**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure transmission-based precautions (TBP) were initiated for 1 of 1 resident (R64) suspected of having clostridioides difficile (c-diff-a highly contagious bacteria that causes significant diarrhea, often attributed to antibiotic use). Findings include: R64's admission Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment, no behaviors, substantial assist with activities of daily living (ADL's), transferring, and bed mobility. It also indicated incontinence. R64's diagnosis list includes incontinence and urinary tract infection's. R64's care plans included R64 required an assist of 1 for transfers, bed mobility, toileting, toilet hygiene, and ADLs. During interview and observation on 10/14/24 at 3:41 p.m., R64 stated diarrhea episodes started a couple days ago. No indication of transmission-based precaution noted on door. No personal protective equipment (PPE) noted outside room. During interview on 10/15/24 at 2:09 p.m., nursing assistant (NA)-A stated occupational therapy assists R64 with getting ready for the day and nursing staff assist R64 with cares and toileting the rest of the day. Nursing assistants also assist the nurses with positioning during dressing changes. NA-A stated R64 had loose stools for at least the past two days and received antibiotics for a urinary tract infection. NA-A stated loose stools are immediately reported to the nurse. During interview and observation on 10/15/24 at 2:12 p.m., R64 reported having loose stools for the past couple days that were loose enough to have occasional bowel incontinence. R64 was told by the facility medical provider the morning of 10/15/24 a stool sample was going to be collected. No indication of transmission-based precautions noted on resident's door. No PPE noted outside room. Progress notes indicated R64 was started on cefdinir (antibiotic) for UTI on 10/9/24. On 10/10/24, R64's antibiotics were changed from cefdinir to Augmentin. A large loose stool was noted on 10/11/24. R64 refused antibiotics due to having loose stools on 10/13/24. Two medium loose stools were documented on 10/14/24. October medication administration record (MAR) confirmed R64 received cefdinir on 10/9-10/11 and Augmentin 10/10/24-10/15/24. A provider order dated 10/14/24 indicated: -stool sample to rule out C-diff -hold Miralax, senna [stool softeners] if [R64] is having loose stools -given antimicrobial resistance on recent urine culture, would prefer to not change antibiotic at this time and would encourage [R64] to take Augmentin if [R64] is willing. Provider progress notes dated 10/15/24 indicated R64 had loose stools and C-diff/stool assessment was ordered 10/14/24 but not yet obtained. It also indicated R64 refusal to take prescribed antibiotic. During interview 10/15/24 at 2:48 p.m., registered nurse (RN)-A stated R64 has had several loose stools and was recently placed on Augmentin. RN-A stated the interdisciplinary team (IDT) met and discussed R64's loose stools, orders for stool sample, and placing R64 on C-Diff precautions. During interview on 10/15/24 at 4:41 p.m., the infection preventionist (IP) stated there is an IDT meeting every day however did not attend that morning due to a quality improvement meeting. The IP stated progress notes are reviewed every morning for documentation of any infection related issue. Residents are placed on TBP when suspected of having symptoms outside of their baseline and prior to when ordered labs are obtained. IP stated the provider did not want to adjust R64's antibiotics due to history of antibiotic resistance and wanted to rule out C-Diff. During observation on 10/15/24 at 4:29 p.m., no TBP or PPE were noted outside R64's room. During interview and observation on 10/15/24 at 4:49 p.m., the IP confirmed the facility received an order for C-diff testing on 10/14/24, was processed the afternoon on 10/14/24. IP confirmed R64 should be on TBP pending lab results. IP stated an email was sent to the care coordinator and nurse manager the morning of 10/15/24 indicated R64 is to be on precautions. IP confirmed there was no TBP or PPE located outside of R64's room. IP stated a clarification email was sent the morning of 10/15/24 confirming R64 should be on TBP while waiting for lab sample to be obtained. During interview on 10/16/24 at 12:25 p.m., the director of nursing (DON) stated if staff request orders from providers for testing for gastrointestinal illness, the expectation would be for resident's to immediately be placed on transmission-based precautions. This is necessary to prevent the spread of potential infections to other residents and staff. A policy titled Isolation Precautions: Modified Contact Procedure- Mayo clinic Health System, Rochester dated 7/8/24, indicated a purpose of provide personnel with the direction to safely care for a patient requiring Modified Contact Precautions to prevent the transmission of diseases spread by contact, specifically Clostridiodes difficile (C. Difficile), C. auris, or norovirus infections. Section titled Procedure indicated use Modified contact Precautions for suspected or confirmed Clostridiodes difficile (C. difficile), C. auris, or norovirus infections because these organisms require cleaning with bleach. A policy titled Clostriodioides Difficile (C-diff) guideline-Rochester dated 7/3/23 indicated Suspected infections of clostridium difficile will be verified by culture or by evidence of positive cytotoxin assay. Nursing should be alert to isolate residents with any symptoms when suspected and prior to obtaining confirmatory lab results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 3 of 5 (R5, R114, R9) residents were appropriately vaccinated against pneumococcal disease upon admission and/or offered updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. Findings include: R5 was [AGE] years old, admitted [DATE]. R5 received PCV-13 on 6/8/15 and PPSV-23 on 9/19/17. There was no documentation to support R5 had a discussion with a medical provider regarding the PCV-20 vaccine, according to current CDC guidance for vaccines. R9 was [AGE] years old, admitted on [DATE]. R9 received PCV-13 on 4/26/17 and PCV-23 on 12/3/18. There was no documentation to support R9 had a discussion with a medical provider regarding the PCV-20 vaccine, according to current CDC guidance for vaccines. R114 was [AGE] years old, admitted on [DATE]. R114 received PCV-13 on 1/29/16 and PPSV-23 on 10/1/99. There was no documentation to support R114 had a discussion with a medical provider regarding the PCV-20 vaccine, according to current CDC guidance for vaccines. During interview on 10/15/24 at 2:26 p.m., the IP stated immunizations are reviewed upon admission for COVID, pneumococcal, respiratory syncytial virus (RSV) and influenza. If residents have had PCV-13 and PPSV-23, they are deemed fully vaccinated and not triggered to receive PCV-20. IP stated she would ask facility providers if resident's were evaluated for eligibility of PCV-20. During interview on 10/16/24 at 9:30 a.m., the IP stated facility providers reported immunizations were generally deferred to the residents' outside primary care provider due to residents' stay being short term. IP reviewed medical records and confirmed R9, R114, and R5 were eligible to receive PCV-20 however, the records lack any documentation the vaccines were offered or evaluated for appropriateness. During interview on 10/16/24 at 12:25 p.m., the DON stated she would expect vaccines to be offered to residents who are eligible. A policy titled Vaccination of Resident's Policy-Rochester dated 7/2/24 indicated All residents will be assessed for current vaccination status prior to admission. Vaccinations will be offered annually or as indicated, unless medically contraindicated. Policy notes section of the policy states Vaccinations are offered to short Term Rehabilitation Center residents on admission, annually, and as needed. CDC pneumococcal guidelines located at https://www.cdc .gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: Received PCV-13 at Any Age AND PPSV-23 AFTER age [AGE] Years: aa) Use shared clinical decision-making to decide whether to administer PCV-20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to immediately report an allegation of abuse to the State Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of abuse. Findings include: A Nursing Home Incident Report submitted to the state agency on 8/12/24 at 5:10 p.m. indicated R1 alleged rough care with nursing assistant (NA)-A on 8/12/24 at 1:50 a.m. and the resident outcome was fear and anger. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition and no noted behaviors. R1 had limitation in range of motion on one side of lower extremity and was dependent with toileting, transfers, and toileting hygiene. R1's progress note dated 8/12/24 at 3:48 a.m. indicated R1 had refused cares x 2 by certified nursing assistant (CNA) by approximately 1:50 a.m. R1 was educated of the risks and benefits of refusing cares, R1 then began breathing erratically, shouting, being verbally aggressive to writer becoming visibly overwhelmed. Writer allowed R1 to vent their feelings. R1 suddenly stopped speaking and asked writer why they were in their room pestering them. Writer then explained the risks and benefits of bed changes for incontinent patients. R1 then shouted at writer, Stop hurting me. Writer reminded R1 that they had not been involved with their cares this shift and R1's affect visibly relaxed and breathing slowed. Writer explained they have no intention of bringing any kind of harm to resident and stated in fact that is why I am here now to make sure you are safe and cared for. R1 stated, then make sure that girl doesn't come in here again, she's the one that hurts me, and I have the right to refuse. R1's respirations increased and became visibly overwhelmed again. During an observation and interview on 8/28/24 at 10:30 a.m. R1 was seated in a recliner in her room with the legs elevated. R1 stated she did have a complaint about a girl that worked the night shift a couple weeks ago, she was not listening to me and said she needed an answer to put in her report, it was very upseting and my preference would be for her to never work with me again. She did not watch where my foot went when rolling me and hurt my foot, my foot had a bruise on it, it's not there anymore, she was not careful, R1 pointed to her right foot. My preferencewould be to not have people taking care of me if they are going to hurt me. During a phone interview on 8/28/24 at 4:50 p.m. nursing assistant (NA)-A stated, she was responsible for R1's cares on 8/12/24 from 12:00 a.m. until 6:30 p.m. R1 had refused incontinence cares from me twice, she did not want me in there, she had said something about me bruising her, after the second refusal this was reported to my nurse between 1:30 a.m. and 2:00 a.m. and was no longer able to provide