m. the director of nursing (DON) confirmed the facility did not have a formal process for monitoring medication fridge temperatures. The DON verified the thermometer located in the fridge door was at 32 degrees Fahrenheit. On [DATE], at 12:46 p.m. the medication fridge was reviewed with registered nurse (RN)-A. Bottles of liquid suspension medication, suppositories, and eye drops were stored in the fridge door compartments. A thermometer was stored in the top left compartment of the fridge door which aligned with the freezer compartment when closed. The freezer compartment was open and full of frosted ice. The fridge shelf directly below the freezer compartment had two bins of boxed insulin pens. One of the boxes was touching the bottom of the freezer compartment. Additional shelves contained bins of resident medication. The CP stated, the policy Thrifty [NAME] shares with all facilities states that medication fridge temperatures should be monitored daily. CP stated he planned to follow-up with the facility because they needed to be checking and recording temperatures daily to ensure the fridge temperatures were safe for medication storage. The facility provided an inventory list with each drug and quantity stored in the fridge. Five out of 20 medication manufacturer instructions were reviewed. As listed below, all instructions indicated a storage temperature range greater than 32 degrees F. -Tresiba Flex Pen: between 36 degrees to 46 degrees Fahrenheit (F) -Levemir insulin pen: between 36 degrees F and 46 degrees F -Trulicity pen: between 36 degrees F to 38 degrees F -Immunization, boostrix: between 36 degrees F and 46 degrees F and should be discarded if frozen. The facility policy Storage of Medications dated [DATE] indicated, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. The policy did not address how the facility ensured the medications were stored at proper temperature. E Kits expirated medications On [DATE], at 12:46 p.m., the Emergency Kit (E-kit) containing three vials of insulin was stored in the medication fridge in a plastic box with a zip tag lock numbered 3730017. The sticker on the outside of the plastic box read: First Drug to Expire: [DATE], Date last checked: [DATE]. RN-A verified the label indicated a medication inside the box was expired. RN-A stated the crash cart was checked one time a week, but she wasn't sure if the insulin E-Kit was included. On [DATE], 12:57 p.m. the DON confirmed the sticker on Insulin E-Kit read: First Drug to Expire: [DATE]. The DON read dates for each of the three vials and confirmed that the Novolog insulin was expired. The DON stated that he did not think they checked the E-kit for expiration dates daily, and then pulled the ADON into the medication room for clarification. On [DATE] at 1:00 p.m. the ADON stated as part of their service, the pharmacist should be reviewing dates of e kits to ensure they are not expired; staff do not do this. The facility policy titled Pharmacy Services, Emergency Pharmacy Service and Emergency Kits dated [DATE], indicated that facility staff would check the emergency medication kit(s) at least once a month to make sure it was properly stored, sealed, and medications were not outdated. The policy indicated a pharmacist designee would also do the same checks once a month.

Based on observation, interview and document review, the facility failed to safeguard personal and medical information contained in the Electronic Medical Record (EMR) when the EMR was left accessible for any staff, visitor or resident to view on two sperate occasions. This deficient practice affected all 48 residents who resided in the facility. Findings include: On 11/29/22, at 2:51 p.m. Point Click Care (PCC), the facility's EMR program was left open on one of the medication carts. The cart was parked across from the elevator doors along a guard rail on the second floor. The screen displayed a list of resident names and pictures. There were not any staff present at the cart or in the hallway. On 12/1/22, at 12:43 p.m. the nurse medication cart was parked in front of the second floor nurses station in the hallway. There were not any staff at the cart. The EMR was open and accesible for anyone to view or access. On 12/1/22, at 12:44 p.m. registered nurse (RN)-A returned to the medication cart and locked the screen. RN-A confirmed she had left the EMR open while she left the cart to obtain a blood sugar and stated she should have locked the screen before leaving her medication cart. On 12/1/22, at 2:30 p.m. the director of nursing (DON) stated before staff leave the medication cart he would expect them to lock the cart, clear the top of the cart of medications and/or anything a resident could hurt themselves with, and then make sure the EMR was closed so it could not be viewed or accessed. The facility policy Electronic Medical Record dated March 2014, indicated that only authorized persons would have access to the EMR. The policy reference list included The Health Insurance Portability and Accountability Act (HIPAA). The HIPAA Privacy Rule established national standards to protect individual's medical records and other individually identifiable health information.