anymore cares to R1. NA-A denied the allegations. During a phone interview on 8/29/24 at 9:53 a.m., licensed practical nurse (LPN)-A stated, she was the nurse that worked the night shift on 8/12/24 when R1 alleged abuse from nursing assistant (NA)-A. R1 was very upset it took almost an hour to get R1 calmed down. R1 said NA-A hurt her, so NA-A was not allowed back into R1's room. This incident was reported to the charge nurse and documented in the progress note right after the situation was handled. During an interview on 8/28/24 at 9:48 a.m., registered nurse (RN)-A stated, she was working offsite that day and was reviewing the 24-hour progress notes and saw R1's progress note that identified R1 stated, then don't let that girl come in here again, she's the one who hurts me, and I have the right to refuse. R1 then became visibly overwhelmed. That was a red flag. (RN)-A stated the allegation of abuse that was alleged by R1 on 8/12/24 at 1:50 a.m., should have been reported immediately but no later than 2 hours to the state agency because she felt it was a potential allegation of physical abuse. During a phone interview on 8/28/24 at 5:16 p.m., RN-B stated, she had worked on 8/12/24, and was the charge nurse, the night nurse said something about R1 and the NA-A got into an argument or something, the nurse said she documented it. Due to an unawreness of abuse allegations it was not reported. We used to submit reports to the state agency ourselves, recently we were directed to report to the DON. The DON does all of the reporting to the state agency. RN-B was unsure of the timeline for reporting abuse. During a phone interview on 8/29/24 at 10:32 a.m., operations specialist (OS)-A stated, in other states she had worked in, abuse should be reported immediately to the state agency but no later than 2 hours, but because this facility's policy with abuse reporting was to report within 24 hours with no injury, we were trying to figure out if we were doing it right. During an interview on 8/29/24 at 10:55 a.m., interim director of nursing (IDON) stated any abuse allegation should be reported immediately but no later than 2 hours to the state agency. DON indicated the facility policy would be revised immediately to meet regulation and new education would be provided to staff. Review of the facility's Vulnerable Adult Reporting and Investigation Procedure dated 3/20/24 was not consistent with the requirements for reporting allegations of abuse. The procedure included: The nurse in charge, Nurse Manager, or designee must submit a report to Office of Health Facility Complaints (OHFC) through the Nursing Home Incident Reporting portal online within twenty-four hours of the incident's discovery, or within two hours when the alleged maltreatment involves serious bodily injury or death. State Operations Manual Appendix PP - (Rev. 211, 02-03-23) included §483.12(c)(1) Ensure that 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 involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure all residents were protected after R1 reported an allegation of abuse and was protected. This had the potential to affect all other residents residing in the facility at the time of the allegation. Findings include: A Nursing Home Incident Report submitted to the state agency on 8/12/24 at 5:10 p.m., indicated R1 alleged rough care with nursing assistant (NA)-A on 8/12/24 at 1:50 a.m., and the resident outcome was fear and anger. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition and no noted behaviors. R1's progress note dated 8/12/24 at 3:48 a.m. included R1 had refused cares x 2 by CNA by approximately 1:50 a.m. R1 was educated of the risks and benefits of refusing cares, R1 then began breathing erratically, shouting, being verbally aggressive to writer becoming visibly overwhelmed. Writer allowed R1 to vent their feelings R1 suddenly stopped speaking and asked writer why they were in their room pestering them. Writer then explained the risks and benefits of bed changes for incontinent patients. R1 then shouted at writer, Stop hurting me. Writer reminded R1 that they had not been involved with their cares this shift and R1's affect visibly relaxed and breathing slowed. Writer explained they have no intention of bringing any kind of harm to resident and stated in fact that is why I am here now to make sure you are safe and cared for. R1 stated, then make sure that girl doesn't come in here again, she's the one that hurts me, and I have the right to refuse. R1's respirations increased and became visibly overwhelmed again. During a phone interview on 8/28/24 at 4:50 p.m., nursing assistant (NA)-A stated, she was responsible for R1's cares on 8/12/24 from 12:00 a.m. until 6:30 p.m. R1 had refused incontinence cares from me twice, she did not want her in there, she had said something about me bruising her. After R1's second refusal it was reported to my nurse between 1:30 a.m. and 2:00 a.m. NA-a stated she was no longer able to provide cares to R1. NA-A further stated, she had no supervision while providing repositioning and incontinence care to other residents until 6:30 a.m. During a phone interview on 8/29/24 at 9:53 a.m., licensed practical nurse (LPN)-A stated, she was the nurse that worked the night shift on 8/12/24 when R1 alleged abuse from nursing assistant (NA)-A. R1 was very upset it took me almost an hour to get R1 calmed down. R1 said NA-A hurt her, so NA-A was not allowed back into R1's room. LPN-A stated NA-A did provide care to the other residents unsupervised until the end of her shift on 8/12/24 at 6:30 a.m. During an interview on 8/28/24 at 10:54 a.m., interim director of nursing (IDON) stated that NA-A was allowed to work with other residents after the allegation of abuse and should not have been working with other residents unsupervised. Review of facility policy, Vulnerable Adult Reporting and Investigation Procedure, dated 3/20/24, identified . Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Immediately remove the implicated personnel from further contact with the resident, and ensure the personnel is accompanied by other personnel during any direct contact with other residents. Implement one of the following: Partner the implicated personnel under continuous, direct observation with other personnel (i.e., implement paired care); or Re-assign the implicated personnel to an appropriate non-resident care role as available, or: Place the implicated personnel on temporary paid administrative leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed for 1 of 1 resident (R1), reviewed for medication administration . Findings Include: R1's significant change minimum data set (MDS) assessment dated [DATE], indicated R1 was cognitively impaired and totally dependent on staff for bed mobility, dressing and toilet use. R1 diagnosis included aphasia (language disorder caused by damage in a specific area of the brain that controls language expression and comprehension; it leaves a person unable to communicate effectively with others), and respiratory failure. R1's face sheet included diagnosis of cerebral vascular accident (CVA, or a brain attack, is an interruption in the flow of blood to cells in the brain), non-Alzheimer's dementia (a variety of disorders characterized by pathological changes involving various cortical and subcortical circuits), hemiplegia (paralysis of one side of the body), seizure disorder, asthma, chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). R1's care plan updated 10/6/23, indicated pulmonary/oxygen use with pneumonia history and interventions included nursing to provide medications and oxygen supplements per orders and to encourage cough and deep breathing exercises especially after each pair of nebulizer's. R1's physician orders dated 9/5/23, included ipratropium 0.5 milligram(mg)-albuterol 3 mg (2.5 mg base)/3 milliliters (ml) nebulization solution (3ml) ampule for nebulization; ipratropium-albuterol (duoneb) 0.5-2.5 mg/3 mL nebulizer solution. Inhale 3 ml by nebulization four times a day. During observation on 11/14/23 at 12:41 p.m., registered nurse (RN)-A emptied a vial/ampule of duoneb into nebulizer container and placed face mask onto R1's face. After set up, with duoneb being administered via inhalation, RN-A stated R1 had a self-administration of nebulizer and could be left alone while nebulizer treatments were ongoing. RN-A left R1's room. During observation on 11/14/23 at 1:01 p.m., R1 was in room alone while nebulizer treatment was being administered via face mask. R1's medical record lacked a self-administration of medication (SAM) assessment. During interview on 11/14/23 at 3:00 p.m., RN-A stated her understanding was R1 had a SAM assessment and could be left alone since there was also a camera monitor in R1's room. Care coordinator, RN-C, mentioned during interview with RN-A, R1 did not have a SAM assessment and should not be left alone during nebulizer treatment. During interview on 11/14/23 at 3:05 p.m., nurse manager, RN-B verified R1 did not have a SAM assessment and should not be left alone during nebulizer treatment administration. During interview on 11/16/23 at 12:06 p.m., with director of nursing and quality assurance nurse (RN)-D stated residents should have a SAM assessment completed to ensure resident could be left alone based on the assessment findings. The facility policy for self administration of medication was requested and was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and document review, the facility failed to ensure residents were free from physical restraints for 1 of 1 resident (R1) reviewed. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was dependent on almost all activities of daily living (ADLs) and did not use restraints. R1's Medical Diagnosis Form (undated) indicated the following diagnosis: diabetes, Aphasia from stroke, hemiparesis, hemiplegia, muscle weakness, morbid obesity, abnormal posture, debility, unspecified dementia. During an observation on 11/13/23 at 6:46 p.m., R1 was in the dining room, right arm was secured to right arm rest of wheelchair with two Velcro straps. Under same right arm was a wedge shaped cushion that elevated R1's elbow. No visible skin abrasions, tears, or issues observed on right arm. R1's clinical physician orders were reviewed and lacked orders for a restraint. R1's most recent care plan dated 9/8/23 indicated assistance with positioning and risk of falls due related to weakness, hemiparesis, hemiplegia, but had no indication of restraint or durable medical equipment use. During interview on 11/14/23 at 2:37 p.m., R1 stated they don't remember who ordered the Velcro straps for her arm and wheelchair, or how long they had been used. During interview on 11/14/23 at 3:03 p.m., Registered Nurse (RN)-E, stated only been employed at facility for around three months, no training given regarding R1's Velcro straps, only that they're present for safety and protection. RN-E further stated no mention by facility that the straps were used as a restraint. During interview on 11/14/23 at 3:32 p.m., Registered Nurse (RN)-B, stated not sure how long ago the Velcro straps were ordered or implemented. During interview on 11/15/23 at 7:20 a.m., RN-B acknowledged R1's current care plan does not mention reason for use, an assessment, or have a record of a physical device evaluation, or how to evaluate use of straps for R1, and mentioned the straps are not a restraint. RN-B indicated they are being used as a safety device due to R1's lack of use of her right side. RN-B also stated no record of staff training for Velcro straps. RN-B further stated the facility found a durable medical equipment (DME) order, dated 5/31/19, which was only for a swing away lateral pad. No other documentation was provided by facility. RN-B stated facility expectations are every resident is receiving the appropriate care and devices as needed and each staff member is aware, educated, and trained on use of DME and competencies are evaluated. RN-B also stated a resident using any DME would receive ongoing evaluation of DME usage to ensure safe and appropriate use. RN-B further stated an expectation is care plans are properly followed, and evaluated. During an interview on 11/15/23 at 8:02 a.m., Nursing Assistant (NA)-B, stated received training around two and half years ago regarding how to use the Velcro straps for R1, but believed it was an informal, on-the-job type of instruction and training. NA-B further stated does not remember receiving training or instruction on charting and assessment of the straps and has not been charting these areas. Facility restraint policy requested. Director of Nursing (DON) stated they don't have one because they don't use restraints, documentation provided was a copy of the [NAME] of Rights.

Based on observation, interview and document review the facility failed to ensure gloves were changed during dressing change for 1 of 1 resident (R109) reviewed for skin tear. Findings Include: R109's face sheet included diagnosis of unspecified dementia, and history of falling. R109's physician orders dated 11/14/23, indicated check wound for drainage. Cleanse with normal saline, pat dry leave steristrips in place for seven days or until falls off. During observation on 11/14/23 at 1:53 p.m., registered nurse (RN)-C entered R109's room. RN-C donned gloves and removed old transparent dressing from skin tear to R109's right thigh. RN-C did not change gloves. RN-C then took saline and placed onto 4x4 gauze and cleaned the skin tear to R109's right thigh. RN-C did not change gloves and then placed steristrips onto R109's skin tear. RN-C assisted R109 to pull up pants and then removed gloves and sanitized hands. During interview on 11/14/23 at 2:03 p.m., RN-C verified had not changed gloves after removing R109's old dressing, cleaning the skin tear with saline and gauze and then applying steristrips to R109's right thigh skin tear. RN-C stated she normally would have changed gloves but had not done so during R109's observed dressing change to right thigh skin tear. During interview on 11/16/23 at 12:06 p.m., with director of nursing and quality assurance nurse, RN-D stated it was the expectation hands should be sanitized before cares, gloves donned and when soiled dressings were removed, glove were to be changed and hand sanitized. The facility Hand Hygiene policy updated 10/4/21, indicated hand hygiene must be performed in patient care settings: after contact with blood or body fluids and after glove removal; when moving from contaminated body sit or activity to another body site during patient care (e.g., after changing a wound dressing and then brushing the patient's teeth).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure 1 of 3 residents (R16) who were dependent of staff for nail care, received assistance for long and jagged nails. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and required extensive assist with most activities of daily living (ADLs) due to a recent fall that required surgical repair of right hip. MDS indicated R16 had moderate difficulty with vision and hearing and R16 did not wear glasses. R16's care plan indicated R16 had moderate impairment of vision and hearing. During observation on 4/4/4/22, at 5:43 p.m. R16 was lying in bed and noted to have fingernails which were brittle, long, and had jagged, chipped edges. R16 stated she scratched something open on her leg today and a nurse had told her to stop scratching it. During observation on 4/5/22, at 10:08 a.m. R16's nails continued to be long and jagged. R16 stated staff had not assisted her with nail car, I need help to have this done, as I cannot see clearly. When interviewed on 4/5/22, at 3:27 p.m. nursing assistant (NA)-B stated R16 needed one person assistance with ADL's which included nail care and bathing. NA-B stated NAs do not complete nail care as nurses were required to perform that ADL. NA-B stated he would only clean under the nail bed during baths. NA-B stated R16 had very poor vision. During an observation on 4/6/22, at 11:19 a.m. R16's fingernails observed to be long and jagged. Registered nurse (RN)-B removed R16's ACE wraps on lower extremities. R16's toenails were observed to be long, jagged, and thick with yellow discoloring. R16 was observed to have a new right calf abrasion with a skin flap hanging off of the area. When interviewed on 4/6/22, at 11:51 a.m. RN-B stated NAs should be doing nail care on bath days for non-diabetic residents. RN-B stated nail care consisted of cutting, filing, and kept clean. RN-B confirmed R16's fingernails were long and appeared to not have been cut since admission. R16 stated, I had previously asked for a fingernail clipper as they are too long, so now I just rip them off with my teeth. RN-B asked R16 to perform nail care after lunch and R16 got teary eyed. When interviewed on 4/6/22, at 12:11 p.m. RN-H stated nail care should be performed for non-diabetic residents on bath days by a NAs. RN-H confirmed R16's bath days were twice a week on Monday mornings and Thursday evenings. RN-H confirmed NAs should complete a pink bath sheet twice a week on bath days and the form is handed to a nurse to document skin changes and resident refusals. RN-H confirmed R16 had no refusals documented since admission. RN-B and RN-H found one pink bath sheet since admission. When interviewed on 4/6/22, at 2:29 p.m. RN-E stated nail care should be performed for non-diabetic residents on bath days by a NA. RN-E stated NA should fill out pink bath sheet with each bath and the nurse would document in electronic record as an assessment or progress note. When interviewed on 4/7/22, at 10:02 a.m. RN-D stated nail care should be completed for non-diabetic residents by facility NA's. RN-D stated she was unaware of when this should be completed. When interviewed on 4/07/22, at 11:14 a.m. R16 stated her nails were cut and filed down yesterday by RN-B. R16 stated, They are perfect now and my toenails are getting checked by a provider soon. R16 stated her daughter cut them at home prior to admission. When interviewed on 4/7/22, at 12:06 p.m. director of nursing (DON) stated NAs should be completing nail care on non-diabetic residents. DON stated expectation for nurses and NAs to be monitoring this on bath days at least weekly if not more often. DON stated NAs should complete pink bath sheet and identify any conditions and give this sheet to nurse to follow-up on any identified concerns. DON stated expectation is for the nurse to document and chart in electronic health record any identified concerns. DON expressed concern for staff not completing a thorough head to toe assessment, lack of hygiene, potential contamination, and possible skin integrity including skin tears. The facility policy titled, Nail Care Procedure - Rochester revised on 9/28/21, indicated to ensure the needs of residents who are unable to complete nail care or trim their nails, staff are to provide assistance with fingernail or toenail care and trimming as indicated, and are to follow safe nail care practices including infection control procedures. -Licensed nurses are to be notified by CNAs of the need for assistance for nail trimming and care for residents who are diabetic, immune suppressed, and/or on anticoagulants, so the licensed nurse may complete trimming of resident fingernails and toenails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide meaningful and ongoing activities for 1 of 1 residents (R16) reviewed for activities. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and required an extensive assist with most activities of daily living (ADLs). The MDS indicated R16 had moderate difficulty with vision and hearing and R16 did not wear glasses. The MDS interview for activity programs dated 3/23/22, identified it was, important but can't do or no choice, for the following activities: have books, newspapers, and magazines to read, doing favorite activities, and participate in religious services or practices. The interview also identified it was very important to R16 to listen to her favorite music, be around animals and pets, and go outside to get fresh air when weather is good. R16's Activities assessment dated [DATE], indicated, resident had a lot of expressed activity interests however due to vision, hearing and hand deficit it makes it very hard for her to engage in them at this time. R16 was provided a voice amplification device during assessment and was noted to make a huge difference in communication with resident. The assessment indicated R16 grew up growing her own food on the farm. R16 stated she enjoyed listening to the news and watching television but no longer could due to vision and hearing deficits. Due to vision problems R16 needed large print reading material. Goal for R16 included activity and socialization daily over the next 15 days. R16's greatest strength was her ability to socialize and tell different stories from her childhood. R16's care plan dated 3/16/22, indicated R16 was at risk for alteration in socialization related to recent hospitalization and Group activities may be limited or restricted during [COVID-19] outbreak status or when unit is on quarantine. R16 would eat meals in room the first 14 days following admission if not fully vaccinated. R16 has moderate impairment of vision and hearing. Staff were directed to allow time for R16 to process information, encourage repetition to ensure R16 can hear you including an intervention to encourage use of amplification device for quality of life. R16's activity care plan indicated she would have activity and or socialization daily. The activity care plan directed staff of the following: -During room visits, provide choices for in-room recreational activities from the activity care such as (large print reading materials such as books on history, Z Gray novels, or magazines