Based on observation, interview, and document review the facility failed to ensure opened foods were dated and free from ice particles; food was stored off the floor; clean dishware was not exposed to contamination; and food temperatures were maintained according to standards. This had the potential to affect all 48 residents who consumed food from the kitchen. Findings include: During the initial kitchen tour with the dietary manager (DM)-B on 11/28/22, at 1:55 p.m. the following was observed: -Dijon mustard had a date 8/19, and a best by date of 11/2/21, on the shelf. DM-B confirmed this should not be used. -A box with seven packages of beef and packages of tator tots were on the floor of the freezer. DM-B confirmed these should not be on the floor but should be on a shelf. -A package of opened peas, carrots, and lima beans with no opened by date was in the freezer. -An opened bag of waffles was unsealed in the freezer with ice particles forming in the bag. DM-B confirmed these should not be used. -One bucket of vanilla frosting was located on the floor and DM-B stated foods should not be stored on the floor. During interview and observation on 11/28/22, at 2:21 p.m. cook (C)-A pushed a rack of clean dishes out of the dish washer using the tray of dirty dishes he pushed into the dishwasher. The DM-B stated clean dishes should not be pushed out of the dish washer by using the dirty dish tray going into the dishwasher. During interview on 11/29/22, at 2:13 p.m. dietary aide (DA)-A stated breakfast started at 7:30 a.m., lunch was at 11:30 a.m., and supper was at 5:00 p.m. During interview and observation on 11/30/22, at 8:15 a.m. C-A checked the temperature of the eggs in the food warmer and stated the temperature was 123 degrees Fahrenheit and stated the eggs were very cold. The temperature of the French toast was taken and was 104 degrees. C-A stated the eggs were supposed to be 150 degrees and thought something was wrong with their vent. On 11/30/22, at 8:20 a.m. C-A dished up a plate with eggs, oatmeal, and toast from the warmers. C-A was asked to check the temperature of the eggs; DA-A asked DM-B to heat the plate up. At 8:22 a.m., the temperature of the eggs in the warmer was at 120 degrees. During interview and observation on 11/30/22, at 8:27 a.m. DM-B stated the oatmeal was not warm enough and stated it should be at least 160 degrees. During interview 11/30/22, at 9:01 a.m. maintenance (M)-A stated a reheat coil valve failed 11/26/22, and would be repaired 12/1/22, but stated this would not affect the warmers. During interview on 11/30/22, at 10:20 a.m. R28 stated he did not eat his breakfast because the butter was sitting on top of his toast and when he picked up his toast, it was cold and stated that was why the butter had not melted. R28 stated the eggs were also cold. During observation and interview on 11/30/22, at 10:44 a.m. licensed practical nurse (LPN)-A stated the small refrigerator on the second floor was for the residents and stated that maintenance or housekeeping checked the refrigerator temperatures daily and would defrost them if needed. The small refrigerator had an unlabeled chicken pot pie in the freezer and the freezer had a buildup of ice. During interview on 11/30/22, at 10:48 a.m. the director of nursing (DON) verified there was a buildup of ice in the freezer, but did not know who was responsible for defrosting the freezer. During interview on 11/30/22, at 10:51 a.m. housekeeper (H)-A stated maintenance was responsible to defrost the freezers, and housekeeping would complete the task if asked. H-A stated it looked like it had been a while since the freezer had been defrosted. During interview on 11/30/22, at 1:18 p.m. the administrator stated she expected food to be stored on shelves, not on the floor; foods should be hot; foods should be dated; and freezers should not have ice buildup. During interview on 12/1/22, at 10:24 a.m. DM-B stated temperature standards for reheating foods used to be160 degrees, but stated it changed to 165 degrees. Facility policy Food Temperatures dated 2013, indicated all hot food items must be served at a temperature of a least 135 degrees Fahrenheit. Hot food items cannot fall below 135 degrees Fahrenheit and need to be reheated to at least 165 degrees Fahrenheit prior to serving. Facility policy Food Storage dated 2013, indicated food items were to be stored on shelves, food was to be dated when placed on shelves, date marking was to include the date by which food was to be consumed, or discarded, and food was to be stored a minimum of six inches above the floor. Additionally, the policy indicated freezer units were kept clean and in good working condition at all times and all foods were to be covered, labeled, and dated.