with recipes or patterns), musical supplies (likes WCCO on radio and used to love to dance) and sewing supplies as desired. -Encourage participation in activities that provide enjoyment (listening to music, reading, and sewing) as R16 is able to tolerate due to vision, hearing, and hand deficits. -Due to hearing impairment, before beginning a conversation with R16 help her put on her pocket talker but respect resident right if she chooses to refuse it. -Provide a copy of activity schedule and allow R16 to choose activities. -Assist R16 to attend/participate as needed such as musical programs, reading groups, and special events while keeping in mind residents right to refuse. -R16 to eat all meals in the dining room as tolerated. Review of electronic medical record, R16 was on isolation precautions until 3/31/22, due to vaccination status. R16's activities note dated 4/1/22, indicated, [R16] observed to be sleeping more and refusing some meals. The note indicated checks were done daily, and staff engaged her in conversation as well as brought her daily schedules and reading packets from the group activities. During an observation and interview on 4/4/22, at 5:54 p.m. there was an isolation cart outside of R16's room. Licensed practical nurse (LPN)-A stated R16 had been on quarantine related to COVID-19 precautions, however, R16 was no longer on precautions. R16 stated she had not participated in any activities since admission. R16 stated she had all kinds of hobbies in the past such as sewing, crocheting, knitting, farming, gardening, [NAME] fresh fruits and vegetables, and reading the local newspaper. R16 stated she had carpel tunnel in both of her wrists and had very poor vision which made it difficult to enjoy her past hobbies. R16 was animated and smiling when she spoke about farm life and crocheting activities. R16 indicated prior to admission she still lived on her farm. During an observation on 4/4/22, at 6:10 p.m. R16 was observed eating alone in the dining room with no other residents seated at table. Other residents were observed seated together in small groups amongst the other tables in dining room. When interviewed on 4/5/22, at 10:08 a.m. R16 was seated in recliner in room next to window. R16 stated yesterday was the first time she ate in the dining room. R16 stated she was allowed to go to breakfast the day of 4/4/22, but then a nurse stated she had to return to her room to eat alone as she was still on isolation precautions. R16 stated she was supposed to be off isolation precautions last week. R16 stated she was allowed to come out for lunch and dinner on 4/4/22, but facility staff sat her at a dining table alone. An activities schedule and Daily Chronicle newsletter was observed lying on R16's bed not within reach. When asked if R16 could read the print, R16 replied, no and got teary eyed. R16 stated the facility staff did not read the activity schedule or newspaper to her. Multiple newspapers and a big print search-a-word puzzle book was located in R16's window sill. R16 stated daughter-in-law buys the newspaper every Christmas, but she is unable to read the fine print anymore. Activities schedule for 4/5/22 included: -10:30 a.m. Bible Study - Church -11:00 a.m. 27 Dandelion Facts that will blow you away (In Honor of Dandelion Day) -1:00 p.m. Severe weather awareness presentation in [NAME] Hall -2:30 p.m. Social Hour and Snack -3:00 p.m. Mind Binders Puzzle. During an observation on 4/5/22, at 10:23 a.m. R16 sat in a recliner next to the window in her room. RN-B applied pain relieving gel to R16's joints. Staff did not attempt or offer to take R16 to bible study that started at 10:30 a.m. R16 was observed not to be in attendance in bible study. During an observation on 4/5/22, at 12:48 p.m. R16 was eating lunch in dining room at a table alone with no other residents located at table. A laminated activity cue card was located in the middle of each table. Activity included, Would you rather dance or sing? Why? What would you name your boat if you had one? What's the most ridiculous fact you know? Fun fact: There is only one fish that blinks with two eyes. A [NAME]. Staff were not observed to read or converse with her about the card. After lunch R16 returned to her room and it was not observed staff approached her to offer the 1:00 p.m. activity nor was it observed R16 was in attendance. During an observation on 4/5/22, at 1:47 p.m. R16 was asleep in the recliner in her room. During an observation on 4/5/22, at 2:05 p.m. R16 was asleep in a darkened room in bed. An activities sheet titled, 27 Dandelion Facts that will blow you away was observed lying on bedside table next to activities schedule and Daily Chronicle. Multiple paged pamphlet observed in regular sized print given to all residents on unit. Pamphlet had not been opened as a staple was located in left hand corner and pages were not bent over. The pages were unwrinkled and remained untouched. During an observation on 4/5/22, at 3:17 p.m. a social worker sitting on edge of bedside discussing discharge plans for R16. When interviewed on 4/5/22, at 3:27 p.m. a nursing assistant (NA)-B stated R16 only walks with staff outside of room. NA-B was unsure if R16 participated with activities. NA-B stated R16 was on quarantine for two weeks but came off of quarantine on 3/31/22. During an observation on 4/5/22, at 3:42 p.m. R16 was sitting on edge of bed with bedside table not within reach. R16 stated she was not aware of the Dandelion activity, nor did staff offer to take her to the activity. During an observation on 4/6/22, at 7:12 a.m. R16 was lying in bed awake on right side. During an observation on 4/6/22, at 9:20 a.m. R16 was observed sitting at far dining room table by television with no other residents at table. Four other tables of at least two to three residents sitting together socializing after breakfast were observed. During an observation and interview on 4/6/22, at 11:19 a.m. surveyor asked R16 if facility is utilizing the pocket talker microphone to communicate. R16 shrugged shoulders, got teary eyed, and stated not really. Activity schedule for 4/6/22, located on bedside table and appeared untouched. R16 stated facility did not offer bingo activity at 11:00 a.m. During an observation on 4/6/22, at 11:49 a.m. RN-B walked R16 to dining room and sat R16 at a table alone. RN-B stated that activities (ACT)-A does activities schedule for unit. RN-B stated most of the resident's do not come out to group activities and one-to-one activities are provided individually. During an observation on 4/6/22, at 2:23 p.m. R16 was sleeping in bed on her back in darkened room. ACT-A completing a one-to one in commons area in front of health unit coordinator (HUC) desk with another resident. When interviewed on 4/7/22, at 8:36 a.m. ACT-A stated he was doing a lot of social visits with R16. ACT-A stated he had a difficult time interacting with R16 as she seems more isolated after coming out of quarantine and more withdrawn. ACT-A stated R16 was quarantined for an extended period due to no current COVID-19 vaccination and now seems to be set in her ways. ACT-A offered large print reading material, music, and sewing supplies upon admission, but R16 refused as one of her hands no longer works to knit. ACT-A stated he brings in activity schedule and group packet information daily to R16. ACT-A confirmed he did not read it out loud or provide information in larger font. ACT-A stated one-to-one social visits are one to two times weekly and he completes weekly notes for all residents on every Friday. ACT-A stated R16 does not engage with him other than enjoying having someone to speak to about her daily life. ACT-A confirmed R16 came out to dining room on 4/4/22, for first time since admission. ACT-A stated he was uncertain why R16 was kept in her room beyond the discontinuation of quarantine precautions. ACT-A stated a nurse brought R16 out to breakfast on 4/4/22, but then shortly thereafter R16 was brought back to eat in her room alone. ACT-A stated will not wake R16 when sleeping but does not go back to room to reevaluate at a later time. ACT-A confirmed he did not know R16 lived on a farm previously but then retracted statement stating a majority of his activities do not include farm, gardening, or knitting related activities. ACT-A stated he felt it was hard to replicate farm life to R16. When interviewed on 4/7/22, at 9:49 a.m. ACT-A stated he uses activity connection and cater activities to look at special days of the week such as dandelion day. ACT-A stated he provided lots of activity packets so residents can complete and read at their leisure. ACT-A completes two group activities per day, but R16 was not included since 3/31/22. ACT-A stated R16 was very sleepy lately and seemed to be withdrawn since COVID-19 quarantine precautions. ACT-A confirmed he charts refusals of all group activities. When interviewed on 4/7/22, at 10:02 a.m. RN-D confirmed R16 was seen listening to music or reading a newspaper in the activities area approximately one week ago with ACT-A on only two occasions. RN-D stated R16 enjoyed sewing, being a home-maker, farming, and speaking about her life and great grandchildren who also learned to sew. RN-D stated she will read R16 the memo and agenda for day, but only works three days per week. RN-D stated she did not think other staff completed this with R16. During an observation and interview on 4/7/22, at 11:14 a.m. daily activity schedule was observed sitting in cupboard space located between bathroom and resident bed. R16 stated facility staff did not notify her of schedule or read it aloud to her that day. At 11:29 a.m. occupational therapist arrived to R16's room and going to walk R16 down to therapy room. When interviewed on 4/7/22, at 11:37 a.m. RN-A stated expectation for activities to be completed daily by staff and if a resident was on isolation the activity would be completed with resident in room. RN-A expected ACT-A to encourage R16 to come out of room as much as possible. RN-A stated ACT-A charting should be completed daily and marking refusals appropriately. RN-A stated it was not observed if R16 had come out of room this week for activities. R16 was only observed out of room for meals and not aware R16 was placed at table alone. RN-A confirmed she was not certain if staff was reading activities schedule and education pamphlets to R16 due to vision deficits. RN-A was unaware of staff bringing R16 out to dining room for breakfast on 4/4/22, and then bringing her back to room to eat alone. RN-A stated she only observed staff speaking to resident and never observed R16 participating in activities. When interviewed on 4/7/22, at 12:06 p.m. director of nursing (DON) stated expectation is for staff to provide meaningful and individualized activities for each resident based on initial activities assessment upon admission. DON stated she would expect staff to read information out loud to a resident with visual deficits. DON stated she would expect staff to ensure each resident could read material and not just assume a resident could read. She would expect staff to engage with resident to come out of room for activities and to encourage socialization. DON stated if a resident is on isolation/quarantine she would expect staff to bring activities into a residents room. DON expressed concern stating a resident could become depressed due to lack of activities and social isolation. DON stated she would encourage staff to adapt to resident wishes and hobbies they enjoy such as providing an I-pad device to do a zoom visit with family members. When interviewed on 4/7/22, at 12:48 p.m. RN-A stated R16 refuses voice amplification device sometimes. RN-A stated that ACT-A completes daily notes, offered a sewing kit upon admission, but did not use activities that R16 was interested in. RN-A confirmed ACT-A did not know R16 enjoyed farming. During an observation on 4/7/22, at 2:01 p.m. activities pamphlet titled 100 Facts about [NAME] Holiday's Life and Legacy was found lying on R16 bed between two pillows unopened. R16 was asleep in recliner next to window. Pamphlet was not provided in large font and same material used on all residents residing in the facility without visual deficits. When interviewed on 4/7/22, at 2:11 p.m. R16 stated today was first time ACT-A spent any significant time speaking to her and discussed her previous farm life and hobbies. R16 appeared happy and content with a smile on her face for the first time all week. R16 stated she didn't understand why facility could not have completed activities or socialization with her prior to today. A facility policy and procedure regarding activities including individualized care was requested but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R16's admission MDS dated [DATE], indicated R16 was cognitively intact and required an extensive one assist. R16's medical diagnosis included: heart failure (a condition which occurs when the heart muscle does not pump blood as well as it should resulting in swelling in the legs, ankles, or feet) and disorders of veins in bilateral legs. R16's physician orders dated 3/22/22, indicated daily weights were to be completed in the mornings as R16 was on a diuretic. Notify certified nurse practitioner (CNP) if three pound weight gain overnight or five pound weight gain in one week. Also notify CNP of 5 pound weight loss in one week. On 4/5/22, apply compression wraps in the morning and take off at bedtime was ordered. R16's physician notes dated 3/22/22, indicated, R16 had trace edema in bilateral lower extremities and compression wraps to bilateral knees. Daily weights were requested but these had not been completed by facility. Daily weights reordered with notification of CNP. R16's care plan dated 3/16/22, indicated to obtain weight per orders by nurse or nursing assistant, float heels on pillow in bed, and encourage elevation of legs as able to reduce swelling. Weekly head to toe skin monitoring. R16 is at risk for fluid imbalance related to cardiac issues. R16's treatment administration record (TAR), compression wraps were initiated on 4/5/22. Weight monitoring daily starting 3/23/22. Skin assessment and weight completed two times weekly starting 4/6/22. Requested March 2022 TAR on 4/7/22, but facility did not provide. During an observation and interview on 4/4/22, at 5:43 p.m. R16 was observed lying in bed with no compression or ACE wraps applied to legs. R16's legs were observed to have edema present in both bilateral lower extremities and feet. R16's left leg was more swollen than right leg and was wearing white cotton socks. R16's legs were not elevated on a pillows in bed. R16 stated she is supposed to wear compression stockings on legs at all times due to past medical history of vascular problems and previous venous stasis ulcers. R16 was observed to have purplish discoloration of skin to bilateral lower extremities. R16 stated a nurse previously applied ACE wraps to her leg one day, but then looked at her white paper sheet located in her pocket and immediately removed the wraps stating R16 did not have an order for them. R16 questioned staff why she was unable to wear her compression wraps on numerous occasions but could not remember specifics dates and times since admission. During an observation on 4/4/22, at 6:10 p.m. registered nurse (RN)-B was observed walking R16 to dining room table. R16 was wearing white cotton socks and black crocks on feet with notable edema present in both lower extremities and feet. During an observation on 4/4/22, at 9:52 a.m. R16 was observed sitting in recliner next to window in room with lower extremities on floor. RN-B present in room with resident taking her vital signs. During an observation and interview on 4/5/22, at 10:08 a.m. R16 was observed sitting in recliner in room next to window with bilateral extremities on floor. R16 stated her legs were wrapped by RN-B earlier this morning . R16 observed wearing bilateral ACE wrap compressions from feet to knees. At 10:23 a.m. RN-B came into R16's room to apply pain relieving gel. R16 stated legs felt better now that they were wrapped this morning. During an observation on 4/5/22, at 12:47 p.m. R16 was observed asleep in recliner with ACE wraps to bilateral lower extremities, but legs were not elevated. During an observation on 4/5/22, at 2:05 p.m. R16 was asleep in bed with ACE wraps on bilateral legs with pillows located under both legs. During an observation on 4/5/22, at 3:42 p.m. R16 was sitting on edge of bed with ACE wrapped legs dangling to the floor. During an observation on 4/6/22, at 7:12 a.m. R16 was asleep in bed with legs elevated on pillows, but no ACE wraps on. During an observation on 4/6/22, at 9:20 a.m. R16 was observed sitting at dining room table with ACE wraps on. During an observation on 4/6/22, at 10:30 a.m. R16 was observed sleeping in recliner in room with ACE wraps on, but legs not elevated. During an observation and interview on 4/6/22, at 11:19 a.m. R16 notably upset after physical therapy and nursing staff as facility placed white cotton skin protection wraps underneath ACE wraps today. R16 was observed with ACE wraps on bilateral lower extremities, but legs were not elevated. RN-B came to R16's room after physical therapist voiced to her that R16 was very upset in room. R16 requested wraps be removed immediately as it was causing her extreme pain. RN-B took wraps off and educated R16 that the cotton wraps located underneath ACE wraps were for skin protection. R16 stated staff did not inform her why those were added this morning. R16 observed with considerable edema in bilateral feet as wraps were placed from ankle to knee and fluid built up in feet as a result. When interviewed on 4/6/22, at 11:36 a.m. RN-B stated R16's ACE wraps were not ordered until 4/5/22. RN-B confirmed R16 wore compression wraps at home prior to admission. RN-B stated R16 preferred leg wraps to be applied after she gets back from the bathroom in the morning. RN-B confirmed she placed wraps on R16 today while resident was in bed prior to going to the bathroom. RN-B stated R16 had not had swelling in her legs until she noticed it in R16's feet today due to the wraps not being placed correctly. RN-B stated R16 wore compression wraps for comfort verses edema. RN-B stated R16 did not have edema in legs yesterday. RN-B stated R16's physician confirmed she did not have edema in legs since admission to facility. RN-B confirmed R16 asked for compression wraps. RN-B stated R16 normally does not sit in her recliner and only lies in bed or walks with physical therapy. RN-B stated R16 should have pillows underneath legs at all times while in bed with heels floating off the edge. When interviewed on 4/6/22, at 12:11 p.m. RN-H stated he would not know if R16 wanted compression leg wraps nor if she would have edema. RN-H confirmed nursing staff should be completing a head-to-toe assessment daily. RN-H stated assessment should be documented daily in skilled nursing Medicare progress notes. When interviewed on 4/6/22, at 2:29 p.m. RN-E confirmed nurses should be completing an edema assessments and if a resident had edema staff would elevate extremities right away and send a note to physician for further intervention and treatment plan. RN-E stated R16 should have legs elevated on pillow in bed or elevated while sitting in recliner to reduce fluid in legs. When interviewed on 4/7/22, at 10:02 a.m. RN-D stated she heard that R16 requested compression wraps this week. RN-D stated she completed R16's admission assessment and noted edema in bilateral legs. RN-D confirmed R16 was wearing compression hosiery and elevated her legs on pillows while in bed and while sitting in recliner in room. RN-D indicated wraps should have been on R16 since admission to present. RN-D stated nursing assistants (NA's) applied these daily in the mornings and were removed at bedtime. RN-D stated R16's legs were +1 edema (when compressed with digit, would leave an impression of 2 millimeters) upon admission and not as swollen as they were this week. When interviewed on 4/7/22, at 11:14 a.m. R16 stated her legs were wrapped this week on 4/5/22 mid-morning suddenly. R16 stated, I don't know why facility did not listen to me requesting leg wraps prior to this. R16's room was observed to have no compression hosiery socks located in room other than current ACE wraps which were applied to her legs. When interviewed on 4/7/22, at 11:37 a.m. RN-A stated expectation for nurses to assess for edema daily and ensure physician is notified for treatment and intervention orders. RN-A confirmed if a resident requested leg wraps, facility staff should notify physician immediately. RN-A stated nursing interventions of elevating legs on recliner foot rest, encouraging ambulation to shift fluid build-up, and use of pillows to elevate extremities should have been completed for R16. RN-A stated facility had standing orders for compression wraps and was unsure if facility completed an edema assessment upon admission. RN-A was uncertain if edema was monitored daily. When interviewed on 4/7/22, at 12:06 p.m. director of nursing (DON) stated expectation for edema assessment to be completed upon admission with a skilled nursing note to be completed daily on each resident; especially for residents with known heart failure or known edema. DON expected nursing staff to complete interventions such as weight monitoring, assessing skin integrity and pressure spots, listening to lung sounds, elevating legs so swelling did not become dependent, care planning, monitoring, measurements of swelling, and ensuring physician was aware of condition. DON stated concern for static edema to worsen medical diagnosis of residents. The facility provided a lower extremity edema algorithm to follow for patients with lower leg = to or > than +2 peripheral edema not dated which indicated, elevate and provide medical management x 24 hrs. If patient meets at least 1 exclusion criteria of (pitting edema +1 or less), that lower leg wraps NOT recommended and to discuss with provider and consider vascular studies. If patient is ambulatory, apply short stretch & padding for 24 hrs. If edema decreases within 24 hrs, continue to elevate and apply previous compression wraps only if patient continues to have >+1 edema. Discontinue if edema resolves. If edema does not decrease in 24 hrs, discuss with primary provider for ongoing independent edema management. A facility policy related to lower extremity edema was requested on 4/7/22, but facility did not provide. A care plan on R16 related to edema was not provided. Based on observations, interview and document review, facility failed to follow orders, assessment and treatment protocol for 1 of 1 residents (R119) reviewed for non-pressure related skin problems. In addition, the facility failed to identify/evaluate and monitor edema and failed to ensure physician orders were followed for edema management for 1 of 1 residents (R16) reviewed for fluid overload. Findings include: R119's progress note in the medical record dated 3/22/22, indicated R119 was admitted to the facility for rehabilitation and cardiac monitoring. The note indicated R119 was alert and oriented to person, place and time. The note further indicated R119, had several skin issues related to graft bypass surgery-see skin assessment. R119's progress note dated 3/22/22, indicated R119 was admitted with skin issues to his lower abdomen, bilateral groin and inner thighs were extremely dry. R119's progress note dated 3/26/22, indicated, Several skin issues related to graft bypass surgery-see skin assessment. Slight excoriation noted coccyx. Barrier cream applied. Mepilex (an adherent, occlusive foam dressing) to be applied. A review of R119's electronic Treatment Administration Record (TAR) did not identify a treatment order had been obtained or transcribed for the excoriated coccyx area. R119's record did not include a comprehensive wound assessment after the area of excoriation had been identified. R119's progress note dated 3/30/22, written by registered nurse (RN)-C indicated R119's coccyx open area 4.5 cm's [centimeters] length, width 1 cm, also another area next to that is 0.5 cm's. Appearance is friction and moisture, TX [treatment] xeroform [a medicated dressing] to wound bed and covered with Mepilex border dressing was applied and to be changed every other day. This note indicated the medical provider was notified, but did not indicate an order had been received; however, the TAR indicated that RN-C had written in the recommendations as a physician order on 3/30/22, and the (treatments) were discontinued on 4/5/22. R119's corresponding Wound Assessment Detail report dated 3/30/22, identified the area as moisture associated skin damage. Progress note dated 4/3/22, indicated, coccyx has 2 open areas 4.5 cm's by 1 cm and an area of 0.4 cm's TX Xeroform covered with Mepilex border dressing. R119's record did not include an assessment of the newly identified open area that measured 0.4 cm. During an observation on 4/5/22, at 10:31 a.m. R119 had two bright red areas about the size of a nickel, one under each of the ischium of buttocks (the bony prominence at the bottom of the pelvis) with peeling skin surrounding each of them. Small scattered sacral open areas were also noted. Licensed practical nurse (LPN)-A said they had just noted these areas but was not sure there was a treatment order, however, a Mepilex dressing had been covering the sacrum, so that is what LPN-A planned to do for a treatment. LPN-A asked a nursing assistant (NA)-A if they used anything else, and NA-A pointed to a container labeled Z-guard (an over the counter barrier cream containing petroleum and zinc that protects against moisture). LPN-A put a large amount of Z-guard in palm and spread over entire buttocks and sacrum and then placed the Mepilex over the wet ointment. R119's progress note dated 4/5/22, 12:23 p.m. included, coccyx has multiple small open areas. NP [nurse practitioner] was there to assess all skin concerns. R119's record did not identify or address the skin breakdown on the ischium. R119's provider note dated 4/5/22, a nurse practitioner (NP)-A wrote that two SBAR's [a notification of change in condition] had been received from the facility however, indicated the SBAR's were unrelated to R119's impaired skin integrity to his coccyx, sacrum, or ischium. NP-A did note a non-pressure related pin point open area of the left gluteal cleft was found during assessment, however, the assessment did not identify or address the observed red and peeling areas of the ischium. NP-A wrote an order to apply a prophylactic Mepilex to sacrum and coccyx, ensure it is in direct contact with skin to prevent moisture related breakdown, lift twice daily to check skin and change every three days and as needed. The provider note did not include a treatment plan to areas on the ischium. When interviewed on 4/5/22, at 3:57 p.m. LPN-A stated a nurse finding a new area of skin concern should first check the resident's chart to see if that problem had previously been noted and documented. If not, LPN-A stated the nurse should notify the medical provider to get an order, and then follow that order. LPN-A also stated the wound should be assessed and findings documented. This assessment should include a description of the wound, any pain or any sign of infection. LPN-A stated, I wasn't 100% sure if wound care had been done [before she applied application of Z-guard and dressing], the provider came today and looked at it. She just gave us an order now. I was just helping out. I don't necessarily do a treatment without looking at an order, but I just knew we were covering it in the meantime. LPN-A stated a nurse could use facility standing orders if there was not an order in the TAR, but then should enter that order into the TAR. LPN-A was unable to find a list of standing orders in R119's chart. LPN-A was not sure if Z-guard was a standing order or if it could be used on open areas. LPN-A reviewed standing orders in another resident's chart and noted lubricating barrier cream could be used on reddened skin, but LPN-A did not know if Z-guard was considered lubricating, and confirmed R119's skin was open on some areas of buttocks and sacrum. During an interview 4/5/22, at 4:18 p.m. RN-A stated a superficially open area may be described as excoriation, but would still require an order for care. RN-A said a nurse should check the TAR prior to performing any treatment. If no treatment order was found, the nurse should assess the wound and enter the information into a computer app they called the Risk Watch system. RN-A stated a nurse must have an order to provide a treatment; could use standing orders, but should notify the provider. RN-A said Z-guard is a barrier cream but is generally used for incontinence as it helps to dry the skin. RN-A stated it did not match facility standing orders that say to use a lubricating barrier for red areas. R119's physician orders of 4/5/22, entered into the computer at 3:14 p.m. indicated care of the coccyx was: 1. Clean and dry areas 2. Apply prophylactic Mepilex boarder sacrum dressing. Lift twice daily to asses skin and ensure dressing is changed every 3 days and as needed. During an interview on 4/6/22, at 8:55 a.m. RN-A stated when a new area of concern, such as a wound, was noted the nurse should assess the wound and enter information into a computer app they called the Risk Watch system so staff and providers would be aware of the problem. RN-A stated she was unable to find that R119's skin problems were listed in the app. RN-A stated the facility does have standing orders, but they must be reviewed and signed each time a person is admitted . If they are not in the chart, they should not be used, and an order from the medical provider must be sought out. RN-A stated the physician and family should be notified of any new wounds, and this should be documented in the chart. If standing orders are utilized they must be transcribed from the hard copy into the electronic record so they flow to the TAR. During an observation on 4/6/22, at 9:49 a.m. RN-B stated R119 did have superficial, upper layers of skin peeling off the ischium on the right side extending up in an oblong path for about 3 inches, and also, a less noticeable area on the left ischium. RN-B also stated there were several tiny open areas to the left and right sides of the coccyx, inside the crack of the buttocks, and wondered if this was due to friction from using a lift sheet during transfers. R119's progress note dated 4/6/22, included, coccyx has multiple small open areas. There are areas that are healing from what might be friction. These areas are blanchable, slightly pink in color and not open. When interviewed on 4/6/22, at 9:59 a.m. RN-H reviewed R119's chart and stated R119 did not have a signed current standing order sheet. RN-H reviewed standing orders in another residents' charts and stated xeroform dressings were not listed on the standing orders and to use the product an order from a physician would need to be obtained. RN-H also stated Z-guard does not meet the criteria of a lubricating barrier cream and should not be applied to open areas without an order. When interviewed on 4/6/22, at 10:25 a.m. the director of nursing (DON) stated any new area of concern on the skin should be followed by a, good clinical assessment and obviously notification to the provider, and then documentation is the Unity Wound Assessment [facility electronic assessment form]. DON stated if a wound was superficial, I don't know if would notify family but should be documentation and monitor so does not get infected. If very superficial we might notify physician but assess for worsening and then notify MD as needed. DON stated she was in charge of over site of all nursing in the facility and the associated assisted living facility, so did not stay closely in-tune to all orders, but said nursing staff should use standing orders, and any policy or wound care protocol. DON did not know if Xeroform was on standing orders or if Z-guard was a lubricating ointment that would match standing orders. DON stated a nurse cannot write orders, but can transcribe what is given by a provider. A facility policy titled, Skin and Wound Management undated indicated, aid staff will perform routine skin inspections daily with cares, nurses are to be notified to inspect the skin if any skin conditions and/or pressure ulcers are identified. Document on any pressure, stasis skin ulcer, skin tear or open wound with treatment will include: location and size, type, stage of wound, drainage, signs symptoms of infection, treatment, date and time of dressing change. Additionally, policy indicated skin care alert form is to be used if there is noted disruption in skin integrity and the physician/NP and family will be notified upon discovery of a skin concern. The policy did not include reference to the facility standing orders. Charter House Standing orders 10/19/21 signed by medical director, indicated: Facility lubricating/barrier cream or ointment three times daily PRN (as needed) for dry skin and/or for prevention of skin breakdown secondary to incontinence (E.g. Lubriderm®). For Stage I OR Reddened area: If affected by friction & shear: For prevention, may apply a film dressing and change every 5 days prn soiling. For Stage II Pressure OR Partial Skin Loss Area: Intact serum filled blister: apply hydrogel impregnated dressing, attempting to avoid rupturing blister and change every five days prn soiling, secure with secondary dressing. Shallow crater: apply hydrogel impregnated dressing/hydrocolloid (if minimal drainage) or foam dressing (if moderate drainage) and change every 5 days prn soiling, secure with secondary dressing.)

Based on observations, interviews, and record reviews, the facility failed to ensure physician orders were transcribed correctly for 1 of 1 residents (R3) reviewed for medication administration. Findings include: R3's face sheet indicated resident had medical diagnoses which included: type 2 diabetes mellitus with chronic kidney disease and long term (current) use of insulin. R3's physician orders dated 3/22/22, indicated R3 was to receive insulin Aspart 100 unit/ml (3 mL) subcutaneous pen and to inject 4 units under the skin 3 (three) times a day with meals. Hold if skipping a meal. Monitor blood glucose four times a day, before meals and at bedtime. R3's electronic medication administration record (EMAR) dated April 2022, R3 received Fiasp FlexTouch 100 unit/ml (3 mL) subcutaneous four units three times a day starting 3/22/22 Inject four units under skin three times a day with meals. Hold if skipping a meal. Also known as Aspart. Fiasp insulin documented as received by R3 from 4/1/22-4/6/22. (Fiasp is a modified form of Insulin Aspart. The addition of vitamin B3 to the structure of Insulin Aspart results in its rapid onset of action and rapid absorption via the skin when administered into the skin). Fiasp insulin order re-transcribed by registered nurse (RN)-F on 4/6/22 at 10:07 a.m. to corrected order received by physician on 3/22/22. Incorrect insulin charted by numerous facility staff from 3/22/22 until 4/6/22 when surveyor was monitoring medication administration at 9:21 a.m. with RN-F. During an observation and interview of medication administration on 4/6/22, at 9:21 a.m. RN-F observed to check insulin pen orders against EMAR and noted R3's insulin pen from pharmacy did not match R3's orders in record. RN-F looked up Fiasp insulin on Google website and noted it was not the same medication as insulin Aspart. Fiasp is insulin Aspart plus vitamin b3 which has the potential to work more rapidly against elevated high blood sugars. RN-F brought insulin Aspart pen over to hard paper chart and checked pen against last physician orders dated 3/22/22 and noticed the wrong medication was transcribed into EMAR on 3/22/22. When interviewed on 4/6/22, at 9:45 a.m. RN-H confirmed insulin order in EMAR, stated R3 should receive Fiasp. RN-H printed off original physician order from 3/22/22 and confirmed R3 should receive insulin Aspart. RN-H stated RN-B transcribed the order incorrectly into EMAR. RN-H confirmed order was entered on 3/22/22 for R3 to receive 4 units of insulin Aspart with meals and at bedtime. RN-H confirmed correct insulin had been administered by facility staff and EMAR was incorrectly transcribed from the physician order in the electronic chart. When interviewed on 4/6/22, at 10:25 a.m. RN-F expressed concern of R3 could have received the wrong type of insulin. RN-F confirmed staff should be performing five rights of medication administration with every medication pass. RN-F stated staff should be checking residents name, date of birth , right dose, right time, right route, and right medication against physician orders. RN-F stated the health unit coordinator (HUC) transcribed all medication orders into EMAR when they are working or the nurses will enter them if the HUC is off duty. A second person will double check orders for accuracy. RN-F stated facility had been trying to enforce second and third medication transcription checks for some time now. RN-F stated the facility had sent out emails regarding this enforcement recently for staff to complete second and third (24 hour) checks. RN-F stated she thought the nurses were responsible for entering orders, checking the fax machine regularly for new orders, and notifying the nurse assigned to the resident if a new order came through for the day. When interviewed on 4/6/22, at 12:30 a.m. RN-B stated new medication orders are entered by the HUC if they are on-duty, enter it into a draft mode and flag the medication, flag gives alert to nurse so they can complete the second check, and night shift nurse would complete the 24 hour check against the hard copy orders to EMAR transcription order. RN-B stated she specifically remembered R3's Fiasp insulin order as she had never heard of that type of insulin before. RN-B admitted to looking up insulin Fiasp and discovering on a random medication website that Fiasp was also known as insulin Aspart. RN-B stated she did not look further into medication discrepancy prior to performing the second check on R3's orders. RN-B admitted to now knowing that Fiasp insulin also contained vitamin B3 which could have had the potential for adverse reactions for R3. RN-B stated the insulin pen that facility received from Thrifty [NAME] pharmacy was a regular insulin Aspart pen so facility felt comfortable administering medication to R3. RN-B confirmed she did not consult with a pharmacist that day and she was part of entering R3's orders. RN-B confirmed licensed practical nurse (LPN)-A entered R3's initial orders from physician on 3/22/22 at 12:22 p.m. RN-B stated she edited the order transcribed at 7:07 p.m. to include a notation on the Fiasp order Also known as insulin Aspart. RN-B admitted to not understanding why R3's insulin pen was labeled as insulin Aspart and the transcribed orders stated insulin Fiasp. RN-B stated she received training from facility on how to edit/discontinue medication orders into EMAR and just started entering orders on 4/5/22 on her own without having RN-H walking her through the process step by step. RN-B stated agency pool staff receive formal facility training of two days which included: outlook email, Educare modules, MyUnity charting system, EPIC charting system, a brief overview on how to find things in the system, order entry, and practice on a simulated fake dummy resident record. RN-B stated, I should have looked it up better and questioned it better, but I felt comfortable as it said insulin Aspart as it was the same number of units per ml and that's why I only entered an additional comment into the order saying also known as insulin Aspart. When interviewed on 4/6/22, at 12:51 p.m. LPN-A stated staff transcribed physician orders into EMAR, then double to verify by placing the medication with a flag, medication sits in draft mode until a second nurse can verify the original order entered. LPN-A confirmed staff should be signing off original hard copy physician orders with both checks and then the night shift nurse will complete what is known as the third check or 24 hour check and that's completed in red ink. LPN-A confirmed he did not sign or place black checks next to original physician orders nor question himself upon entering insulin Aspart into EMAR as insulin Fiasp. LPN-A admitted to not knowing what insulin Fiasp was and he would have to get back to surveyor on that question. LPN-A confirmed insulin Aspart was originally ordered for R3 on 3/22/22 and insulin Fiasp was entered into EMAR. LPN-A indicated the two insulins are not the same and could not remember who he requested to complete his second check. LPN-A stated he was unable to look at MAR prior to the seven day lock back period. LPN-A confirmed R3 did not receive insulin ordered at lunch time on 3/22/22 and there was not a note stating why it wasn't given. LPN-A stated medication was administered late at 9:04 p.m. LPN-A stated insulin Aspart should be administered with meals and uncertain why no dinner dose was given. LPN-A confirmed R3's blood glucose was 196 at dinner time. LPN-A expressed concern that medication orders transcribed did not match for R3 and concern noted R3's blood sugars could have been off due to her not receiving correct insulin ordered. LPN-A stated his concerns for R3 included: possible allergy to Fiasp insulin, possible anaphylaxis as different insulin types work differently on each resident and control blood sugars differently. LPN-A indicated he did not complete five rights of medication administration correctly for R3 and not triple checking verification prior to administering R3's medications. LPN-A stated he received two days of orientation to facility which included: going through physician orders, care plans, MyUnity charting system, and received three shifts of being precepted by a Charter House experienced nurse. LPN-A stated if he has a question that he would ask a peer, RN-H, a nurse manager on duty or the Charter House nurse supervisor that covers the entire building on evenings and night shift. When interviewed on 4/7/22, at 10:51 a.m. Thrifty [NAME] pharmacist consultant confirmed the local Thrifty [NAME] store receives original physician orders from provider verses receiving transcription orders from facility. Pharmacist consultant confirmed there is not an interface between facility system and Thrifty [NAME] system. Pharmacist consultant stated Fiasp insulin would work faster than regular insulin Apsart as it contains vitamin D. He stated it could have potentially been a big medication error which could have resulted in R3 receiving adverse reactions and low blood sugars. When interviewed on 4/7/22, at 12:06 p.m. director of nursing (DON) stated expectation of nurses to check physician orders and have a second and third nurse check order for accuracy. DON stated nurses should be initialing and dating the original order with who checks the transcription into their EMAR. DON expressed concern regarding staff not completing the five rights of medication administration and following the correct facility process for resident safety. DON confirmed facility needed more steps in place to mitigate medication errors. DON stated facility has two different groups of pool agency nurses hired; one hired by Charter House and the other hired by Mayo Clinic. Charter House pool agency nurses get four weeks of training; while Mayo Clinic pool agency nurses only get three days of orientation which included Educare online modules, only 3 shifts on the floor prior to being alone. Training included physician order entry and introduction to facility electronic charting system. DON reinforced that good training is based off of a good preceptor and that can make or break how a nurse's training outcome will be. Pool agency staff are precepted by an experienced Charter House nurse. The facility policy titled Administering Medications Charter House Procedure - Rochester reviewed on 4/7/20, indicated medications shall be administered in a safe and timely manner, and as prescribed. -If a dosage is believe to be inappropriate or excessive for the resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss concerns. -The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document reason medication not administered at the scheduled time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document the facility failed to ensure a medication brought from home was appropriately labeled and secured for 1 of 1 residents (R122), failed to ensure 2 of 2 medication carts were appropriately secured, and failed to ensure eye drops and insulin were labeled/refrigerated/and discarded in accordance with manufacturer's guidelines for 2 of 2 residents (R3, R13). Findings include: R122's admission Minimum Data Set (MDS) dated [DATE], included cognitively intact with diagnoses including right hip bursitis and tendinitis. R122's physician orders dated 4/2/22 indicated R122 was to receive Voltaren 1% topical gel (350 g) four times a day as needed for bilateral knee pain. During observation on 4/4/22, at 2:56 p.m. an unlabeled, undated, home medication silver tube of Voltaren 1% topical gel was on R122's bedside table in room. During observation on 4/4/22, at 3:04 p.m. registered nurse (RN)-D applied Voltaren 1% topical gel that was on R122's bedside table to R122's right hip. During observation on 4/4/22, at 3:42 p.m. RN-D removed Voltaren 1% topical gel from R122's room and proceeded out to hallway. R122 stated the facility leaves her Voltaren gel at her bedside at all times, R122 stated she was not aware why it was now removed from her bedside table. Shortly after R122 put on call light to ask staff where it went as she was concerned that it was her tube of medication from home. When interviewed on 4/4/22, at 5:15 p.m. R122 stated RN-D had notified her the medication was removed from her room and placed in the East medication cart in hallway. When interviewed on 4/5/22, at 10:38 a.m. R122 stated she thought the Voltaren 1% topical gel was accidentally left on her bedside table and has noticed this happen previously. When interviewed on 4/5/22, at 3:05 p.m. R122 stated RN-D thought the Voltaren 1% topical gel had been left out accidentally prior to her shift During observation and interview on 4/5/22, at 3:53 p.m. surveyor requested to see inside medication cart for R122's medication slot and observed an unlabeled silver tube of Voltaren 1% topical gel was inside cart licensed practical nurse (LPN)-A confirmed the silver tube of Voltaren did not come from facility's pharmacy and was uncertain how it got in the medication cart. LPN-A confirmed facility should not leave medications at bedside LPN-A stated medications brought from home should be sent home with family or have facility pharmacy identify the medication and staff nurses would apply a proper label. When interviewed on 4/5/22, at 3:58 p.m. director of nursing (DON) stated expectation for medication reconciliation to be completed by nurse and physician for any home medications brought into facility. DON stated expectation for medications be in a locked box inside resident room as her concern is there would always be an opportunity for other staff or resident's to come in and take someone else's medications. DON stated the facility staff should be verifying any unlabeled medication with the pharmacy and obtain an identifying label for each medication. DON stated medication should be dated on the day it was opened, marked for expiration after 30 days, and expect if a medication was dated that it should be opened. On 4/5/22, at 4:02 p.m. Surveyor returned to East medication cart to complete the medication storage review, although no further concerns with labeling and storage were identified, LPN-A left his medication cart unlocked and walked away with RN-B while surveyor was still going through medication storage of cart. During observation and interview on 4/5/22, at 4:05 p.m. surveyor requested RN-G to secure the East medication cart. RN-G stated medications should never be left at the bedside as facility would want to ensure safety of all residents and staff. RN-G stated facility policy requires family to take medications from home back out of the facility. RN-G stated that medications should be dated with the date they were opened and to discard of any medication in cart if found unlabeled. During an observation of [NAME] wing medication cart on 4/5/22, at 4:15 p.m. RN-I proceeded to leave unlocked and opened medication cart with surveyor despite knowing surveyor was doing medication storage and handling of cart as she had to do medication pass with a resident. Survey team requested RN-A come out of her office to assist with medication storage. R3 had an opened but not dated bottle of Latanoprost 0.005% eye drops. The box identified it was opened 2/14/22, and according to manufacturer's guidelines it should be discarded and not used after 28 days. Medication received by facility on 3/10/22. A second bottle of R3's Latanoprost 0.005% eye drops were found in cart opened but not dated. The box identified it should be refrigerated per Thrifty [NAME] Pharmacy and was found in medication cart. R13's Latanoprost 0.005% eye drops were opened on 2/14/22, but not discarded at 28 days and facility was administering these daily. Medication was received by facility on 1/27/22. When interviewed on 4/5/22, at 4:50 p.m. RN-A confirmed medication carts should be locked by facility staff before walking away. RN-A stated unlabeled and expired medications could potentially affect resident safety as medications can increase or decrease in strength beyond their expiration dates. RN-A confirmed medications from home should not be in the medication carts and pharmacy should verify home medications with medication reconciliation prior to use. During an observation of medication administration on 4/6/22, at 9:21 a.m. R3's Lantus Solostar U-100 Insulin 100 unit/ml (3 mL) subcutaneous pen observed opened on 3/6/22 and should have been discarded per pharmaceutical guidelines after 28 days. RN-F called pharmacy for renewal of medication as new pen was not located on unit. When interviewed on 4/6/22, at 2:29 p.m. RN-E stated facility does not usually accept home medications and they do not use them if not provided from our pharmacy. Facility will encourage a family member to bring them back home or should be stored in a locked box and placed inside the secure medication storage room. RN-E stated that insulin and eye drops are discarded after 28 days from being opened. RN-E voiced concern that medications would no longer be safe to use past their expiration date. When interviewed on 4/7/22, at 9:29 a.m. RN-D stated medications should not be kept in resident's room at the bedside. Home medications would be labeled with resident identifiers and kept in the locked medication storage room. RN-D stated she just started on duty on 4/4/22 when R122's Voltaren gel was noted to be at resident's bedside. RN-D confirmed she removed it from resident room and placed it in east med cart on 4/4/22, however, the medication had since been removed. RN-D was unable to confirm when the date of the silver tube with Voltaren had been opened prior to administering on 4/4/22. RN-D confirmed she was not aware it was a home medication. RN-D stated facility policy for home medications would consist of locking them into a secure medication storage area on the unit, labeling them with correct resident identifiers, informing both the resident and family, telling facility staff, and informing her nurse manager. When interviewed on 4/07/22, at 12:06 p.m. DON stated expectation that home medications should be sent home with family or stored in a lock box in a secured medication storage room. Medication should include resident name, mayo clinic number, and date of birth using at least two resident identifiers. DON confirmed home medications should not be stored in medication cart and the only time would be in a special situation if facility is unable to obtain from pharmacy. DON expressed her expectation for staff to not leave medication at the bedside and it is ideal for staff to watch medication is taken by resident. DON stated most medications expire at 30 days but not sure which medications expire prior to that. Medications should be dated upon opening and discarded upon expiration. DON's concern would be that expired medication would not be as effective in treating medical diagnoses and staff need to order new medications prior to being discarded so resident's did not miss doses. DON stated expectation to keep medication carts on unit at all times as her concern would include resident safety and medication diversion. Medications from home should be verified online and with facility pharmacist. The facility policy Medications Brought to the Facility by the Resident/Family Guideline - Charter House - Rochester revised 9/28/2020 indicated, the facility shall ordinarily not permit residents and families to bring medications into the facility. -Medications brought into the facility that are not approved for the resident's use shall be returned to the family. -Medication(s) awaiting return to family will be recorded on the Drug Inventory record, which shall include the date, medication name/strength, by two licensed staff and noted on resident inventory record and shall be stored in the medication room until returned to resident and/or family. The facility policy Administering Medications Charter House Procedure - Rochester reviewed 4/7/2020 specified medications shall be administered in a safe and timely manner, and as prescribed. -Medications must be administered in accordance with the orders, including any required time frame. -If a dosage is believed to be inappropriate or excessive for the resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. -The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. -The expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be written on the container. -During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. -The individual administering the medication must utilize the Pulled function when preparing medications for administration. Initial verification of the 5 Rights occurs during the Pulled process, second verification occurs when medication is placed in medication cup and third verification occurs when reviewing medications against the MAR prior to administration of medications.